A Formidable Foe: Cancer in the 21st Century

Panelists: Dr. Amy Gutmann, The Honorable Joseph R. Biden, Dr. Carl June, Dr. Otis Brawley, Dr. Nancy Davidson, Kim Vernick

Announcer: Welcome to the 2017 David and Lyn Silfen University Forum. Please welcome to our stage University of Pennsylvania president Dr. Amy Gutmann.

Amy Gutmann: Thank you, thank you, wow. Welcome everybody, it's great to see you all. Really wonderful to see you all here. So many friends, so many wonderful Penn people. Today we are going to confront a formidable foe, Cancer in the 21st Century. This is a very special program for many reasons. First, we honor the memory of Penn's former trustee leader David Silfen. Together with his wife Lyn, David generously endowed the Silfen University Forum. We lost David in 2015 from cancer. With us here today to honor David and to celebrate this great university tradition that he made possible and his wife Lyn made possible are their beloved children, Adam and Jane. Let's hear it for David and Lyn and Adam and Jane. Stand up.

Today's program is also very special because of the unrivaled caliber of our panelists. Join me in welcoming onstage Carl June. Carl. Nancy Davidson. Nancy. Otis Brawley. Kim Vernick. And Vice President Joseph Biden.

This forum also gives me the opportunity just to more quietly welcome Vice President Biden to his first formal appearance on campus since he joined the Penn faculty just three weeks ago. Joe Biden will lead the new Penn Biden Center for Diplomacy and Global Engagement in Washington, D.C. He will not only lead it, he will develop it. But like all new Penn faculty, the vice president arrives with an outstanding set of achievements. And I won't recount them all, but I think you should know that he may be the only Penn faculty member to have appeared with Amy Poehler, not once but twice on Parks & Recreation. And also whose CV could be padded with citations and clippings from The Onion. Not to mention, however, that he is also the only faculty member, I believe, I'm sure actually I know this, he is the only faculty member in the world to have been awarded the Presidential Medal of Freedom with distinction. He and all our panelists bring remarkable expertise to this afternoon's discussion about the past, present, and most importantly the future of cancer research.

The American Cancer Society estimates about 1.7 million Americans will be diagnosed with cancer this year. 40% of us can be expected to be diagnosed with cancer in our lifetimes. But for our audience today, this forum constitutes the unique experience, and very important experience, of being able to sit before a team of cancer experts without having to worry about a prognosis. In fact, the prognosis today compared to any other time in human history is good. But for this team, delivering a good prognosis is not good enough. They are avid about optimizing expert collaboration to slay, yes to slay, the emperor of all maladies.

So let me take a moment to introduce our assembled experts to you, moving from left to right.

Joe Biden served as the 47th vice president of the United States after 36 years as a US senator from Delaware. One of the greatest statesmen of our time, Vice President Biden leads the Moonshot to Cure Cancer, an ambitious effort to move cancer treatment dramatically forward. I also have to add that Vice President Biden and his family have a long and close affiliation with Penn. His late son Beau, his daughter Ashley, and his granddaughter Naomi are all Penn graduates, and the vice president himself holds an honorary degree from Penn. So one more time let us welcome Vice President Biden.

Kim Vernick is a Penn Medicine patient and pancreatic cancer survivor. She is an absolutely avid advocate for Penn's work on immunotherapy, proton therapy, and pancreatic cancer research. She's a member of multiple patient advocacy groups and with her grand-dog Callie, she is a founder of the Radiation Pet Therapy Program. Thank you for being with us, Kim.

Otis Brawley is chief medical officer for the American Cancer Society where he promotes cancer prevention, early detection, and quality treatment. Dr. Brawley is professor of hematology, oncology medicine, and epidemiology at Emory University. Welcome, Dr. Brawley.

Nancy Davidson is the senior vice president and director of the clinical research division of the Fred Hutchinson Cancer Research Center. Dr. Davidson also leads the Seattle Cancer Care Alliance. She is professor and head of the Division of Medical Oncology of the University of Washington School of Medicine. Thank you so much for being with us, Nancy.

Carl June heads the Center for Cellular Immunotherapy at Penn's great Abramson Cancer Center. He is the Richard W. Vague professor in immunotherapy at the Perelman School of Medicine. Carl's work has shifted the paradigm in cancer research by employing reengineered T-cells. We have an exceptional group of panelists here. Let's thank Carl for being with us today. It is time for the conversation to begin so I am going to take a seat and I will simply moderate this wonderful group. Okay, I have to start with you Mr. Vice President, if you don't mind.

Joseph Biden: Madam President.

Amy Gutmann: Thank you for that shout-out at the event by the way which I was honored to be at.

Joseph Biden: Well I'm glad I'm still accustomed to being able to address the president.

Amy Gutmann: Okay, the 21st Century Cures Act which you ushered through Congress and ushering anything through Congress requires us to salute you, especially when it's so positive. It was just amazing. This is something that you put as a very high priority for the US government. Now given the history of attempts to come to terms with cancer, I'd like to begin actually with what your hope is for it. What is your greatest hope for this initiative?

Joseph Biden: Well my greatest hope I guess, Madam President, would be that we continue to make the progress that's been made, particularly in the last five or six years. Like a lotta people in the audience, everyone who's had someone in their family or themselves been diagnosed with cancer, raise your hand. And you all know full well, if it's someone you love and they're diagnosed with cancer, you try to learn as much as you can as quickly as you can, about the prognosis, about the particular cancer they're dealing with. When my son Beau got back from Iraq after a year and was diagnosed with cancer, and a particularly virulent form of brain cancer, glioblastoma, I tried to learn all I could. And I had great access being vice president. I had the ability to pick up the phone and call Dr. June, who's by the way one of the leaders in the world, known all over the world. I was down in Australia, they just a had a new billion dollar effort, they're gonna focus on immunotherapy, your name was invoked by them repeatedly. But I got to have access to an awful lotta people. And what I didn't realize is I didn't realize up until literally maybe six, seven years ago this wasn't much of a team sport. Immunotherapy which first appeared in the early 1900s and it was sort of dismissed in a sense, was not a major element in the panoply of experts dealing with cancer. But for the first time ever, a whole group of disciplines were beginning to merge and work together more than they ever had before, from immunotherapy to virologists to biological and chemical engineers, et cetera. And so what I found out was that there's enormous promise now.

In 1971 when President Nixon declared the war on cancer, he was fully well intended, he meant it seriously, but he had no army, he had very few tools. Correct me if I'm wrong doctors but I think at the time we thought there was one cancer that located in different parts of the body. There's now over 200 individually identified strains of cancer. And we didn't know a whole lot. There wasn't much need for or there wasn't much of an instinct to share, there was no ability to share data and information. Hospitals couldn't do it. And the model was sort of, as I see it, in retrospect, is that there was sorta the Jonas Salk model, one great scientist in a laboratory finding a silver bullet, the cure, et cetera, and so the institutions that were set up to be able to institutionally aggregate data and the rest didn't exist very much. But in the last 45 years, there's been enormous progress that the doctors on this stage have been part of initiating. And yet the institution hadn't changed very much as to how the data is shared.

