Nasa / UGREEN 3S / Science Photo / Shutterstock / Paul Spella / The Atlantic

Cancer: The Final Frontier

Landmark breakthroughs in cancer treatment and a policy structure where those advances can flourish have given fuel to the ambitious “Moonshot” to cure the disease. But is it really possible?

Condense, if you will, the 50,000 years of cancer’s recorded history in a time span of but a half-century. If it were 50 years old, human beings would know very little about its first 49 years, except that it killed men and women with the ease of a scythe slicing through wheat. About a year ago, mankind finally began to fight back, using the crude tool of surgery as a caveman would use a cudgel. Two months ago, humanity finally began to understand the nature of cancer and began to use radiation therapy. This week, humanity declared war on cancer. Yesterday, the modern cancer-fighting apparatus developed, spanning hospitals and academic research centers with cutting-edge research, imaging, and treatments. But now, as the clock strikes midnight, for the most part cancer is still the menace that it was, beyond the reach of humankind and mostly beyond the range of a cure.

In the space of the last tock, however, there might be something remarkable happening. President Barack Obama and Vice President Joe Biden have announced a cancer “Moonshot” with the goal of finding a cure. Even in a last-term presidential domestic docket that includes long-shot solutions for criminal justice, climate change, and guns, this quest seems most quixotic, a tilting at cosmic windmills. As such, the Moonshot has elicited as much scorching skepticism as it has philanthropic enthusiasm. But two new developments may be shifting the landscape: Radical new advances in science provide hope that seemed impossible before, and newly developing partnerships among public entities, private companies, academic researchers, patients, and insurers provide a staging ground for that science to take off. In this instant, there might finally be a window. Maybe the moon isn’t as far away as humanity once thought?

There’s still a scar, just between his eyebrow and the bridge of his nose, a faint reminder of the invasive threat that came so close to ending him. Over lunch, Stan Collender points to his nose in a self-aware and self-deprecating manner that seems natural for him. “Can you see it?” he says. “That’s where it started.”

The spot showed up in August 2012, a small purple mark on the bridge of his nose. It was difficult to distinguish from any other blemish, but Collender was insistent on having his dermatologist take a look. He wanted it gone as quickly as possible.

“It was my vanity that may have saved my life,” Collender told me. After the blemish was removed and a larger piece of his skin taken for examination, a lengthy round of tests determined that the growth was Merkel cell carcinoma. But no sweat: Doctors assured him that after a complete excision and a few days in recovery, he’d be back on his feet in no time, with just a 10 percent chance of recurrence. Six months later, Collender felt something wrong with his throat and ability to make saliva. Using a needle biopsy, they found a recurrence in his lymph nodes. With surgery and radiation, doctors treated that, too. Six months after that, a tumor popped up in his brain. Still sanguine about his chances, doctors treated the tumor with radiation. Just three months later, scans showed another recurrence—once more, in his brain.

This time, there was no rosy outlook from physicians; no kind estimates about his likelihood of survival. After having been at his wife’s side during her fight with breast cancer, Collender knew enough about the disease to understand his odds after multiple tumors in different organs. After the last recurrence, he was facing the end of the line. Doctors gave him just nine months to live.

If there were anyone built to fight the odds, though, it’s Stan Collender. A strong Brooklynite accent conveys his pugnacity, and at lunch, he cracks wise-guy jokes about “kicking cancer’s ass.” His public diary about his cancer treatment and rehabilitation was written with the boardroom bravado of a corporate TED talk, an incredibly sunny outlook from a man staring directly into the shadow of death. He worked out often and beamed about his fitness and strength. Even while facing the exhausting prospect of chemotherapy, he continued working out—against the advice of his doctors, and spent his hours outside of the gym and the office researching every resource he could find on cancer. After the latest diagnostic news, he scoured Google for information about Merkel cell, poring through all of the scant medical research on the rare disease. What he found was terrifying: Merkel cell is much more aggressive than the more common skin-cancer melanomas and much less likely to be stopped by chemotherapy or any other common treatments. Collender was ready to try anything.

