As Jerome Yates reflects on starting up the University of Vermont Cancer Center in the early 1970s, he quotes Joe Simone: “When you’ve seen one cancer center, you’ve seen one cancer center.”
“That’s basically true, because it’s heavily dependent on what the existing expertise is and what the population is like, what the geography is like,” Yates, 85, a retired oncologist who has practiced and administered research at Roswell Park Comprehensive Cancer Center, the University of Vermont, NCI, and the American Cancer Society, said to The Cancer Letter. “It’s a combination of the environment, the expertise that’s available, and the opportunities. And you never know when some of the opportunities are going to occur.”
Yates started at the University of Vermont in 1974 with the goal of building a cancer center. At the time, he was the only medical oncologist in the state.
In 1976, Yates and UVM basic scientist Richard Albertini convinced Irwin Krakoff to move to Vermont from Memorial Sloan Kettering and become cancer center director.
An announcement of Krakoff’s move from MSK appears in The Cancer Letter’s archives:
“We really had an extremely strong program in the late ‘70s. And in fact, it was probably as strong as some of the programs that were in the major cancer centers, fortuitously, because the science was there, and the opportunity to develop a training program in medical oncology and to expand the medical oncology expertise, locally, was really rich at that time,” Yates said.
How do you develop a cancer center?
“It was really the three of us working together that put this together,” Yates said.
“We had strong basic science and drug development—brought [Krakoff’s] expertise to Vermont. He was able to get a contract for studying phase I, phase II drugs. I maintained the affiliation with the Cancer and Acute Leukemia Group B,” he said. “There were people doing basic cancer research. Dick Albertini was an MD, PhD who was looking at carcinogenesis and testing to determine what chemicals or exposures might be carcinogenic.”
Yates and Albertini received a planning grant in 1974 to develop a cancer center in Vermont at a time when funds were flowing from NCI.
“The ability to get a planning grant to develop the cancer center was also critical to stimulate the pursuit of R01s and build programs,” he said. “It was an opportune time. And you look at the way it is now where they’re funding 10 to 15% of the approved grants, it’s not so good. It’s a lot tougher for the young people today.”
“The planning grant on the research side allowed the development of cancer research programs that were really the forerunners of the core grant that we got three years later,” Yates said.
Yates also received a rehabilitation grant from NCI for patients with advanced cancer—which helped develop a clinical infrastructure for the future cancer center.
“I wrote a grant to look at the rehabilitation of cancer patients with advanced cancer, because I felt that the rural environment deprived them of a lot of opportunities that one could find in a cancer center like Roswell Park,” he said. “We essentially laid out a comparison between counties, in which we did this in an intensive way with periodic home visits, versus counties where the patients received customary care being followed only in the clinic.”
The rehabilitation grant allowed Yates to spend a lot of time getting to know the rural populations of Vermont.
He would give talks at social centers for people all around the Green Mountains—churches, and grange halls that organized activities for farmers, a part of Americana.
“That was the social access to lay communities,” he said. “And so, oftentimes, there’d be family practitioners who would be the point people to introduce you to the leaders in these areas, in the small communities.”
In getting to know the communities, Yates learned that the wives of farmers kept impeccable records, which allowed his team to determine what carcinogens may or may not have been present in these rural environments.
“There were lots of anecdotal reports of acute leukemia occurring in populations, and primarily childhood populations, where the residents were close to high tension wires,” he said. “One of the doctors thought we ought to take a look, because the other concern was—were there more miscarriages among the women who were pregnant in these areas?”
These records tracked the health of dairy cows, including any bovine miscarriages.
“Because of the kinds of records they kept, we were able to speculate that the high tension wires were not important in terms of malformations that occurred in the dairy cows,” he said. “And probably, to some extent, that the threat of the electromagnetic fields from high tension wires was not as important as some people had thought.”
There were other theories too. Were fiddlehead ferns, eaten by Vermonters in the springtime, causing bladder cancer? Were microwaves to blame for other cancers?
“We looked at the association of bladder cancer and eating fiddlehead ferns. It turned out not to be real,” he said. “There were studies then that subsequently were done in radar men on ships, where they got exposed to massive doses of microwaves. And they didn’t find that there was an increased incidence of cancer.”
“These are niches that provide unique opportunities to look at exposures and what the relationship between exposures are and cancers.”
Lung cancer was the most prevalent cancer in these populations, and Yates estimated that the smoking rates among farmers hovered somewhere around 70%—a proportion that is significantly lower today.