To summarize, what I learned is that if we didn't make another single breakthrough, if we just were able to aggregate all the data we have, share it in real time, et cetera, we would be extending life for an awful lotta people. Instead of 600,000 people dying a year in the United States, there'd be fewer dying. They may ultimately die of cancer but their life would be much different and life extended. And so that's why when the Moonshot came up we began to focus on trying to figure out how to aggregate this data and we have enormous tools. We can do a million billion calculations per second now. It would take twenty Dr. Junes 20 years to be able to do what, if we were able to get every human genome sequenced in one spot, what you could find out about patterns literally in a matter of three days. And so it's all about figuring out how to change the institutional structures, in my view, a sense of urgency and a sense of changing the culture a little bit of how, and I'm the only non-expert up here, but I know what's not working.

Kim Vernick: Me too.

Joseph Biden: You've become an expert.

Amy Gutmann: So Carl, let me ask you, as the vice president said, you've been one of the people, and the main people, leading what's been called a revolution in cancer therapy, immunotherapy, but it didn't just happen. So what can we learn from what got us to this place and can you say something about the most exciting moment or moments to get where we are now? Because I think we have to appreciate what it takes to get as far as we've gotten before we talk about what more we can do. As the vice president said, one of the things more we can do is to do a lot more in collaborating with the information that's available.

Carl June: Well thank you.

Amy Gutmann: But what was most exciting?

Carl June: Well thank you, it's a real privilege to be here and I think we're celebrating a lot here. We've had disruptive advances in cancer therapy now and there's this toolbox that the vice president was mentioning. In the 70s we didn't even know what caused cancer and in fact what we thought caused cancer was exactly wrong. So now we know the cause and you can imagine trying to fix something when you don't--

Amy Gutmann: Let me interrupt. What was exactly wrong? What did we think and how did that change?

Carl June: Well we had models that didn't predict. So we had mice that had cancer from viruses. Most of cancer is actually caused by the code being wrong in our DNA. And we didn't know that then. We hadn't sequenced the genome. So now we can do that on every patient. Most of our patients here at Penn get their cancer sequenced. Every single base pair we can tell what the mistakes are and then once you know the mistakes, you have a chance of fixing things. Otherwise you're flying blind and sometimes you'll get lucky, you can put blindfolds on, sometimes get a three-point shot but most likely, it's better to know where to shoot. So now we're in that position. In my case, we worked for about 30 years on this idea of CAR T-cells.

CAR T-cells are our own immune system that we reprogram, and we actually use the HIV virus to make the cells become serial killer cells. So we showed in our first patients, treated in 2010, that their own immune system that each cell could kill more than 1,000 cancer cells, and those patients treated in 2010 here at Penn still have those cells on patrol. Which takes now advantage of the fact that if you get a really good vaccine, it'll last the rest of your life. I mean that's the amazing part of the immune system. So the field of immuno-oncology now is now working with the rest of targeted therapies that you're gonna hear about from my colleagues where we can now paint the cancer into a box and it can't get out. And we didn't have before a living drug, so literally the cells that we infused to our patients five, six years ago are still there, we can still find them, and they still will kill cancer if we take them back out of their body. So we never had before a living drug like this and that's one of the tools that we have to be able to launch now in this, that were absent before. We had those ideas before but we didn't have the toolbox.

Amy Gutmann: So Nancy, you have made a very big mark in understanding cancer and treating it with the discovery of hormones, in particular estrogen and it's role in breast cancer. So given that, what in your view, again, give us some insight into how that came about and what it's potential is for driving cancer research and care forward.

Nancy Davidson: I came at this, Amy, from the direction of breast cancer, and I was really fascinated at the interactions between what we could learn in the laboratory and how we could apply it in the clinic. And one of the things that we've learned is that targeted therapies, like Carl was talking about, are also incredibly important in cancer therapy, and one of the first targeted therapies we ever did was therapies that involve manipulating the estrogen pathways in breast cancer. And actually we started doing that before we really understood a lot about it. Once we understood the target, the estrogen receptor, and the molecular pathways, then it was possible to easily figure out how you would interrupt those growth stimulatory pathways and then how you could take advantage of that in the clinic. So that, I think, is one of the first targeted therapies. Another place where it was done was with androgen pathways in prostate cancer. Also even before we understood some of this. But I think that what's made the difference is the knowledge about the biological target, the knowledge about the pathways. Makes it possible to really get in there and try to strike those Achilles heels that we were talking about.

Amy Gutmann: So give us some sense, for those people in the audience and people like me who don't work in a lab or run a lab, what's the timeframe that it took before the first insight that estrogen therapy might hold some promise to the actual breakthrough? And what did it feel like, can you remember when the breakthrough actually happened?

Nancy Davidson: So I don't think there was actually a single breakthrough. I think that one of the important things in research is that sometimes there is a single moment but often it's an aggregation, it's one step at a time. And so in the breast cancer field, the drug Tomaxifen, a very common anti-estrogen drug.

Amy Gutmann: It extended my mother's life until she died of something else.

Nancy Davidson: That's a success for an oncologist.

Amy Gutmann: It was called a miracle.

Nancy Davidson: We love to hear that. So you know, that drug was developed for metastatic breast cancer in the 1970s. It was used in early stages of breast cancer starting in the 1980s. It became a drug that you can use for prevention of breast cancer in the 1990s. And because we understood how it worked and how it didn't work, we could develop other drugs that would also manipulate that pathway and the drugs, the aromatase inhibitors, for example, for post-menopausal breast cancer, have really altered how we think about women in that situation as well. And in younger women we think about therapies that would suppress the production of estrogen by the ovaries.

These all have made a huge difference across the entire spectrum of breast cancer from treatment of advanced disease to treatment of early breast cancer which it sounds like your mom found herself in that situation. And also the ability to think about this in the prevention setting for women who are at high risk for breast cancer. It wouldn't be possible if we didn't understand the biology because of the research that led to these biochemical pathways being discovered and then our ability to really be able to attack them. And that's just one example of targeted therapy. There are so many we could talk about.

Amy Gutmann: So Otis, our founder Benjamin Franklin famously said "An ounce of prevention is worth a pound of cure." Right? And he must have been right on that as he was on so many other things, as in founding this university. Can't miss an opportunity right? What progress have we made on prevention and to what extent do you think, how important does prevention continue to be and does that entail focusing on things like smoking and exercise and screening programs? What else? Give us some insight into the prevention side.

Otis Brawley: We have learned a tremendous amount about what causes cancer and that means that we have learned a tremendous amount about how to prevent cancer. And is cancer preventable? Well, to just give you a couple of numbers. In 1900, for every 100,000 Americans, 70 died of cancer. In 1991, for every 100,000 Americans, 215 died from cancer--three times as many. Humans didn't mutate over that century. It was actually things in our environment that caused cancer. Today we know over 1/3 of all cancers are caused by tobacco use. Close to 30% are caused by the triad. Think of it as three-legged stool. It's obesity, taking in too many calories, and not getting enough exercise. Lot of people just say obesity but it's taking in too many calories and not getting enough exercise. We know that if we could tackle those three things and tobacco, at least half of all cancers that are occurring today could be prevented and we need to work to create an environment that's conducive to behaviors that are healthy.

Amy Gutmann: Is that something that doctors and nurses and healthcare practitioners share, I assume they share the knowledge of that, do they share with their patients and with young people?

Otis Brawley: My criticisms--

Amy Gutmann: And should it?

Otis Brawley: My criticism is that people in the health profession are not promoting prevention enough and also I think when we look at government, all arms of government need to promote it. It's the zoning board that puts the schools too far away for kids to walk from home to school that is promoting cancer by decreasing their exercise. It's not just the health board.

