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Simone's OncOpinion

Secrets of NCI-Designated Cancer Centers

Simone, Joseph V. MD

doi: 10.1097/01.COT.0000465769.50767.91
Opinion
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Many academic oncologists believe that the Cancer Centers Program is the most effective and efficient organization within the National Cancer Institute. Unless you have been in a leadership position in an NCI-designated cancer center, though, there is likely much you don't know about the specifics of how they operate. The term “cancer center” is not copyrighted, nor is it a protected brand, so anyone can call their office or storefront a “cancer center,” often leading, therefore, to misconceptions.

The NCI started this program in the 1960s to help support and improve cancer research. After some early adjustments, the current model took shape; NCI would become a supporter of the infrastructure for cancer research, e.g. staffing, shared resources, biostatistics, advanced technology, etc. To apply for a Cancer Center Support Grant (CCSG) the institution must already have a robust array of individual cancer research grants that are grouped in research programs. The best source for detailed information is at cancercenters.cancer.gov.

Almost any research organization may apply for NCI-designation. Note that I said research organization. Applicants may not have a clinical program if the institution has no clinical cancer program; there are several institutions in the basic research-only category, such as MIT, the Salk Institute, Cold Spring Harbor Labs, and others.

But 63 of the 70 NCI Centers do have clinical programs, which are required to build and maintain a strong clinical research component. A key fact: The NCI does not review the quality of cancer care. So NCI designation is based on research excellence, not clinical excellence.

For the NCI to approve a cancer center for funding, it must meet a very lengthy and rigorous set of standards, which are listed at the NCI's website. I will describe two of them. “Six Essential Characteristics” are required to be considered for funding. They include: a clear focus on cancer research by its members (as opposed to research that currently has little relationship to cancer), adequate institutional support in funds and space, ample authority for the cancer center director to develop the center, and other key qualities.

I have been privileged to lead, be a member of, or serve as an advisor to cancer centers for 48 years. Although there are many requirements, large and small, to make a successful cancer center, my experience has led me to believe that there are three qualities so important that I do not believe it likely that a center can succeed for long without them. I shall describe each of them and explain why they belong in this “must” category.

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Leadership

The director of a cancer center must have excellent leadership skills and substantial authority, even more so than chairs of academic departments or deans. The latter usually have well-defined, long-standing authority that is passed down to successors, such as the power of recommending an academic appointment, delineating salaries, and assigning space that belongs to that department. The director of a cancer center based in a university usually does not have the power of academic appointment or setting salaries; directors usually have control of some office and laboratory space, but the amount varies widely.

A chairman often technically controls much of the space needed by the cancer center.

The director often reports directly to the dean as chairmen do so he can be part of the dean's executive committee. Without this reporting line, he will have little power or even participation in strategic changes, faculty appointments, and space allocation.

This problem is largely absent in freestanding cancer centers such as Memorial Sloan Kettering, MD Anderson, St. Jude Children's Research Hospital, Fred Hutchinson Cancer Center, Dana-Farber Cancer Institute, and others because the director of the cancer center is usually the CEO of the institution.

A key factor for a successful director is having discretionary money through institutional investment, philanthropic sources, and large grants. With ample cash, the director can negotiate with a chairman to jointly recruit needed faculty. Both chip in cash and/or space and both can share credit for the success (or blame for the failure) of the recruit. If the recruit gets grants, the chairman adds that to his/her department's list of faculty successes.

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Environment

The cancer center, whether university-based or freestanding, must cultivate an appropriate environment. That includes strong support from the university hierarchy or a board of directors, collegial department chairmen, and an underlying foundation of trust and doing what is best for the institution and its patients and faculty.

Sometimes department chairs don't like having a cancer center, seeing it as a competitor for limited resources. If they are powerful with connections to the president or trustees, they can find ways to torpedo initiatives before they get going. A whisper here and a camouflaged email there can do a lot of damage to the authority of the director and the respect he/she needs to succeed. Leading a cancer center is a very challenging job and at certain points in the center's development, especially early in her tenure, the director is vulnerable to mischief.

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External Advisory Board (EAB)

Every cancer center is required to have an external advisory board made of a group of experienced scientists, clinical researchers, administrators, and various others with long experience and deep knowledge of the inner workings of a cancer center. The EAB is chosen by the director and the program leaders for their ability to deal with issues needing attention in the center and others with broad experience in a wide array of strategic decisions facing the center. Most EABs visit the cancer center annually.

The usual format is a series of presentations for the EAB to comment on. Some are small issues and others are very large like restructuring research programs and/or changing the leadership of programs and support activities. At times, the EAB may hear from the dean of the school and provide some feedback directly to him/her.

The EAB writes a report of their visit often including suggestions for changes and critiques of any underperforming programs. The EAB written report is sent to the NCI along with the center's annual progress report.

Most of the EABs that I have been a part of are intent on helping the director and the center as a whole. We are sometimes competitors with the center in question, but that bias is universally left at the door so the meeting can focus on one issue: how to help the center improve its programs and succeed with the next renewal of the grant.

Sometimes the discussion between EAB members provides a variety of approaches to problems in different settings. The hardest job for the EAB is helping a new rookie director get his/her bearings and recommending the direction the director should take. It is gratifying to see a center work incredibly hard for 18 to 24 months getting a grant renewal of more than a thousand pages out the door. And then, the EAB often is asked to visit again to help preparations for a site visit team organized by the NCI.

When that is over and successful, the director has about a year to relax a bit and then start preparing for the next cycle, no matter that this is a stressful process. Directors and his/her team deserve all the credit when the grant is renewed successfully.

Other features of cancer centers are important, but if one of the above three fails, the center will eventually suffer and may lose its CCSG support.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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