Yates, through the cancer prevention program he developed at UVM, decided to focus on smoking cessation programs.
“They were beneficial, but they were also difficult at the time,” he said. “Smoking was widespread, and, needless to say, in restaurants and actually even in schools, there were areas where people could smoke.”
The breakdown of labor—men had driver’s licenses and handled farm equipment, while women balanced checkbooks and kept records—proved to cause difficulties when a member of the family became sick.
“When the women would get breast cancer, there were difficulties with the male counterparts handling the financial side of the operation,” Yates said. “When the males got their lung cancer, and had to get treated either with radiation or chemotherapy or surgery, many of the wives couldn’t drive a car.”
Yates hoped to acquire state funding to set up a rehabilitation program for the spouses of patients: the men would learn to manage checkbooks, and the women would take driving lessons.
But the state only agreed to help patients—not their spouses—so these efforts never came to fruition.
“We thought that with a relatively simple program, if it was available, would make a big difference because one of the problems that occurs in rural populations, is transportation,” he said.
Instead, Yates’s team sent nurses, social workers, and physical therapists on house calls.
“There was some continuity of care, and we actually made it a little easier in terms of dealing with the problems that occurred because the nurses would see the patients in the home,” he said. “Similarly, the social workers were making periodic visits in the same homes, and they could help them with other logistical problems that were really social problems at the time.”
The rural environment of Vermont was different than in larger metropolitan areas, where Yates started out.
“There was an inverse relationship between how far away they were from either Hanover or from Burlington, where there were radiotherapy facilities,” he said. “The people that lived long distances away were less likely to get what was then state-of-the-art therapy, because of the transportation problems. And those kinds of problems continue to exist today.”
His 7 a.m. meetings with groups of 20 to 25 people to discuss patient care also wouldn’t have happened in a larger cancer center.
“Some ideas work in the rural areas that don’t work in the cities,” Yates said. “If you ask people in Buffalo to meet once a week, at 7 in the morning, with all of the disciplines, they’d look at you and say, ‘Well, why is that necessary? That seems like a crazy idea.’”
Meetings included social workers and members of the clergy—“and they would develop expertise in areas that you might consider kind of different.”
Vermont Cancer Center received its core grant in 1978. It retained an NCI-designation for three decades, until 2008, when it became the first Comprehensive Cancer Center not to seek renewal of the NCI designation (The Cancer Letter, Nov. 14, 2008).
VCC’s new director, Randall Holcombe, intends to lead VCC to NCI designation again (The Cancer Letter, Oct. 1, 2021).
“What he’s doing is trying to put together programs that will be competitive in terms of a core grant. And that’s not easy,” Yates said. “We did it way back when, because there were pharmaceutical chemists existing in the chemistry department in the university.”
“And so, one’s got to look at the expertise that’s available there, and try to put it together into programs that will have sufficient R01 or program project, or SPORE support—there are no SPOREs in Vermont—so that they will be competitive in terms of a core grant,” he said.
The 1970s was a good time to start a cancer center in Vermont—“because of the resources and the environment and the support we got from the university.
“And we’re trying to help him put that back together again in Vermont,” Yates said. “And I’m confident Randy knows how to do it. He did it in Hawaii. And I think with the right kind of support, he can do it in Vermont.”
Yates’s advice for cancer centers seeking NCI designation in 2022:
“The approach, I think, is the same, no matter where you are, You have to look at your environment. You have to look at the personnel that are available. You have to look at where the opportunities are, particularly now with the funding structure, because you could be tilting at windmills if there’s not external funding available to do this.
“Now, because some of those funding sources have dried up for a variety of reasons, it’s a little tougher, but the approach is still the same. You’ve got to have a strategic plan for how you’re going to do it. And that’s what we did with the people that were available and the opportunities.
“And that’s what Randy is trying to do now in Vermont.”
Yates spoke with Alexandria Carolan, a reporter with The Cancer Letter and associate editor of the Cancer History Project.
Full transcript
Jerome Yates: Yes. Jim Holland came back from Russia in 1973, and we looked at a number of different places to go. He wanted me to go with him. He went to Mount Sinai in New York City. I told him I would go any place with him, but I wouldn’t go to New York City.
I looked for a few jobs. There was a fellow who went to Medical School at Vermont at Roswell, whose name was Jim Wallace. And Jim said, “There are no oncologists in Vermont. Why don’t you take a look at Vermont?” And so I did.
