WASHINGTON, DC—Instead of competing for patients, cancer centers should collaborate and form consortia with one another to enhance their effectiveness, National Cancer Institute Director Andrew C. von Eschenbach, MD, urged at an address here at the Annual Meeting of the Association of American Cancer Institutes.
He called this collaboration “horizontal integration,” and said working in partnership will broaden the critical mass of cancer centers.
Speaking candidly, Dr. von Eschenbach said that in order to meet his “challenge goal” of eliminating suffering and death from cancer by 2015, all those involved in cancer research and care need to work together.
“I believe that by working together as a community, that goal is achievable,” he said. As he has visited cancer centers around the country, he said, there has not been one center he has seen that has led him to believe that the challenge goal he has set is not attainable.
As an example of collaboration, he cited Tulane University and Louisiana State University, noting that they are looking for a way to integrate their research efforts and form a consortium, rather than setting up competing cancer centers.
The NCI director readily stated that the 2015 goal is ambitious and that some thought he was misguided and impatient when he set that goal.
“I apologize for my surgical personality,” he said. But, today in cancer research, “we're no longer in a mode of ready, aim, fire. That has too often been ready, aim, aim, aim, fire. My goal is ready, fire.”
Dr. von Eschenbach said that NCI's investment in the infrastructure of cancer centers “gives us platforms for progress,” and represents the best hope of training the cancer workforce of tomorrow.
He noted that from 1993 to 2003, NCI funding for cancer centers and Specialized Programs of Research Excellence (SPOREs)—which focus on translational research for a single cancer site—has grown by 161%.
“This is growth that is going to have to be sustained; they are vital,” said the NCI director. Sustaining that growth is especially important now, at a time when NCI administrators are seeing a flattening of the NCI budget, he emphasized.
More Autonomy & Flexibility
In a good-news message for cancer institute directors, Dr. von Eschenbach said that in addition to fostering more collaboration and cooperation among cancer centers, NCI intends to allow its NCI-designated cancer centers more autonomy and flexibility.
NCI's Cancer Center Program is comprised of a group of nationally known institutions designated as one of three types: basic, clinical, or comprehensive.
“We need to make better use of the centers as entrepreneurial resources” for planning, innovation, and dissemination of translational research, he said. In that way, he noted, NCI's relationship with the cancer centers it supports becomes “a discussion and a dialogue” with strategic partners, not a “cookie cutter” imposition of NCI policy.
Cancer centers will be needed to help NCI carry out its 2004 goal of setting in place an integrated clinical trials system that answers fundamental scientific questions about cancer, said Dr. von Eschenbach.
“Our clinical trials have been based on a model of empiricism; this must change to a model based on mechanism,” he emphasized. “We need to continuously build biology into the infrastructure of our clinical trials as we go forward.”
The new era in cancer therapy is the era of mechanistically based interventions, he said. “The empiric model has built into it a tremendous amount of waste.”
Waste, he said, occurs when a treatment works for only a small percentage of the cancer patients to whom it is given. To drive waste out of the system, physicians need to profile the patient, profile the tumor, and then direct a targeted therapy at that cancer.
As an example of why the clinical trials of today need to provide insight into and answer questions about the basic biological mechanisms of cancer, Dr. von Eschenbach cited the Prostate Cancer Prevention Trial (PCPT). That NCI-funded prevention trial showed a 25% decrease in prostate cancer among some 9,000 men taking finasteride, but the trial also showed that those who did develop prostate cancer while on finasteride had an elevated risk of developing higher-grade tumors. Scientific insight is needed into these apparently confounding results.
Dr. von Eschenbach said that both NCI and the National Cancer Advisory Board (whose 18 members are appointed by the President) have embraced enhanced bioinformatics as an especially important strategic goal for 2004.
“Could you imagine what Einstein could have done with a laptop?” Dr. von Eschenbach asked.
NCI, which established its Center for Bioinformatics in 2001, plans to strengthen its efforts in bioinformatics through a comprehensive data network known as the Cancer Biomedical Informatics Grid (CaBIG).
During a question-and-answer period that followed his talk, Dr. von Eschenbach was asked what effect the new NIH Roadmap for Medical Research—a sweeping strategic plan for all of NIH announced on September 30 (OT, 11/10/03, p 28)—will have on NCI.
He replied that NCI is already heavily invested in many of the goals set in the NIH Roadmap, so it should not be difficult for NCI to adapt to the new NIH-wide plan. For example, NIH Director Elias A. Zerhouni, MD, also has set as a priority reengineering the clinical trials system.
Of the Roadmap, Dr. von Eschenbach said, “How these things will get implemented is a work in progress. It's in evolution.”
The NCI director was also asked what NCI is doing to improve delivery of health care to the underserved. “There are women dying of cervical cancer in Appalachia,” Dr. von Eschenbach said. “There is no reason for that….I think we have to be doing as much research on the delivery end as we do on the discovery end.”
NCI has partnership education and outreach efforts specifically designed to benefit racial and/or ethnic minority populations in areas served by certain cancer centers.
But ultimately, said Dr. von Eschenbach, improving health care delivery to the underserved requires a broad effort across the US Department of Health and Human Services, of which NIH is a part. In fact, he said, an HHS task force is currently examining ways to enhance health care delivery in needy areas of the United States.
In addition to an integrated clinical trials system, Dr. von Eschenbach said NCI's strategic priorities for 2004—many of which will depend on the work of cancer centers—include:
- Molecular epidemiology.
- Early detection, prevention, and prediction (including behavior modulation).
- Integrative cancer biology that views cancer as a systems problem.
- Acceleration of treatment interventions (which will be accomplished in part through an interagency agreement between NCI and the FDA.
- Reduction of population disparities in cancer.