“That was when I said, ‘Bullshit,’ you know?” Collender says. “We’re treating this wrong.” Unlike most cancer patients with such a developed and aggressive cancer, his preparation and his obsessive research would find serendipity. Collender’s research led him to his oncologist, Dr. Michael Atkins, the deputy director of the Lombardi Comprehensive Cancer Center at Georgetown University and an expert in the science of immunotherapy as a cancer treatment. Collender read about clinical trials for Merkel cell and inquired about them. It turns out that Atkins knew of some promising immunotherapy clinical trials with Merkel cell patients. This unheralded but promising treatment would end up saving Collender’s life.

Immunotherapy is a fancy description for treatments designed to get your body to do what it already does for many diseases. For microbes that your body recognizes, antibodies attach to antigens on the offending cells and the immune system kills the invaders. Vaccines train the body to recognize potentially deadly viruses so it can react quickly if ever infected by the real deal; vaccination is itself a kind of immunotherapy. But cancer is different. Tumors derive from a person’s own cells and are much trickier for the immune system to find and destroy. And it’s even trickier to try to come up with treatments that essentially hack the body into doing just that.

Tricky, but not impossible. Cancer immunotherapy has long been considered a sound proof of concept, at least. The field coalesced around key discoveries in the 1980s and 1990s that turned cancer research on its head. Atkins worked on one of the first immunotherapies with interleukin-2 (IL-2), a naturally occurring immune-signaling molecule that can help the body recognize tumor cells and destroy them. Working groups also made other discoveries about cancer-fighting T-cells—a kind of white blood cell—that could be transferred to patients. In more recent developments, researchers have sought to fight the mechanisms that cancer cells use to hide themselves from the immune system. Others have focused on breaking down cancer microenvironments, which cloak and physically protect the cancer cells from the immune system’s tight security. In all cases, these immunotherapies perform that difficult task of giving the human body the weapons it needs to wage war on tumors.

In the 20 years since its infancy, cancer immunotherapy has matured to take its place as oncology’s vanguard, based on a single founding principle. Atkins describes that principle: “If the immune system is appropriately activated by immune therapy in some patients, the immune system could eliminate the last of the tumor cells and create a cure.” Cure. That’s not a word that gets thrown around lightly when fighting that venerable emperor of maladies.

In Collender’s case, Atkins knew two researchers in Seattle who had been using that principle to break ground in figuring out how to hack the body to fight Merkel cell. Dr. Shailender Bhatia and Dr. Paul Nghiem, along with the Seattle Cancer Care Alliance, were conducting clinical trials of a new treatment that might be able to completely wipe out Merkel cell. Collender’s medical team filled out an application. The requirements for the trial were strict: the proper blood profile, and a young and fit patient. Luckily, Collender matched every description. Atkins called the Cancer Care Alliance team himself, and finally, Collender got word that he’d been accepted. Bhatia called him “the perfect candidate.” So it was off to Seattle to meet this group of researchers who seemed to be doing the impossible.

Nghiem’s research in Seattle was Collender’s last hope, but like all good stories, it came about by sheer chance. “In medical school, I’d never heard of Merkel cell carcinoma,” Nghiem told me. “When I was a dermatology resident, I saw one patient with Merkel cell carcinoma, and it was very unusual.” In the weird world of Merkel cell—a virus-mediated cancer that only affects about 2,000 people a year—that made Nghiem an expert. After being asked by a professor to help write a chapter on the topic, Nghiem’s research took off. “It was quite obvious at the time that early management was very different than melanoma and other skin cancers,” Nghiem said. “So I wrote the chapter, and to my surprise, patients started coming from all over the place. It was obvious that no one else knew how to manage it.” Merkel cell quickly became Nghiem’s main research interest, and he and Bhatia now oversee multiple landmark trials, with most of their lab’s funding going toward the disease.