At the time I went there, there was a chairman of hematology who was relatively conservative when it came to cancer and leukemia and blood dysplasia management. And I saw it as an opportunity to build a program. And so I elected to go ahead and go to Vermont. At that time, I was promised a couple of nurses, a secretary, and some startup funding to start a cancer center there.
JY: Yes. Essentially, I went to Roswell to train because Jim Holland was training fellows in medical oncology. There was no training program in Vermont. There were no oncologists in the whole state of Vermont.
The only oncologists that lived in Vermont were at Hanover at Dartmouth, which was the other side of the state. And there were only a few, basically, solid tumor oncologists—even at Dartmouth at that point in time.
They did have a cancer center and they were part of the Cancer and Acute Leukemia Group B, which I also had been a part of when at Roswell. I transferred my activities from Roswell to Vermont. But when I went to Vermont in 1974, as I said, there were no medical oncologists in the whole state of Vermont.
JY: Yes. There were people doing basic cancer research. Dick Albertini was an MD, PhD who was looking at carcinogenesis and testing to determine what chemicals or exposures might be carcinogenic.
And he and I collaborated as he wrote a planning grant for developing a cancer center. At the same time, I wrote a grant to look at the rehabilitation of cancer patients with advanced cancer, because I felt that the rural environment deprived them of a lot of opportunities that one could find in a cancer center like Roswell Park.
And so I put together a multidisciplinary grant that included nurse practitioners, social workers, physical therapists, occupational therapists, clergy, dieticians, physicians and we structured in such a way that the nurses and the social workers were able to follow the patients in their homes in this rural environment. We essentially laid out a comparison between counties, in which we did this in an intensive way with periodic home visits, versus counties where the patients received customary care being followed only in the clinic.
The rehab grant on the clinical side allowed the building of a strong clinical research structure. The planning grant on the research side allowed the development of cancer research programs that were really the forerunners of the core grant that we got three years later.
JY: Well, we were lucky, I think, at that time.
And one of the fortunate things was that funding was a little easier to acquire when I wrote the rehabilitation grant, and it was a large grant and the direct costs were like $600,000 a year. And in 1975 or 76, this was substantial funding. The National Cancer Institute was looking at ways that they could expand cancer control money and do research in the cancer control field. It was an extraordinary time. At that time, they were funding 45% of the approved grants.
And similarly, on the other side, on the science side, they were interested in developing cancer centers. And so the ability to get a planning grant to develop the cancer center was also critical to stimulate the pursuit of R01s and build programs. It was an opportune time. And you look at the way it is now where they’re funding 10 to 15% of the approved grants, it’s not so good. It’s a lot tougher for the young people today.
JY: Well, let me just say that one of the critical factors, Dick Albertini was important on the science side.
I laid some of the foundation for the clinical side. And then I was able to recruit Irv Krakoff to come from Memorial Sloan Kettering, where he was the chairman of medicine. And he came in 1976.
This was, I think, maybe the second year of the planning grant for the cancer center. And Irv had obviously long experience, 20 or 30 years of experience, dating back to working with some of the real pioneers in medical oncology.
And he brought both the clinical side and the basic science side together writing the core grant, which we were awarded in 1978. It was really the three of us working together that put this together.
Then subsequently, at the same time, Irv was able to get a contract for looking at phase I drugs. One of the reasons he was attracted to Vermont is because we were lucky. We had basic scientists who were working in the chemistry and pharmacology departments: one was working on vinca alkaloids, another was working on anthracyclines, and a third was working on methotrexate related drugs.
We had strong basic science and drug development—brought Irv’s expertise to Vermont. He was able to get a contract for studying phase I, phase II drugs. I maintained the affiliation with the Cancer and Acute Leukemia Group B.
We really had an extremely strong program in the late ‘70s. And in fact, it was probably as strong as some of the programs that were in the major cancer centers, fortuitously, because the science was there, and the opportunity to develop a training program in medical oncology and to expand the medical oncology expertise, locally, was really rich at that time
It was a lot of fun. I think both Irv and I had great fun working together. He used to chide me about the cooperative groups because most of his work was done with the developmental studies and drug development. And I’d say, “Well, you got to depend on the cooperative groups to substantiate what information you’re developing in basic science.”