Amy Gutmann: Right, so it's a whole organizational, institutional infrastructure that needs to take this into account?

Otis Brawley: I like to talk about the built environment.

Amy Gutmann: Built environment.

Otis Brawley: The environment that we've created and we need an environment that actually is conducive to encouraging good habits.

Amy Gutmann: Kim, you hold a very special position on this stage here today. You were treated for a particularly aggressive cancer, treated here at Penn. An aggressive cancer that has too few effective treatments. So can you tell us about the journey that brought you here and what was your experience and what are some of the moments that stand out in your mind, the decisive moments that enabled you to be here, looking great, and I hope feeling great?

Kim Vernick: Feeling great, yes.

Amy Gutmann: Here today.

Kim Vernick: Well, first of all I'm a native Philadelphian so Penn has always been the place to be in Philadelphia, the United States, and probably holds a nice high-esteemed place in the world as well. So that was easy. When my doctor sent me up to Penn for some testing, I felt I was in great hands, no worries. What really blindsided me is when he diagnosed me with pancreatic cancer. I didn't smoke cigarettes. I exercise like a crazy person. I eat very healthy and I'm certainly not overweight. So, I don't know why I got it, that's a mystery but moving on, I had to deal with it.

I met with the doctors at Penn and they gave me their opinions and what we were gonna do. And then I ran down to Johns Hopkins for a second opinion immediately. They put me through all the same testing. And they pretty much came up with the same protocol, except they did say to me, I think you should be treated at Penn. Because Penn had a clinical trial at the time. And that clinical trial was really my best shot. I did not have an early stage of pancreatic cancer. It was in my pancreas, on top of the pancreas, and wrapped around my celiac artery and I was told I was inoperable and that I had a very, very, very small chance of survival. So, I figured I'm gonna do whatever I could and I'm gonna go into the clinical trial. So when I came back to Penn, I took the terror and the fear and I shoved it to the back as best as I could, and I replaced it with hope and then the mental toughness to fight this--which is what you guys are doing too, and women, are fighting. Anyway--gotta take a second, excuse me--Anyway, we put our little helmets on and we're ready to go to war. My family?

Amy Gutmann: Yeah, are they here?

Kim Vernick: They're right there.

Amy Gutmann: Let's--

Kim Vernick: They were in charge of the love, caregiving, and cheerleading and they did a great job. Dr. Jim Metz, who I don't know if he's here.

Amy Gutmann: Is Jim here?

Kim Vernick: There he is, mwah! Dr. Jim Metz is my radiation oncologist and my proton sniper. Ursina Teitelbaum, my oncologist. She was in charge of the chemotherapy and poison control. Along the way, I had the privilege of meeting Bob Vonderheide and we got to know each other a bit and, by the way, I do think he is going to cure pancreatic cancer.

Amy Gutmann: Here, here.

Kim Vernick: And then of course, in the trenches with me, were the Penn staff. You can't believe it. Between the nutritionists that are telling me, “eat the protein, don't eat the salad,” and I'm going, “well what about my heart?” They go, “we'll worry about your heart later.” And the social workers that are making sure that I'm comfortable. And the nursing staff, I mean it really, it takes a community for even one person to get through cancer.

Amy Gutmann: I have to give a shout out to Penn Nursing because we have been named the number one nursing school in the world.

Kim Vernick: I believe it.

Amy Gutmann: And they're really.

Kim Vernick: So, you asked me what brought me to Penn. I'm sitting here, I'm alive, I'm healthy as can be and I'm strong and I'm cancer free, so. So it's not “Why Penn?” it's of course Penn.

Amy Gutmann: Well you mentioned you were in a clinical trial.

Kim Vernick: Yes.

Amy Gutmann: And I would be very interested, Mr. Vice President, in order to get clinical trials going, in order to get drugs approved, there's a process and there needs to be a process obviously, but you have to weigh the risks and the benefits and what risks you're putting people through. In your time both leading in cancer and in the government, do you think we have it right as far as the how the regulations work and the process works? Is there anything that you would see that we could do better or do you think that is pretty much the way it ought to be?

Joseph Biden: No, I think we have to do a lot of things better. And I think--

Amy Gutmann: So can you say—

Joseph Biden: In the year that we were running this Moonshot I visited every major cancer research facility in the United States with the exception of two from the Hutch to MD Anderson to here to Hopkins to Sloane Kettering. And there emerged a consensus among the leaders in each of those great hospitals on a number of things, one of which, for example, of everyone diagnosed with cancer only 4% have access to a cancer trial. Sometimes it's the only thing that may save their lives. And the drug companies who get a bad rap, sometimes deserved but lots of times not, the drug companies don't have enough patients to run trials. They don't know where to find them. So I thought that the cancer network was set up a little bit like a first-rate corporation or an outfit in Silicon Valley and I found out that there was no way to find out where the trials were. For example, my son Beau was supposedly a trial of one with Anti-PD-1 and an injection of an adenovirus into his brain, and I asked how many others have done this. Well, no one knew, and MD Anderson is a first-rate hospital.

I had an idea. I went to, we have a bunch of fellows that President Obama convinced to come, mainly from Silicon Valley--brilliant, young, their average age is probably 40--to come and help us organize the federal government in a way that'd be much more productive. And within a matter of three weeks, they came up with a site that you can go on now if you're diagnosed. If you're from Bemidji, Minnesota, you have a good oncologist, he diagnoses you or she diagnoses you with the particular cancer you have, runs the cancer genome and sequence it, knows exactly what it is. They have no idea, unless they're near a great hospital, what therapies to use. There's no way to figure it out. So what they did was that within four weeks you can go on now on a site at NIH and find out every single trial for the type of cancer you have, near you, and quite frankly, in the world. It took these brilliant young people four weeks to figure that out and we've been going now at NIH for 15 years with a site no one could use. There's a number of examples like that. For example, I'll give you one other example. In this effort to try to figure out, ya know, we all know one of the prevention schemes would be if you got the analysis right the first time and you had a best shot at whatever therapy's most likely to work. And so, the largest hospital in the world is the VA. There are more biopsies, there are more cancer sequenced genomes there, anywhere in the world, et cetera, they're never shared. There's no access to them.

We put together a program whereby now you can go at Walter Reed and get your cancer genome sequenced as well as anywhere in the world. And I got a phone call from the president of IBM, “how 'bout using Watson, do you want Watson.” And I said, “I sure in hell do.” No, I'm serious. Watson's read every single solitary publication ever published on anything having to do with cancer. Period. Now within 24 hours, once you identify the particular cancer, they can give you every single solitary therapy that's every been used thus far on that cancer. Increasing exponentially the oncologist in Bemidji will be able to pick the right thing to prescribe. And for example, we accessed all this information. We set up a formulary which I thought would already exist. The docs can tell you, when they wanna run trials on dual trials, on more than one kind of cancer drug, that's how we beat AIDS. There wasn't any one particular drug, and so what happened, it would take them somewhere between a year and two years to be able to negotiate with two drug companies to be able to two different therapies, two different medicines that they had. So what'd we do? If you go into a bar or a restaurant and you want to play a jukebox, you drop a buck in, you don't have to have a licensing agreement with Beyonce to listen to her song. That's already worked out. Well guess what we did? Common sense, I know nothing about cancer but I know how to make things work.