When Collender arrived in Seattle he was placed in one of those landmark trials, this one involving the drug pembrolizumab, “pembro,” marketed under the brand name Keytruda. Pembro has become a newsmaker as a cancer wonder drug, and it works by blocking the PD-1 receptor. PD-1 is a part of an immune-system checkpoint that basically turns T-cells on and off. Cancer cells overexpress PD-1, which suppresses the immune system’s response. Pembro essentially stops Merkel cell tumors from inhibiting immune response, rendering them vulnerable to T-cells. Collender traveled to Seattle once every few weeks to be injected with a cocktail of the drugs through a port in his chest, and to be monitored and worked over by doctors and nurses.

In Collender’s case, the pembro treatment worked like a charm. After just a few visits, scans for the disease in his body—once riddled by a stage IV cancer—were quiet. And the side effects were a walk in the park compared with the exhausting rigors of chemotherapy, radiation, and surgery. “I felt great,” Collender told me. Aside from the travel time back and forth to Seattle for treatment and monitoring, he never even missed a day of work due to illness.

Collender is but one of the success stories of pembro—President Jimmy Carter has also used the drug to great effect in his fight against melanoma—and pembro itself is but one of the successful immunotherapy drugs. In January 2014, California businessman Johnny Crowell had received the news that he was going to be a grandfather. He was elated. Just days later, his doctor diagnosed him with stage IIIb Merkel cell cancer—which had already reached his lymph nodes. “They told me to expect 24 months and expect that it would end up in my lungs, brain, back, and somewhere, and that I better be figuring my shit out,” Crowell said.

But, like Collender, he was determined to exhaust every option in order to keep himself alive. He also heard about Nghiem and Bhatia in Seattle, and applied for a phase I trial of G100, a synthetic drug that can increase immune responses when directly applied to tumors. There were only 10 people total in the trial.

Crowell’s treatment was not as easy as Collender’s. Drugs had to be injected into his lymph nodes, a painful process that required local anesthetic the first time and a strong nurse to hold him in place. The second process was even more painful as doctors decided against the anesthetic. He could receive neither radiation nor surgery during the course of treatment, and his skin swelled and cracked around the injection sites. But at the end of the treatment, he returned for one last surgery to finally remove the affected lymph nodes. When doctors finished, they found their miracle. None of the tissue they’d extracted showed any signs of Merkel cell.

Collender’s and Crowell’s stories come as just two examples of the remarkable science emerging from the work of Nghiem and Bhatia. A new article released in The New England Journal of Medicine showcases the stunning successes of their work with pembro, Collender’s drug, in treating Merkel cell. In the Phase 2 trial, more than half of all patients had a positive response to the treatment, and, of those, nearly all had ongoing positive responses for over six months. Many of those, like Collender, have seen no turn back toward illness. Even two patients who had to be removed from the trial for complications after one and two doses, respectively, still had sustained responses. For a group of diseases where drugs that have somewhat decent odds of increasing the life expectancies of patients by a couple months are developed for exorbitant prices, this is an accomplishment perhaps on par with John Glenn’s first orbit around the Earth. In the web of hedging half promises and euphemism that is oncology, pembro might be about as close to a wonder cure for a disease as there exists, and it is a strong indication of the future of immunotherapy.

For Crowell at least, immunotherapy gave him a chance to watch his grandson grow up. As we spoke on the phone, he was taking a joyride around town with his grandson, the same child he’d heard news about the night before his diagnosis. His is the joy of a man who had cheated death.

This is a time of breakthroughs, and pembrolizumab in particular is the subject of in-depth and extensive coverage as the new Big Deal. But immunotherapy is still a long way from even becoming a dominant cancer treatment, let alone delivering on any promise to turn all cancer types into acute, curable diseases. Even the success stories of Merkel cell patients showcase just how far the science has to go in order to reach Obama and Biden’s goal for a cure. Merkel cell is a rare cancer, with a large amount of mutations, that is most often caused by a virus. These factors make Merkel cell especially conspicuous to the immune system and a good target for immunotherapy. It doesn’t respond well to conventional treatment and usually attacks aggressively and suddenly, leaving patients and their physicians with few options but clinical trials. It is, in a sense, a slam dunk for the field, one that might not be so easily replicable down the road for other cancers.