And he’d say to me, “Yeah. The cooperative groups reach statistically significant answers to insignificant questions.” And so we had a wonderful relationship that has existed continually through the years.
I also developed a prevention program, a preventative medicine program in the College of Medicine that was funded by the NCI. It allowed me to go to Harvard in 1980 to ‘81 to get a master’s in public health degree. I straddled between Boston and Vermont, which I wouldn’t recommend. I actually had thought about going to Baltimore, North Carolina, but my wife wanted to get a master’s degree in maternal child nursing. And she did that at Boston College while I got my degree at Harvard.
But the Vermont years were a lot of fun because it was an opportunity to put things together and to see them grow and actually to see a real impact on the quality of cancer care in Vermont, and also the quality of the research programs.
JY: Well, I think that most medical students were exposed to what I call water pump epidemiology. Most of it was based in infectious disease. And the ability to look at papers that were critical in terms of understanding which papers were good papers, and which papers weren’t so good in terms of their statistical manipulations, and the conclusions that they reached based on the data they had available.
It was a transformative time. Cancer medicine really improved dramatically in the ’60s when there was a fusion of biostatisticians to look at study design issues and interpretation of information with the oncology community and hematology community, so that they paid attention to protocol design and how they could answer questions about whether or not there were benefits in terms of the treatment—and also understand how they could interpret the side effects, and basically look at how they should stratify patients in terms of their risk factors.
One of the things that I brought to Vermont from my work at Roswell was that the older patients with acute myelocytic leukemia didn’t do as well as the young patients did with the treatment.
Where Irv came from, MSK, Dave Karnofsky had developed the Karnofsky Performance Status Score. That was a forerunner to looking at the stratification of patients in large group trials. The ECOG performance index came after that. There were multiple others. But this was a way of looking at the patients and understanding who might be more vulnerable, who might not be more vulnerable, and also to look at the outcome data.
So it was really, from my perspective, the fusion of biostatistics, providing some rigor to clinicians. Physicians are used to treating each patient individually and sometimes have a little difficulty in conforming to the protocols—but the rigor required for large studies to generate real answers about whether or not the treatments were successful or, in some cases, whether or not they were hazardous in terms of overall survival for the patient population. The fusion of those two things was critical.
And so the prevention program in Vermont for the first year that I developed it—I essentially had the medical students looking at papers, which I considered to be rigorous, and providing good foundations for the prevention studies they were reporting, and good analysis of the results—versus papers that weren’t so good.
There were a lot of anecdotal types of papers suggesting improvements in care. And the other thing that was going on at the time, there was an attempt to look at historical controls, particularly in cancer medicine.
MD Anderson was looking at historical controls and comparing them to the current treatment methods that they were using. And the reality is that, particularly in cancer, there are improvements in supportive care.
In my early years, I worked a lot with new antibiotics because I was doing a fair amount of infectious disease. We were providing platelet transfusions and we were testing white blood cell transfusions to see if we could control the sepsis that many of these patients get because of the suppression effects of the drugs on the bone marrow. And so the ancillary supportive measures for patients was critically important. And as those improve, the outcomes improved for patients.
And so it looked as if some new approaches with chemotherapy were actually better than they were because the comparison with historical controls was problematic.
And so it was an important era in terms of knowledge and understanding about clinical trials methodology. And it was also important in terms of infusing some of that critical thinking into the medical students. And that was what I tried to do with the preventative medicine program that we developed that had not existed in Vermont before.
JY: Well, the prevention program was really looking at the data that was available, critically. There were migration studies that showed, for example, that gastrointestinal cancer among Japanese in Japan, compared to Japanese in Hawaii, compared to American-Japanese, was much different in terms of the incidents.
And the reason it was different is largely because of diet. There were studies going on, particularly with colorectal cancer, to look at diet. There were also parallel studies where lots of information was being generated about smoking patterns. And so these are lifestyle issues that could be looked at and could be studied.
The cancer prevention program in Vermont, because of the relative sparsity of the population, also because the farmers in Vermont were, relatively speaking, heavy smokers compared to some of the other populations around the country—so we focused on smoking cessation programs.
They were beneficial, but they were also difficult at the time. At the time, Smoking was widespread, and, needless to say, in restaurants and actually even in schools, there were areas where people could smoke. Smoking probably received the major attention in terms of prevention programs.
There was an observation made in one of the food substances that people in Vermont eat in the springtime are fiddlehead ferns. There was a suggestion that eating fiddlehead ferns might contribute to the occurrence of bladder cancer.