Amy Gutmann: But you know about licensing agreements with Beyonce.

Joseph Biden: That's true and guess what we did? That's really gonna matter. It's gonna matter a lot. Six drug companies, 270 different drugs they're working on, they're not patented yet, okay? We said, lay 'em all out on the table, let any researcher come and use any one of them, or any three of them, or any two of them, because we've already worked out the intellectual property agreement, we've already worked out the licensing agreement so if it turns out to be a cure, you know exactly how you're gonna profit. Guess what, the drug companies are happy. There are now 17 doing it. It's gonna increase exponentially the prospect. You don't have to know much about cancer, but you have to know about how to aggregate. And so there's those kinds of things that are across the board that can make a great deal of difference in providing these brilliant, and I mean I'm not being solicitous, physicians with the capacity to be able to do more with what already exists, and find pathways. Find pathways.

One last thing I gotta say--it shocked me. If you came to me when I was vice president and you wanted a grant as an astrophysicist to study the seventh ring of Saturn, and you got a 50 million dollar grant, immediately upon you completing your study, fail or success, you have to publish it on the web for the whole world to see. Immediately. You get the same grant for cancer, you don't have to publish it. You don't even have to tell us whether it failed or not. You're supposed to. You learn a lot from failure. It takes a year if it is published, it goes behind a publication, the publications cost somewhere between 60 and 120 thousand dollars a year to subscribe to. And guess what we found out? 65% of docs, never, and under the law required, never publish their results. So I had full authority of the president to hire and fire, I put a little thing in. It said for every single day you finish your study, you don't publish it, you get a personal fine of $10,000 a day. These guys are gonna see Jesus soon. No, but I really mean it. No other occupation in the world--hear me--in the world--would be able to get away with that. It's time to stop. Time to share. Especially with your tax dollars.

Amy Gutmann: Terrific, really.

Joseph Biden: I'm not upset about it at all.

Amy Gutmann: No, no. The stakes are enormous here. So Carl and Nancy, you spoke earlier about the breakthroughs that have been made. Some people have put them forward as a kind of one-hit wonders in immunotherapy. I mean it's still an experimental treatment that hormone therapy works but you need a lot. You need a lot of connections. This goes back to how broadly usable these therapies are going to be moving forward. We know that access is not universal. It's far from universal. And I think this is what the Vice President, the goal and what's so upsetting is that, we have potential now but it hasn't been developed nearly enough. So do you foresee a time within our lifetimes when the access will be broader than it is now? Carl.

Carl June: You know we have, I think, there are in educational terms, Dr. Gutmann, they talk about translational Type 1, Type 2, and Type 3 translational research and so, what we focused on here has been this first inhuman application and that's a Type 1 translational effort. And then we made this decision that you were integral to of in 2012 partnering with Novartis so that they could make what we did here in Penn patients and globalize that. Well that was a huge step and actually I can say that this year Novartis expects to have FDA approval, and so it will be, and they've already actually treated patients in Melbourne, Australia, which Vice President Biden was referring to.

We have now globalized something that was thought to be impossible, a highly individualized therapy will be FDA approved this year for leukemia. Now that doesn't mean everyone has access, as you know. It's an expensive therapy and only those with insurance will be covered, and there are massive issues that need to be addressed and they're way above my pay grade on how that will be done. I can tell ya that in part the solution's gonna be similar to automobiles. So we talk about CAR T-cells. The cars that we make in Michigan and Detroit and elsewhere now, they were initially made one by one with mechanics and now they're made mostly by robots, and human hands never touch them. We need the kind of therapies, these cell therapies, to be made robotically and to be scaled. I thought about that today in preparation for this. At Penn back in 1946, the first computer was made, ENIAC. And everyone who's a student here knows about that. And that thing occupied a room. It was not a small thing that I have here which is a cell phone, and this is more powerful than a room-sized computer.

Amy Gutmann: Much more powerful.

Carl June: Much more powerful.

Amy Gutmann: Exponentially so.

Carl June: Exponentially more powerful. So that was done over more than 50 years of engineering improvements. That's what we need now in these cell therapies, in other kinds of therapies that are being made, personalized for everyone's tumor, that will happen. It will be automated. What I don't know is a time scale of how long, and that's where I think the Moonshot can make a difference. A massive difference in how long, and it takes us, was referred to by Vice President Biden, teamwork. If we have teamwork then it can be accelerated. So we have I think the glimmer and a framework of how to make it happen now and then hopefully accelerate the time to when it does happen.

Amy Gutmann: I would just underscore how important it is to have that collaboration and teamwork both within but as importantly across institutions. The Innovators, Walter Isaacson's book, talks about the history from ENIAC onward and it underscores how important it is to stick to it and have collaborations. Really important. Nancy, what do you see as the future for access to the therapies that are working the best and do you have any sense of timeframe?

Nancy Davidson: It couldn't come fast enough, that's the first thing I would say.

Amy Gutmann: Amen to that.

Nancy Davidson: Yeah, ya know I think your question raises several interesting topics, many of which you addressed in the Moonshot, Vice President Biden. One of them would be how do we take the things that we already know about. I talked about Tamoxifen and aromatase inhibitors. If we simply applied those drugs where we're supposed to, made them available to the patients who need them, insured that the patients who need them took them, so the adherence question, and made them globally available, I think that could have a big impact on a disease like breast cancer. And that's gonna be true for many of our targeted agents as we go forward because of course one of our goals is that many of them will be oral and so they won't be given in the traditional fashion, so we're gonna be relying on a partnership between the provider and the patient. I think the second part of this is the field is changing so rapidly. I only practice breast cancer and it's hard enough to keep up in that, but if you're a general oncologist trying to understand all of the things that are going on in oncology right now is really important. So the concept of pathways, and evidence based pathways that are available to help practitioners and patients understand the best possible alternatives is incredibly important because we have to continuously educate ourselves. And lastly you touched on, for me, the concept of health equity, whatever we do, we need to make sure that all of those interventions, those opportunities, are available across our society. There can't be the haves and the have nots.

Amy Gutmann: Otis, what do you see as things that we are doing right and what we're not doing right here?

Otis Brawley: Well we definitely need to focus on getting people cutting edge therapies but I have some wonderful epidemiologists that I work with and they do all the numbers every year, some of which you've already quoted. And I asked not too long ago, realizing that people who are college educated have a lower risk of death from cancer versus people who are not college educated. I asked my epidemiologists, of the 596,000 cancer deaths that occurred in 2016, how many Americans would have died if everybody had the risk of death of a college educated American? And they came back with 148,000 Americans would not have died if all Americans had the technologies of college educated Americans. 1/4 of all cancer deaths were avoidable if people simply had the care that every human being deserves. And when I say care, I mean preventive care, which includes counseling the mother on what to feed the child. 'Cause I'm one of these guys who actually realizes that what the six-year-old is eating actually determines her risk of breast cancer when she's 60. Literally. I mean, when we talk about prevention, we need to talk about it as a pediatric problem as well as an adult problem. I'm talking about getting people access to good care, getting everyone access to the care that everyone should get.