However, the unique funding and support structure of these trials provides a glimpse at an exciting roadmap for the Moonshot and its new task force, which began meeting in February. Nghiem and Bhatia are part of the Cancer Immunotherapy Trials Network, or CITN. Funded by the National Cancer Institute and Seattle’s Fred Hutchinson Cancer Research Center (known as the “Hutch”), the CITN coordinates the work of academic-researcher hotshots in centers across the country with philanthropy and the pharmaceutical industry in order to create a muscular clinical-trial apparatus, all with the goal of pushing cancer immunotherapy agents to the market and to patients.

When the CITN was founded, the status of cancer immunotherapy was in doubt. Director Mac Cheever recalls the events that led to its formation. “Around 2005 and 2006,” Cheever says, “I was asked by scientists from the American Association of Immunologists and the American Association of Cancer Research to do a sabbatical at the National Cancer Institute.” Those scientists wanted Cheever, a member of the Hutch, to help answer a basic question: Why were there so many potential immunotherapeutic drugs, but so few that had been tested in cancer patients?

“Working for about a half a year or so with administrators and scientists at the NCI, we decided that at least one minor part of the problem was a lack of prioritization,” Cheever told me. So his workshop at the NCI began efforts to ask people in industry, academia, and the Food and Drug Administration about some key top immunotherapeutic agents that might provide benefits to cancer patients now with more funding and research. At the same time, other individuals approached the NCI with the idea of building something to coordinate immunotherapeutic research efforts. The NCI put out a request for applications; Cheever and the Hutch applied and were one of the winners. With the list of agents that Cheever had compiled as its focus, the CITN was born.

“CITN is really a network of now 34 of the foremost immunotherapy universities and cancer centers in the United States and Canada,” Cheever says, “focused on doing early phases clinical trials with immunotherapeutic agents that have been deemed to be high priority by the field.” The network’s funding does not pay for the total costs of each trial, so researchers rely on co-funding from foundations and companies. Pharmaceutical companies provide the agents for study. Based on input from its researchers and from those pharmaceutical companies, the CITN maintains the list of priority agents and promotes work on the most promising therapies.

When Cheever’s intrepid group started working, biotech and pharmaceutical companies paid very little attention to immunotherapy drugs. Several potential cancer immunotherapies simply didn’t make money, and there weren’t very many pathways by which they could, since they didn’t make cancer cells universally melt away in any obvious manner. What’s more, the group targeted specific cancers based on a likelihood of successfully treating them, not on how widespread they were. Merkel cell carcinoma, for example, is so rare that it is considered an “orphan disease,” or one that affects fewer than 200,000 people worldwide. Orphan diseases have real trouble securing pharmaceutical investment in trials and drugs, and for understandable reasons. Drug development is a major cost burden, stretching from initial chemical discovery to lab tests to different rounds of clinical trials. Drug pricing can be exorbitant, but it often does reflect a real cost burden. Without a wide population to use them and pay for them, most orphan drugs or rare uses for existing drugs fall by the wayside. In fact, when the CITN started sponsoring work on Merkel cell, companies weren’t willing to share pembro or help fund trials.

However, three years ago, Bristol-Myers Squibb published data on agents similar to pembrolizumab in treating lung cancer, showing that up to 20 percent of patients exposed to the drug experienced substantial decreases in tumor size. The industry had finally realized the immense promise of investing in cancer immunotherapy. And that gave the CITN the opening it was looking for.

It was probably more lucrative than a gold rush. Drug companies suddenly began working on most agents on the CITN list. They started by looking for agents that could be used in combination with drugs like pembro to provide real responses in cancer patients. The scramble intensified as researchers from the University of Pennsylvania discovered that some kids with leukemia could experience remission using transferred T-cells. Drug companies and the CITN began looking for ways to combine the two main arms of cancer immunotherapy: finding ways to activate the body’s immune response to cancer cells and turning T-cells into efficient tumor assassins. The CITN favored an approach of combining different drugs on its list to attack tumors in as many ways as possible, and that model spread to the industry.