We looked at the association of bladder cancer and eating fiddlehead ferns. It turned out not to be real. The other thing in Vermont that was interesting was, at the time, there were lots of anecdotal reports of acute leukemia occurring in populations, and primarily childhood populations, where the residents were close to high tension wires.
High tension electrical wires have electromagnetic fields. And there was some concern about, could the leukemia be caused by this kind of exposure.
Well, one of the benefits of Vermont is that the farmers, and usually the ladies, the wives of the farmers, kept very good records about dairy cows and the births and the abortuses of dairy cows and what the problems were.
And so, because of the kinds of records they kept, we were able to speculate that the high tension wires were not important in terms of malformations that occurred in the dairy cows, and probably, to some extent, that the threat of the electromagnetic fields from high tension wires was not as important as some people had thought.
The rural environment provided some unique opportunities, but also some real challenges. And one of the challenges was, as I alluded to, many of the male farmers were smokers. Probably at that time, I would guess 70% were smokers. And if you look at it today, it’s much lower. It’s probably 15% the most.
And so lung cancer and heart disease were fairly common, and the disabilities that they suffered required medical care. And they were the primary drivers in the households there. The women on the other hand, as I alluded to, kept the financial records and paid the bills and did that stuff for the family.
When the women would get breast cancer, there were difficulties with the male counterparts handling the financial side of the operation. And when the males got their lung cancer, and had to get treated either with radiation or chemotherapy or surgery, many of the wives couldn’t drive a car.
We attempted to get the state rehabilitation department to actually set up rehabilitation programs for the spouses to balance the activities out in the household. I must report that we were unsuccessful in that operation. The bureaucracy was tougher than we could deal with.
JY: Well, we wanted to have the rehab department pay for women to have drivers training and to have men have some rudimentary training in managing checkbooks and balancing the financial records. They would only help the patients, not spouses.
We thought that with a relatively simple program, if it was available, would make a big difference because one of the problems that occurs in rural populations, is transportation. It is a major, major issue, and particularly if people have to go periodically to get their medical care. So one of the basic tenants of the rehabilitation grant that I had was the nurses went out into the homes of half of the population and saw the patients there as well as in the clinic.
There was some continuity of care, and we actually made it a little easier in terms of dealing with the problems that occurred because the nurses would see the patients in the home. Similarly, the social workers were making periodic visits in the same homes, and they could help them with other logistical problems that were really social problems at the time.
The rural environment is a little different than in the large cities, and the needs of the population are a little different. And we tried to exploit that as much as we could. We worked with the people at Dartmouth to look at radiotherapy and lung cancer. And there was an inverse relationship between how far away they were from either Hanover or from Burlington, where there were radiotherapy facilities.
The people that lived long distances away were less likely to get what was then state-of-the-art therapy, because of the transportation problems. And those kinds of problems continue to exist today. The rural environment is much different than the metropolitan environment that one finds in cities like New York City or Buffalo, or Boston, or wherever.
JY: Well, my dad was a farmer. I grew up in the Midwest. So there wasn’t an adjustment, it was not an adjustment for me. Probably going into medicine and doing what I did was more of an adjustment.
But it’s good to have some insights into what the social factors are that are important in the lives of those patients. I think those of us who have worked in large cancer centers sometimes think it’s so easy that when you tell people that they’ve got to come back to see you in the clinic once a week, or whatever the time factor is. And it’s not always easy to juggle those things for the patients. And it’s particularly not easy if they’re relatively sick. And if they’re sick and they’re hospitalized, then the members of the family have to bear the burden of traveling large distances to go visit them while in the hospital.
It’s a different world. And the social factors become much more important. The one thing at the end of the rehab study we found that we did not improve patient survival, I had theorized that we would make a difference in overall survival for the patients with advanced cancer. Well, that turned out not to be true.
But we did make a difference in terms of their quality of life. And we measured quality of life factors, and the most prominent one was pain control, that we could control the pain much better, where the patients were seen periodically in their homes by the nurses and the social workers.
The other thing we did, because we would meet once a week and go over new patients and other problem issues with other patients—and I’m a morning person having had parents that always got up early in the morning. I’d have the meetings at 7 in the morning, which required a certain amount of adaptation for some of the other people.
But we learned from one another, so that we had a priest and a protestant clergyman. And at that time, there were not many Jewish people in Vermont. And they would develop expertise in areas that you might consider kind of different. And one of them was physical therapy.