Joseph Biden: Doc, I don't wanna sound like the politician that I am but uh ... You know, you're absolutely right about preventing in the first place. But there's another factor here. The other factor is, if you do not have health insurance, your likelihood of detecting whatever cancer you have between being stage one and stage four is exponentially higher to being stage four. Watch what happens, again, if we repeal the Affordable Care Act for 20 million poor people, who in fact will be without cancer and be without the diagnostic access that they have now. And the last point I want to make is the point the doctor made, if you think about what people have available to them to be able to determine what they should and shouldn't do. There is an overwhelming desire around the world. I signed a memorandum of understanding with ten different countries that want to collaborate with the United States and share data because they know that therein lies an awful lot of answers to the problems they face abroad. And here's the deal, it is true drugs are very expensive, particularly the ones that really work, and they're extremely expensive, some are as much as 150, 160,000 dollars a year. But here's the deal guys. If in fact you do not treat that cancer, the cost to society for hospitalization and all that follows from it far exceeds the cost of making available the drugs at a reasonable price and a reasonable co-pay. It's not all the insurance company’s responsibility. Some of it is unjustified in my view. How a drug goes from being 26 grand a year when in fact it was invented and 15 years later it's 150 grand a year is beyond my conscience. But the point is, keep in mind, the total cost to a patient and to society when poor folk don't have access to the prevention in the first place increasing their prospects of not being hospitalized. There's an awful lot of costs here and it's a hidden cost but it's all right out front and it's astronomical.

Amy Gutmann: Could I ask you about the future of biomedical research funding. Obviously you've talked about how important…

Joseph Biden: The only bipartisan thing left right now and I'm not being facetious.

Amy Gutmann: No, say it, listen up this, this is important.

Joseph Biden: It's a perfect example of how we have to get back to where we used to be.

Amy Gutmann: Yeah.

Joseph Biden: In this Cures Act, which was over 6.3 billion dollars with a week left to go in the Congress and everybody is telling me, “there's no way, Biden, you can get this done.” We had four leading Republicans, in the House, in the Senate, who are dedicated men and one woman, who are dedicated as can be, line up with four Democrats. And they made the case as to why the long-term impact on cost and the short-term impact on life made such a difference. And it was only the second time in my career I went up on Capitol Hill and everyone was saying, “Oh it's wonderful.” When you don't run for president you become incredibly popular. And so everybody, they're naming things after me and the rest, and I went up, I said “Look, I want a favor,” and I went, I button-holed the people I knew were different, knew what the right thing to do was. I said, “For me, I want you to do this. You owe me, do this.” And they bucked what was the leadership in both parties at the time and created a consensus. When the final vote came, over 80% of the House and Senate voted for this. My point is, that it's a way, when you have intelligent people and there are a lot of intelligent people in the House and the Senate, you have intelligent people who care about something that they know the public cares about.

My concluding point is this, I know the docs, and these docs know all the docs I'm dealin' with. I know they get tired of me saying you've got to be able to translate what you're doing to ordinary people, whether they are an astrophysicist or whether they work as a waitress. You gotta be able to explain what the impact of their tax dollar is doing. You've gotta translate, you gotta speak English, not as opposed to Spanish but plainly, straight-forwardly, because the reason why we're gonna be able to get a lot of funding for biotech is because, when you explain to people the impact on their lives and what you're doing with it, they will support it. And you have an awful lot of very bright men and women in the Congress who aren't afraid of being labeled as big spenders, aren't afraid of being labeled as they're having Uncle Sam take over healthcare. These are conservative members of the Senate and the House who did this. Because, the public, the public understood what's at stake. And so there's ultimately a need, whether it's foreign policy or cancer policy, to be able to translate to the American people exactly what you're doing without talking down to them. And that's why these docs are so darn good. No, I really mean it. Because you do it all the time. You go out there and you explain in plain, simple English what's at stake and people will back it up and you'll embolden the people who know better to stand up, to stand up. Because we can change the face of cancer in the next five years.

Amy Gutmann: Hear! Hear! Wow, wow. Just as a personal, I remember you're speaking at Arlen Specter's memorial service and you and Arlen went way back in supporting the importance of research funding.

Joseph Biden: Arlen was able to double the funding for NIH.

Amy Gutmann: Yeah.

Joseph Biden: And then along came, along came Jones, as the old song goes, and we ended up in a different place.

Amy Gutmann: So Kim, you're a businesswoman as well as a cancer treatment volunteer and advocate. We spoke about the importance and nobody, I think, I don't think anybody doubts, even though not everyone supports, the importance of government funding, but what about the importance of philanthropy, volunteer activity, private/public partnerships. I want to ask you and also Otis to talk about, 'cause both of you work in a realm which is, I believe, the realm that makes America great and will continue, which is this collaboration among private and public for great causes. So what's your experience been?

Kim Vernick: I personally think the philanthropy is as important and maybe more important than government funding. And I think what you are doing Vice President Biden with the Cancer Moonshot is fabulous. But I also think we're all trying to fix it, but I think it needs to be cured. That's the way I look at it. And it seems that you put the best and the brightest in a network, you're talking about a network. If they can't be in one location they can be communicating totally and curing this disease. Okay, so the government's gonna fund what the government's gonna fund, but then to really get a cure, you're gonna need very generous supporters. Believe me, if I had the means I'd write a check. But I really think that someone like Carl June, who had the support of the Abramson family.

Amy Gutmann: I see Madeline Abramson's here today. Madeline, thank you so much. Madeline.

Kim Vernick: A very integral part in curing leukemia. And with the other doctors such as Bob Vonderheide. He's so close to curing pancreatic cancer. He needs funding, they all need funding. So when I was talking behind stage, I was saying cancers are not gonna be cured all at once, it's gonna be one cancer at a time. And I think that's the way we have to go, with philanthropy.

Amy Gutmann: Yeah, yeah, so Nancy and Carl, we're here in a major university with a major academic medical center where we're not only big believers but we continue to commit ourselves to collaboration across boundaries with a great school of business, The Wharton School, and engineering and nursing and we have a veterinary school and dental and so on. What's the role of great academic medical centers today and what do we have to do to collaborate with pharmaceutical companies, with other non-profits, and with other industries to move this forward? Do you have some specifics on this? Because I think we cannot rely, we have to rely to some extent, as Kim said, on government but we can't rely only on government, and we are the place where the great minds are at work. Not the only place, however. So what do you see as working and what more can we do? A small question.

Carl June: So yeah, I think there's a lot of, I mean where we're at now is this realization that it's multi-disciplinary. The vice president referred to, I mean, we need chemical engineers working side by side with computer programmers and physicians, et cetera. The total investment required to get there is unknown at this point. We have, as you know, this experiment with Sean Parker now where he last year committed 250 million dollars to join six universities together in a philanthropic ban for cancer immunotherapy. And so with Bob Vonderheide and John Wherry here, we are doing that and we're working side by side now with investigators at Stanford, MD Anderson, UCSF and UCLA. And it's accelerating things because we talk and don't have to duplicate things that we would otherwise do in our own foxholes here, say at Penn or at Stanford. So now I think that's one way that's gonna go forward are public/private partnerships. And it will accelerate the process.

Amy Gutmann: And that's a great example of how important private philanthropy is because it really brought institutions together and gave enormous amount of extra funding to what we can do. Nancy, what's your sense of the role of academic medical centers moving forward?