During the immunotherapy gold rush, pharmaceutical giant Merck finally said they’d share pembro and co-fund trials. The CITN’s gambit had worked. Funding from NCI and other foundations—combined with coordinated, in-house expertise—dramatically reduced the cost exposure of the trials to Merck and made the CITN’s research a reality. “They get trials done for much less financial investment than they would have had to make in their own trials,” Cheever says. “The field has really gotten really vibrant in the past three years.”

The CITN had performed a minor miracle: They had successfully cut the red tape and funding issues that prove an impossible barrier to so much of drug development. Eric Rubin, vice president and head of oncology early stage development at Merck, notes that the CITN-backed initiative helped align the stars.

“This was a proposal that came to us through investigators who’d worked on understanding the biology of Merkel cell,” Rubin says. “They came to us and said, ‘Hey, we’d like to do a study with your drug.’ We looked at it and thought it made great sense, and we’d like to help.” The expertise and conviction of Merkel cell CITN researchers convinced Merck. “That’s not a study that we would probably have prioritized as a key Merck study, but it was one that made good sense and we were happy to support,” Rubin says.

Rubin does not agree with the characterization of Merck and other pharmaceutical giants as ruthless profiteers. And in many ways, the pembro trials combat—or at least complicate—that image. A former researcher himself, Rubin had worked in academia before, as did several of his colleagues. “We’re driven by the science,” Rubin told me. “We’re all in this together. I think the underlying passion is to find ways to help people with cancer, and so there’s a lot of commonality there. Merkel cell and others are examples where that’s a win-win.” At the very least, the CITN helped to align incentives and was able to motivate a wide coalition of partners toward the common goal of treatment.

Promising trials involving other types of cancer and other immunotherapy agents have also been developed along this model. In mycosis fungoides, a type of cutaneous T-cell lymphoma, CITN-backed research shows about a third of the patients respond to anti-PD-1 therapy. CITN researchers are also considering using immunotherapy for some cancer patients who have HIV. In fact, Cheever told me that their trial is the only active clinical cancer trial involving HIV-positive patients. And from rare diseases and rare cases, the CITN has been able to scale up, pushing trials for its agents in more common cancer types. If it can make orphan diseases attractive for study, the opportunities for larger, more lucrative cancer populations are eye-popping. “Everyone is interested in leveraging their funds, is what it comes down to,” Cheever says. “Foundations need to do that, companies need to do that, and the NCI needs to do that.” This is exactly the kind of model that any kind of national effort to cure cancer, Moonshot or otherwise, would be wise to borrow or promote.

The nation has been here before. The hope of a cure is well worn and threadbare, and it’s easy to see strains of previous Icarian efforts in much of the optimism around the Moonshot and immunotherapy. “The Congress is totally committed to provide the funds that are necessary, whatever is necessary, for the conquest of cancer,” President Richard Nixon said to Congress after he signed the National Cancer Act of 1971. That signing launched his War on Cancer, a crusade to cure cancer. The Act was designed to help coordinate federal resources and philanthropic anti-cancer efforts. It amended the Public Health Service Act and elevated the National Cancer Institute, a part of the National Institutes of Health, to a unique status. The NCI’s “bypass budget” has since given the institute unique authority to submit budget requests directly to the president.

By most measures, the National Cancer Act has been good public-health policy. Much of the country’s cancer infrastructure can be traced to that December 23 signing in 1971, including the funding structure for the CITN itself. The President’s Cancer Panel and the National Cancer Advisory Board, created by the Act, bring together some of the most prominent cancer researchers in the world. The Advisory Board especially is like a who’s who of cancer research: the Koch Institute for Integrative Cancer Research, the Dana-Farber Cancer Institute, the Winship Cancer Institute, the Memorial Sloan-Kettering Cancer Center, over a dozen universities, and several government agencies—even the Pentagon—are represented among its ranks. These two bodies help coordinate the massive multibillion-dollar research effort and keep the nation’s highest leaders directly abreast of new developments and opportunities.