One of the most important findings in the study was, if the physical therapist went out into these homes and there were mobility problems for the patients, or logistical management issues, they oftentimes made suggestions that allowed patients who had some restricted mobility, or it was difficult for them to do things that we take for granted every day, that they could improve things.
Well, when the clergy met with… and I used to chuckle about this, the Catholic priest would make suggestions about—we should get the physical therapist to come and look, or they should get the social worker to help them deal with their insurance problems. So there was cross education for all of us.
And this group of 20 or 25 people met, as I said, once a week. In the morning we’d go over the new problems, and we all learned from each other. It was a different kind of environment. If you ask people in Buffalo to meet once a week, at 7 in the morning, with all of the disciplines, they’d look at you and say, “Well, why is that necessary? That seems like a crazy idea.” So, some ideas work in the rural areas that don’t work in the cities,.
JY: Well, because there were no oncologists, there wasn’t competition. And what I did was establish relationships with the referring physicians, and most of whom were surgeons at the time in the outlying hospital.
So once a month, I would go do tumor boards in Saint Albans, which is about 40 miles north of Burlington. I’d go across the lake to Plattsburgh, once a month to the hospital in Plattsburgh, New York. I’d go down to Rutland once a month and then central Vermont.
One of the things that made it a little easier at the time was I had an airplane. I could fly to these places and not spend so much time traveling, particularly going to Plattsburgh, you’d have to drive, take the ferry across, and whatever. But it was like a 10 minute flight to go across the lake from Burlington to Plattsburgh, plus it was fun.
JY: Well, I learned to fly when I was in Buffalo. And actually when I was in Buffalo, I went down to the Southern Tier, in the Arnot Ogden Hospital in Elmira, NY.
I would go down there once a month. And that drive is a three and a half hour, four hour drive, whereas it’s about a 40 minute flight from Buffalo.
JY: So I’d always wanted to fly. And when I was a fellow, in 1968, one of my friends said, “Why don’t we go learn how to fly?” And we did. And then I did that until I got married and had kids, and your priorities shift at that point in time. That’s when I got rid of the airplane.
JY: Well, in some ways. But it was probably as much fun as it was making the contact.
The critical factor is that now, there are lots of oncologists. And so life is different. But at that point in time, we were viewed with a certain level of suspicion.
There were people who felt that we were treating patients aggressively with treatments that were making some of them worse. And this isn’t anything new, we were called poison pushers. We were called other disparaging descriptive comments because of what we were doing.
The reality was chemotherapy was emerging as very important in terms of the adjuvant treatment of breast cancer. It was clearly making a difference in terms of treating Hodgkin’s disease and lymphomas.
When I went to Vermont, the hematologist was very conservative and he wasn’t treating any of these people aggressively in the way I thought was appropriate treatment, the way I’d been trained. And it took a few patients to show that you could make a difference in terms of controlling these diseases.
There were surgeons who were collaborative and cooperative, who also made a difference. And as you could show that you really could help some of these people either with controlling their disease or providing supportive care that was important in terms of making their quality of life better, there was an increasing respect. But there wasn’t much respect in the departments of medicine for medical oncologists in the ’60s. And certainly, in that period of time, there were no medical oncologists who were chairs of departments of medicine.
But that too has changed over the years. So now there is more respect and more collaboration and more understanding. Things have evolved because of the advances of the clinical research programs and the basic science programs.
JY: Well, the bulk of the cancers that we were seeing at that period of time, a lot of lung cancer because of the relatively heavy smoking.
And carrying over, I thought the nurses and the team would pick these up these complications earlier and then we could actually prolong survival. Because at the time, we dealt in survival curves because the treatment interventions weren’t so good.
But you’re right. I did do that. And as a result of that study, I then had a grant from the Robert Wood Johnson Foundation to help develop—there were 23 hospices around the country that were funded by, then HCFA, which is now CMS, to develop an RFP contract to look at the quality of care and quality of care outcomes in hospice in the 23 demonstration hospices.
And so I participated with the evaluation group and a special study group put together by the Institute of Medicine to look at the evaluation of the care issues for the 23 hospices, which subsequently, the information was used to develop the reimbursement.
At the time, HCFA was very concerned about reimbursing hospices for their care, because when they reimbursed home care for home nursing, there was an explosion of home nurses and what they perceived to be some inappropriate billing activities.