Nancy Davidson: I think they've been critical since the beginning, since they were first established. I worked at one of the original ones, Johns Hopkins, and I think their role is only gonna continue to increase because the discoveries which really fuel this by and large take place at our academic medical centers. But we can't do it alone. Carl June can't deliver cell therapy across the world from the University of Pennsylvania. It has to be put out in a more broad fashion and that's where our collaborations come with our pharma partners, for example. As we already heard, it wouldn't be possible without philanthropy, but cancer centers work together too. 'Til just a couple months ago I was the director of the cancer institute at the other end of the state at the University of Pittsburgh. I see out here Chi Yang, my soulmate, from the Abramson Cancer Center, and the kind of collaborations between cancer centers are also very real. We have come together over a government funded grant that brings early phase clinical trials, so-called Phase 2 trials, that are now able to take place across our institutions because of this federal funding. We brought together interactions that have to do with metabolism, Chi's expertise, and how we might think about taking that for a clinical perspective. Some of the things that are wrapped around tumor environment and how might we look at that. So those kinds of interactions are also going to be critical and they are fueled by the government, by pharma collaborations, and by philanthropy.

Amy Gutmann: So if we don't do the basic research nobody's going to do it because of the timeframe but if we alone try to do the translational research and the clinical trials, we don't have the full panoply of expertise and support, so we really have to increasingly look for partners, right?

Otis Brawley: Yeah, that's actually a very important point. In the universities is where the basic discovery, where things are learned about how biology works. That happens in the universities and you need really federal and some private money. The American Cancer Society and other charities do fund some of that, and that's research where nobody's gonna be able to make money off of it. Then there's the research that's a little bit more applied and there you have some pharmaceutical companies who are coming into it, but more and more I see some of the larger universities and larger not-for-profit research entities that are actually starting to patent things and actually, in some instances, using money off of their patents to fuel other discovery, which I think is a very good thing.

Amy Gutmann: Yep, terrific, so Kim, you mentioned the goal of curing cancer, which clearly would be an amazing goal to achieve. Carl, I remember seeing a short film called Fire with Fire where you expressed some trepidation about using the word cure with regard to cancer and I'm wondering, Mr. Vice President, and I'd love to hear all of your views on this, should we be using the word cure as our goal but being careful about using it too promiscuously if you will? What do you think? Mr. Vice President, can I start with you on this?

Joseph Biden: Well I think that there are some cancers we're gonna be able to cure and there's some cancers we right now don't have any idea how we're gonna cure and I think we should be talking about both. What are the things we can do to extend people's lives in a way that they can live a normal life and God willing, like your mother, not die of the cancer that they were diagnosed with having because it was able to be controlled. And what are the cancers that can be cured? Some of the cancers that are very difficult to cure are the brain cancers, others I won't go into what they were, but some are just harder than others. We know less about them. And the pure research and applied research, there's an ongoing debate among some of your colleagues, if you name the top 50, top 20 folks in the field, there's a debate about the allocation of pure versus applied research.

By the way, one thing you should understand, I'm not making the case for government, but understand government is by far a factor of 10, 15, 20 more than all philanthropies combined. The federal government does 30 billion dollars a year out there, okay? So let's not carried away here with the idea you don't need government. The fact of the matter is, one of the brightest presidents, the most underrated presidents in the world, in our history, is Dwight D. Eisenhower. When Sputnik went up he came up with a group he called, wouldn't call today, the Wise Men, and they made recommendations how we're gonna catch up and how we're gonna increase access. And they came up with this elaborate plan how we're gonna invest in government he said, no no no. We should invest in research universities. We have more research universities that are of high quality than all the rest of the world combined.

Amy Gutmann: We can give a round of applause for that. (applause)

Joseph Biden: No but it's true.

Amy Gutmann: It's true, no it's absolutely true.

Joseph Biden: But understand, tomorrow and you hired me as the Ben Franklin professor and I start a program sayin' we don't need federal funding, watch what happens to Penn. That's your tax dollars, guys.

Amy Gutmann: Right, anyone else, Carl, since I referred to you, when should we use the word cure or how should we use it and when should we be careful?

Carl June: It's gone both ways and I think we do need, I mean the C word is cure. When I was a resident and a fellow with Dr. Brawley.

Amy Gutmann: Right.

Carl June: We had the saying ABC which is Always Bet on Cancer and usually it won. We're at a time now where the optimists can see a time to end of cancer and I think that should be the goal, but I think early detection and prevention need to be at the foundation of this. So we will have assays to screen and find early cancers, and then from own immune-centric point of view, I think we'll be able to make vaccines to prevent those then. So that's where we wanna be but that's not now and so we'll have a time scale of in this intermediate time of more and more cancers will be controlled with the eventual goal of curing through early detection, I think, and knowledge of what really causes those cancers.

Amy Gutmann: And Otis is--

Otis Brawley: I would agree wholeheartedly with that. We already cure some metastatic cancers. Metastatic testicular cancer, many of the leukemias. By the way I had a old professor who used to tell me cure is a four-letter word. We have very long, complete remissions but we don't cure. Ya know, so, we will put some people into extremely long, complete remissions. We already do. With certain cancers, we're gonna get into the diabetes model or the HIV model where people actually live for a very long time taking a drug or two every day and the cancer's like a smoldering fire and the person lives in peaceful co-existence, may even live to a normal lifespan. Their cancer will not be cured but their cancer will be held in obeyance. I think that is going to happen. It actually already is happening in several diseases, it's going to happen in more over the future. And I think the idea of actually getting to the point where we can have true cures of metastatic disease, I think that's a fine goal that we need to continue pursuing.

Joseph Biden: Doctor, all three of you, are we gonna get to the point where we're able to determine what makes that cell go bad, as they say? What is the thing that makes that cell continuing to multiply?

Otis Brawley: In some instances, we already do and I can tell you the chemicals, there's 70 of 'em, in tobacco smoke that actually cause the mutation and if the mutation happens in the right place in DNA, you're going to have a cancerous cell. Or sunlight in the case of melanoma. Sometimes the problem is people don't have good DNA repair where once the damage is made, you can repair that damage and prevent the cancer. And we may actually eventually have some drugs that help us to improve the person's ability to repair the DNA. In some instances, the cell goes down that cascade toward cancer and the immune system currently finds it, snaps it up, T-4 cells and kill it. We may very well be able to, with technologies from Dr. June, spur on the immune system and actually help the cancer patient not become a patient because their immune system.

Joseph Biden: It’s amazing. Cancer would learn to hide.

Otis Brawley: Yeah, exactly, exactly.

Joseph Biden: You oughta explain, I found it fascinating. I'm serious, as a layperson I found it absolutely fascinating how, quote, smart cancer is. How it actually camouflages itself within the body so the immune system, which would ordinarily if you could get to it can kill it, is unable to get to it. I mean, I don't know whether I'm outta line here asking you to talk about that.

Amy Gutmann: Be my guest.

Carl June: I think you were a quick study and got that right.

Otis Brawley: It's fascinating science. When you understanding this part of human nature, you can't just but be fascinated. I share your enthusiasm.

Nancy Davidson: Can I just chime in?

Amy Gutmann: Yeah, please Nancy.

Nancy Davidson: Ya know I think we're thinking about the verbs of control and cure which are both very important but I do wanna put in that prevent one again.

Amy Gutmann: Loud and clear.

Nancy Davidson: Taking it from Otis, but you know sometimes in our focus on therapy which is absolutely critical. We should remember that therapy does go back into that prevention sphere and we should put a lot of focus on that, as you did, Vice President Biden, in the Moonshot initiatives. 'Cause that would be the best of all. We wouldn't have to worry about the cure or the control, we'd be on the prevent.