The Act also established 15 of the country’s 69 NCI-designated cancer centers, which are the engines of that research. Included in that number is the Hutch, and many other original members are also part of the CITN. Treatment for several cancers, such as acute leukemia in children, has advanced by leaps and bounds since Nixon signed the Act, and over the decades, scientists have eked out precious extra months for people with the most aggressive cancers to spend with their families.

Still, though it has helped push the greatest advances in cancer treatment in history, 45 years into its life, the National Cancer Act has not yet delivered on Nixon’s promise to “conquer” cancer. Millions have been born and have died of cancer since. And while supporters and beneficiaries of the law’s many successes point out that it has saved and extended countless lives, the fact remains that the ability to cure cancer continues to be as much science fiction as it is science fact.

The United States has even played the coronation game with immunotherapy before. A Newsweek cover article in 1985 hailed immunotherapy pioneer Steven Rosenberg and his “search for a cure” after the early successes of IL-2. Follow-up work seven years later was met with the same optimism. While, on any rational scale the developments in immunotherapy have been cause for celebration, it is likely that people might look back on the current cure craze in the same way they viewed previous wonder drugs and potential cures: Close, but no cigar.

Cancer immunotherapy itself might eventually prove to be limited, even if it is developed by efforts like the CITN to its most futuristic ends. So far it has proved most effective in cancers with high levels of mutations and in those that are directly caused by viruses. These kinds of cancers are the easiest to identify and have security vulnerabilities that can be exploited, allowing the immune system to respond. Other cancers might not be so easy to crack, or they may be uncrackable. Immunotherapies are so far also only as effective as the tumor microenvironments allow them to be, physically and chemically. T-cells won’t work if they can’t even enter the tumors. One such example is pancreatic cancer, which forms a dense fibrotic network around tumor cells and is almost impervious to the immune system.

Even if clinical trials are increased tenfold by partnerships between research entities, they are difficult to enter and navigate for patients and physicians, which might prove to be the main limiting factor. Crowell and Collender share a sense of dogged resourcefulness, and both had physicians armed with research to help them make early decisions. They were both also out of options, with a cancer that simply would not respond to traditional treatments. Similar scenarios are hard to imagine for patients with less time, knowledge, or access to information, or with physicians who aren’t as connected to the field.

Bhatia speaks to that key barrier. “For a cancer like Merkel cell, most physicians haven’t heard of it or trials,” he says. “So they certainly don’t feel comfortable treating these patients. There’s not a whole lot of data around to guide us. I think patients feel that lack of comfort when physicians are talking to patients about treatment options. It’s hard to present an optimistic view when you know the treatments don’t work that well.” For patients in doctors’ offices around the country, even those with more common cancers, the idea of joining immunotherapy trials just simply doesn’t enter the conversation, even if the opportunity is there. Many are stuck undergoing treatments that they know won’t be much help, before being left to fringe or palliative care, and that’s if they even have the insurance to cover those treatments.

People without insurance—and even many with it—run up against the old issue of cost. While public-private partnerships like the CITN can be scaled up to reduce cost exposure and risk for pharmaceutical companies in clinical trials and bringing drugs to market, treatment at the patient level still costs money. Lots of it. Current cancer drugs of the non-miracle variety can cost thousands of dollars a month. Documents from a 2013 Citi review estimate revenues for the field of cancer immunology at $24 billion or more yearly, much of which is drug purchasing by insurers. Even if something approaching a cure is developed, the ability to pay for it may provide enough of a practical barrier for many cancer patients. As incomplete universal health-care reforms leave behind many poor people and people of color—especially in states that chose not to expand Medicaid—the prospect of a cure could very likely solidify deep health-care segregation.

In an email to me, Biden’s press secretary, Meghan Dubyak, sent a brief description of the Moonshot mission. “The Cancer Moonshot Task Force is aimed at marshaling the full resources of the federal government to bolster the prevention, detection, and treatment of cancer,” the statement reads. “The Vice President is also utilizing his ability to convene and to break down silos that undermine advancements and bring the research and advocacy communities together. He is encouraged that many philanthropists and research institutions have been inspired by the Moonshot to boost resources and to establish partnerships.”