Amy Gutmann: So I have some questi--

Joseph Biden: We don't need an EPA though right?

Nancy Davidson: Well.

Kim Vernick: I don't know, I still. I still like the cure word, I'm sorry.

Nancy Davidson: I agree with you.

Kim Vernick: No, like the cure, how 'bout if you go for the cure and then kind of if some of them are in remission that's okay, you'll settle for that?

Amy Gutmann: Right.

Nancy Davidson: I like all three of those words.

Amy Gutmann: Absolutely. So we have some questions from the audience but before I get to, and I wanna get to the questions, I have them, people wrote them ahead of time and I have some right here and I wanna get to them. But before I want you to, we need a modest crystal ball gazing, as follows. If we, as I would love to do, reconvene ten years from now, in the Silfen Forum, and I ask each of you what you're proudest of having achieved, not yourselves individually but having as a society and world achieved in the realm of cancer prevention, remission, cure, what would you like, realistically, to be able to say ten years from now?

Joseph Biden: That I brought my grandchild for her or his school physical, they got a vaccination against measles and mumps and they got a vaccination against a half a dozen cancers.

Amy Gutmann: Wow.

Joseph Biden: And that's in realm.

Kim Vernick: That's the way I see it too. I see a vaccine in ten years.

Amy Gutmann: I think you're getting Kim's vote on that one.

Kim Vernick: Yes, definitely have my vote.

Amy Gutmann: You're seconding it.

Kim Vernick: Absolutely, I'm hoping that the next generation will go and just get vaccinated.

Amy Gutmann: Otis?

Otis Brawley: Well, the HPV vaccine can actually help tremendously. We still live in a United States where 15 to 20% of adults smoke tobacco which is the only product that I know of which when used as intended kills two out of the three people who uses it. And so I would hope that ten years from now we would be able to drive the smoking rate much closer to zero. And that would not save lives immediately from cancer, that's gonna save lives from cancer years down the road. It actually would save lives from cardiovascular disease almost immediately.

Nancy Davidson: It gets tougher and tougher when you're on this end of the podium, huh Carl? I would hope that we will have developed precision prevention and treatment strategies that are based on our understanding of cancers and that we would have evidence-based ways of getting them out there to everyone.

Amy Gutmann: Terrific. Carl.

Carl June: And as the last I'll say that the solution I think actually is gonna require a political one. I think right now we have a market failure which is we will have the tools in ten years to diagnose and treat cancers at a curable stage. Right now we don't have an incentive for companies to develop that because the profit mode, to prove someone never got a cancer, takes a long time, and the way drugs are developed, it's just not done. So we need to have bipartisan working to make a situation where there's an incentive to develop curative therapies and vaccines. Off the tumor diagnosis, it will happen. We have those technologies, they'll be ready to be deployed in ten years.

Amy Gutmann: So one of the things, I hope you realize how when great collaborative minds come together what just happened, which is the vice president gave a scientific cancer-related answer on vaccines and Carl June the doctor gave a political, economic answer. So perfect, perfect. Really.

Joseph Biden: Dr. June is right.

Amy Gutmann: You are too.

Joseph Biden: Dr. June is right.

Amy Gutmann: So here I have some questions from members of the audience. Max Alper, who's a student, Max are you here somewhere? Well, somewhere Max.

Otis Brawley: He's right there.

Amy Gutmann: There, okay great, Max. This is Max's question. "My mom is a stage four cancer patient "whose breast cancer spread to her liver. "She has received the best care "at Wash U in St. Louis. "This care is not available to everyone. "What can we do to get everyone the care "and help they need?" That's a wonderful way of putting a very important question. Who would like to take that?

Nancy Davidson: The vice president.

Kim Vernick: Moonshot, Moonshot.

Joseph Biden: An interesting thing I'd say to you Max is that, I was, a guy who's a wonderful man, a very prominent Republican named Huntsman--The Huntsman Institute--they asked me to come out to Utah.

Amy Gutmann: He's a Penn graduate, too, we have to say.

Joseph Biden: He is. And he's devoted to Penn.

Amy Gutmann: He's devoted, yes.

Joseph Biden: And you know what they wanted to know? They wanna know what the government could do to help them make sure that they could get to indigenous populations to get the care that they had available to them now for people, for prevention as well as putting people in remission and some cures. What could they possibly do to be able to get that out to Native Americans in the Far West. So the reason I mention that, there's a lotta things to do, I won't go into it, but I wanna make a point about the people on this stage. The failure to collaborate is not because these aren't the brightest, the most dedicated people in the world. They are the most impressive group of women and men I have dealt with in my entire career, around the country. And they really, really, really care. But one of the things that has to happen is we have to sort of change the mindset to bring the public in to understand that the net cost to the American public for healthcare diminishes significantly if in fact the very opportunity that your mother has is extended to other people who do not have access to either because of dollars or because of locale. And there's a whole lotta solutions. I'd be happy to talk with you after this. I don't wanna take more time.

Amy Gutmann: Terrific. Another question from Dr. Anna Mesick who's at Penn Vet, a post doc at Penn Vet. There she is, Anna. "What are the most effective actions that scientists and people who are concerned about scientific issues should take to make sure our voices are heard?" I think Mr. Vice President this is for you as well. Am I correct, Anna? Yes.

Joseph Biden: Anna, folks in your position have to be able to communicate to the people around them, their friends, their family, their community. The direct correlation between what you're doing and what has to be done and their lives. Unless you can translate it into making people understand. I keep goin' back to this fundamental proposition. Unless you can translate to ordinary, bright Americans that look, this is why if we do A it will result in this outcome. They have to be educated. Or when we did A, B, C, and D and made that investment, look at what the effect was. But there has to be some correlation because people are cynical about an awful lotta things, particularly government, but also cynical about investment in research and development.

We used to be the country that, and in fact, it was raised, all you had to do was appeal to science and technology. And say we could do anything. Think about it today. Think about the mindset of America today to compare what it was 25 years ago when we said there's nothing we can't do. Now we act like, whoa is me, we are so far advanced from any other country in the world. We have the greatest capacity to make progress of any time in the history of the world. And we're acting like, "oh my God, we're in tough shape, we're in bad."-- It's simply not true. It's simply not true.

I haven't found one single leader--I've met every major leader in the world in the last 35 years--there's not a single solitary one I can tell you would even remotely hesitate to trade places with the president of the United States of America, in terms of where we're seated. Name me a product guys that has transformed the world that doesn't have a Made in America or invented in America sticker on it. I'm serious. Look, the great thing about this country is we have no respect for orthodoxy. Which is a really good thing. No kid, as bad as our public school education is, no kid gets in trouble for challenging orthodoxy because to make new things ya gotta break the old mold. This is an enormously, enormously, talented country. And so we gotta get back to the point where there's not a damn thing we can't do if we set our minds to it. And that's part of the problem that exists now. People are goin' “aw man, I don't know, things are really ba—“ Come on, man. Give me back the good ol' days. When you couldn't be a doctor because you're black. Give me back the good ol' days when women couldn't work. I mean, I'm so sick of it. This country is ready to get up and move. I really mean it. It's an incredible country.

Amy Gutmann: Amen.

Joseph Biden: The last thing I'll say, if there are any angels in heaven they are all nurses. They're all nurses. I give you my word.

Amy Gutmann: There's the dean of our nursing school.

Joseph Biden: Seven months in the hospital. Three months in ICU watching my son. It's amazing, amazing, amazing, amazing, what nurses do.

Amy Gutmann: Well Toni Villarruel is the dean of our nursing school.

Joseph Biden: As my mother would say, “God love ya, dear.”

Amy Gutmann: Maddie Kaufmann, who's a medical student. Maddie, are you here? Yeah. "Minorities are underrepresented in research "on targeted cancer therapies. "How can we address this disparity "in cancer research and novel cancer treatments?"

Otis Brawley: Let me start off and others can jump in. You're absolutely correct. By the way, if you're a medical student I'll give ya a little hint right now, nurses train doctors.

Amy Gutmann: We may have a rebut, I think this is great and I'm all for it but we also have our dean of our medical school.

Otis Brawley: He'll admit that I'm tellin' the truth.

Amy Gutmann: Larry Jamison, Larry and Toni are great partners, and they are partners so. Larry, welcome.

Otis Brawley: One answer to your question goes back to the first question that was asked which is actually a very important question. You had a gentleman who said that his mother was getting state of the art care at a major American medical center and his question is, how can other Americans get that same state of the art care. That is a really true, truly great American question. And all of us need to start asking that and if all of us start asking that, a lot of our healthcare problems in this country will start going away. How can our fellow Americans benefit and get the same things that we actually get. I think we've gotta change a lot of minds, gotta get a lot more access to care through various and sundry ways,  but that's how we end up fixing the problem. One last thing I'll say about minorities in health. I'm much more concerned about the large number of minorities, and non-minorities, who don't get adequate healthcare than the number or paucity of minorities who go on the clinical trials.

Joseph Biden: Can I say one thing about this? Minorities aren't getting research monies because minorities are new to the field. And the way the system is set up, for you to get research money and particularly in cancer, you have to be out of a lab that is an established lab.

Otis Brawley: That's right.

Joseph Biden: And it is run by white boys and white girls. Because they've been around a long time.

Amy Gutmann: And more boys than girls.

Joseph Biden: And more boys than girls but all kidding aside, it's not intended, it's just the nature of it's very hard for any brilliant, young person who isn't associated with someone who's established in a laboratory, in a research facility that's already been set up, to be able to get those kinds of grants. It's part of the institutional changes I think we should be looking at and it's a little bit like how the courts were. When I first got to the Senate, I did the courts my whole career, we had very few women on the courts. They said, “why aren't you appointing women to the high court?” Well, there weren't that many women in law school. Now more than half the people in law school are women. We have a hell of a lot more. We have a pipeline that now we have a hell of a lot more judges. So, part of it is the pipeline and part of it is the age and the timing.

Amy Gutmann: Denise LaMarra who's on the Perelman School of Medicine staff, you can see we have a wide range of wonderful people here. Her question is "Doctors have difficulty talking to patients when it is time to stop curative therapy. How can we best prepare doctors and other providers to treat patients through their entire journey?"

Nancy Davidson: Well I guess we can all try to tackle that one.

Amy Gutmann: Yeah.

Nancy Davidson: To me that's a societal question, actually. It's not only the doctors and the nurses it's also what our expectations are when we're patients and family members of patients. I do like to think that in oncology though, that we are increasingly able to think about those very tough questions that Denise is talking about. Many on this stage have been through those discussions. Vice President Biden, you certainly have. But there is a skill set and I think that medical students, nursing students, increasingly are being trained. And then part of this also ultimately happens at the bedside, right? Part of the practice of medicine, it seems to me, involves being involved in these kinds of discussions and seeing how they're done effectively and then learning how one can take this on one's self. But you're right, we have to understand that our care extends across the entire continuum and that most times, of course, we hope that it will eventuate in that cure, but occasionally it will not and so we need to be prepared to think about the other parts of the conversation.

Otis Brawley: There's also some regionalization in how we view death in this country. People in the Midwest are more likely to have those conversations than people on either coast.

Amy Gutmann: Why? You wanna explain that a little bit?

Otis Brawley: I'm not exactly 100% sure why. I've been told by some people who were theorizing that folks who live on farms see animals die and death is something different if you're a Midwesterner versus someone who lives in a big city.

Amy Gutmann: So it may be more urban/rural.

Otis Brawley: It may be more urban/rural, although I think in Midwestern cities as well. Yeah, we've seen this in other things too. For example, remember the old data that showed that women with low stage breast cancer, they were more likely to have lumpectomy and radiation, and treatment on the east and west coasts and mastectomy in mid-America. We see things like this and I think our ability to talk about death is one of these things that’s a little bit regionalized but the principles are all the same. We all need to get better at doing it.

Amy Gutmann: So here's a question that actually does make the connection between homo sapiens and the rest of the animal kingdom. It's by Evelyn Galton who's a faculty member at Penn Vet. Our School of Veterinary Medicine trains 3/4 of the veterinarians in the state and it's the on--

Joseph Biden: My niece is there.

Amy Gutmann: And I didn't know that. Oh yeah, actually, you told me that once before. I should have remembered. Remember everything you say.

Joseph Biden: She's smart as hell, too.

Amy Gutmann: Of course. So here's the question. Evelyn, are you here? Oh right there, Evelyn. "What role do you see for the study of translational medicine in the fight against cancer and how can we support this collaboration between veterinary medicine and human medicine?" I should, because I can't help myself, put in a plug for Penn Vet. Penn Vet, it does phenomenal research as well as translational research and care. But it also has the only veterinary doctor in the world who received the National Academy of Science Medal, Ralph Brinster, for his research. And anybody who has any animal or pet that they care for, as I do, I have a grand-dog, will only want Penn Vet care for it. So that's a long preface to a hard question, which is, “how can we support the collaboration between veterinary medicine and medicine for homo sapiens?”

Otis Brawley: The National Academy of Medicine just published a whole book on comparative medicine, looking at veterinary medicine to human medicine and the comparisons, I can point that out.

Carl June: I'll say, I mean we have a growing effort here.

Amy Gutmann: We have…right.

Carl June: We have between the vet school and with Chi Yang here and the Abramson Cancer Center, we have now a comparative medicine group that's really vibrant and this is now between the deans of the medical Perelman School and the vet school. And now Parker, Sean Parker, is supporting part of this. We actually have dogs, which are being treated with CAR T-cells. And Nikki Mason is an associate professor here at the veterinary school that's working on this, and I think it's gonna be an increasingly important aspect. Only very few medical schools actually have on-campus the vet school at the same place so geographically we're really blessed that way. And we intend to really grow this over the next five years.

Amy Gutmann: And it's another example of how we have to bring knowledge together, not only knowledge across doctors and nurses and scientists who study human beings but studying the animal kingdom which holds real promise for us. We are at the end of our time and I am just going to get up here and ask you all to join me in thanking our esteemed panelists. Made my job as moderator so easy. And I want to thank again Carl June, Nancy Davidson, Otis Brawley, Kim, just wonderful to have you and share your experiences and Vice President Biden or should I say Benjamin Franklin University Practice Professor, Professor Joe Biden, let's thank everybody. Thank you all also, I want to thank everybody in the audience. Thank you, thank you all for safe travels. Thank you all very, very much.