One good example of those partnerships that Biden seeks might be the CITN, and it also provides a clear and likely scalable model of aligning financial incentives so that researchers and pharmaceutical companies are not at odds, but working on the same team. Although many commentators have panned the Moonshot’s budget of $1 billion as a token gesture compared with the true costs of drug discovery and cancer treatment, it represents an investment that is a few orders of magnitude greater than the CITN’s. And while the Moonshot is a chump-change investment compared with the truly astronomical numbers involved in cancer research, the evidence is there that small sums of funds can be leveraged for maximum effect. The Moonshot could super-charge a specific, targeted effort focused on a list of useful agents, and could leverage government funding to bring philanthropic, academic, and pharmaceutical partners to the table. And federal officials are perhaps best suited to roping in insurance companies and to providing more opportunities for patients to join clinical trials. After all, federally funded trials need patients as much as the patients need trials.

The curative intent of the Moonshot is probably less entrenched in the realm of fantasy than that of its 1971 predecessor, despite the ever-more-apparent complexity in the science involved. Now, more than ever, oncology is equipped to deal with the complexity of the problem, with tools ranging from supercomputers to genome-based precision-medicine and pincer-assault-like combined therapies. Rosenberg, chief of surgery at the NCI and probably the closest thing cancer immunotherapy has to a “father,” is optimistic. “I think immunotherapy today is providing us the best possibilities for developing these effective treatments, and it’s a field that’s moving very rapidly now.” In that rapid development, recent research has identified a whole crop of cancers that respond to immunotherapy, including a host of carcinomas that include some of humanity’s most prolific killers. The next phase of development—providing combination therapies involving one or more immunotherapeutic agents and the old standbys of radiation, chemotherapy, and surgery—could very well be close enough to a cure to turn several cancers into treatable acute diseases instead of quick-striking, chronic, slow marches to death.

“In my view, [immunotherapy] represents an approach that’s most likely to solve some of these problems of curing cancer patients over the next decade,” Rosenberg told me. As the proof of scientific concept, cancer immunotherapy is matched by the CITN’s proof of administrative concept, a policy model that has finally found a way to manage the difficult task of arranging every piece of the cancer-fighting apparatus into a well-oiled machine. On the level that would be required by Biden’s vision, such coordination would resemble nothing less than the space race itself, with multiple prongs of society—researchers and administrators across nonprofits, universities, cancer centers, industry, and the government—aligned and incentivized toward a common goal. Only in this race, the goal is not space, but the same frontier of cancer that has stared back at humanity from the abyss for 50,000 years.

Can it be done? Realistically, a cure is probably as far off as the stars that haven’t yet been conquered. Even a Moonshot operating at maximum efficiency might not be able to overcome some of the cost issues. And while it is easy to predict scientific advances in cancer immunotherapy based on previous progress, sometimes dead ends happen and can’t be beaten by all the investment or coordination in the world. Sometimes, science just doesn’t work. However, the national will has never before been presented with such a promising science as immunotherapy, and few models have held the policy promise of the CITN. Stranger things have happened.

Stan Collender leaned back after I asked my last question. He sighed. “What’s it like to be a pioneer?” he repeated. The self-deprecation faded into consternation as he thought about it. I rephrased the question. “You’re basically a medical marvel. What does it feel like being a pioneer?”

“I don’t feel like I’m a pioneer,” he responded. “The doctors did all the work, and I would have done anything to stay alive. What I feel like is a test pilot.” He nodded.

The characterization makes sense. He’d gone where most men never go, face to face with risk of death. He had taken one of the greatest adventures a person has ever embarked on, and he had done it alone, with no predecessors to advise him or console him. It is his hope that, soon, the science of immunotherapy and organizations like the CITN and the Moonshot can take every cancer patient on that journey, too.