And because they were a fiscal agent, they were concerned that there may be runaway expenses as a result of hospice programs springing up around the country.
But it was an area of research that I was interested in. And it gave me an opportunity, as a hospice physician in Vermont for a couple of years. I worked with the visiting nurses association to sit in on their meetings to make sure that we were doing things the best possible way.
I’d love to step back a little bit just when we were talking about the farmers earlier and their wives and how they kept important records that would help in cancer prevention research.
I’m curious, how did you go about making the connection? You talked about—I think it was power lines that people thought were maybe causing people to get leukemia. And then the wives of the farmers kept the records on the cows and the abortuses of cows. How did you go about receiving those records from farmers, and how did you go about making that connection?
JY: Well, at that point in time, granges were very important.
There were two things that are important in rural communities like this. Granges, which were organized activities for farmers, but also the churches in the rural communities were very important in terms of making connections.
One of the things I did besides do tumor boards was to go and give cancer talks to the various groups in the churches and the grange halls. And it’s funny, I hadn’t thought about this in a while, but now I remember one of the grange halls in Richmond, Vermont—was a meeting hall right next to the grange storage facility. Public education was the goal.
Anyway, in Vermont, the churches and the granges at that point in time, and most of the granges don’t exist anymore—were part of Americana. And that was the social access to lay communities. And so, oftentimes, there’d be family practitioners who would be the point people to introduce you to the leaders in these areas, in the small communities.
I’d go give talks about what was important currently. There was a paper about the association of high tension electric wires and acute leukemia in one of the journals. And so then it was really a suggestion of one of the doctors thought we ought to take a look, because the other concern was—were there more miscarriages among the women who were pregnant in these areas?
At the same time, people were concerned about microwaves and microwave ovens and whether or not they caused adverse effects, or caused some bad diseases because of the strength of the microwaves.
There were studies then that subsequently were done in radar men on ships, where they got exposed to massive doses of microwaves. And they didn’t find that there was an increased incidence of cancer.
These are niches that provide unique opportunities to look at exposures and what the relationship between exposures are and cancers. And it’s much the same as fiddlehead ferns. If you ask people in the Midwest about, have they ever eaten fiddlehead ferns, most of them wouldn’t know what you’re talking about.
JY: Well, Dick Albertini had a laboratory assay looking at carcinogenesis of chemicals.
The existence of three pharmaceutical chemists in the university who actually were looking at the developing new chemotherapeutic agents. The fact that Irv Krakoff was willing to move from Memorial to Vermont—he had a summer place in Vermont but brought extraordinary expertise to the efforts.
I was lucky enough to get the rehabilitation grant that provided the structure for the clinics. And also that supported me to run around the countryside and to do some of the things that I was doing.
I think every core grant—Joe Simone used to say, “If you’ve seen one cancer center, you’ve seen one cancer center.” And that’s basically true, because it’s heavily dependent on what the existing expertise is and what the population is like, what the geography is like.
The other thing we used to say is that if you look at Vermont, the patients flow off of the green mountains just like the rain, so that if you look at the Central Vermont Hospital, half the patients go to Burlington, half of them go to Hanover, to Dartmouth, and the people all along the Connecticut River, basically from Brattleboro to St. Johnsbury, they go to Hanover, because it’s geographically closer and it’s more convenient.
You have to look at all of those social factors, the academic factors, what the university is willing to invest in. I still have some ties in Vermont because one of the beneficial contacts I made was in Glens Falls, New York.
One of the old industrials left a large chunk of money for cancer research at the University of Vermont. And we’re still supporting it. Over the years, I would guess we’ve probably contributed somewhere around 20 million dollars in supporting cancer research in Vermont. It’s a combination of the environment, the expertise that’s available, and the opportunities. And you never know when some of the opportunities are going to occur.
The opportunity for me was to show that treating lymphoma patients could make a difference, also that you could actually treat people with Hodgkin’s disease and they’d respond and they’d have good quality of life and they’d do OK. Or you could take care of patients with advanced cancer and you could make their life a little easier and their families life a little easier if you could provide them with better supported care, even if they weren’t curable in terms of their disease. And so it was a lot of fun.
In 1982 I went to the National Cancer Institute and I was the associate director for Cancer Centers and Community Oncology, a big program at the National Cancer Institute where I had some responsibility for developing programs around the country.
Irv, the year after that, went to become the chairman of medicine at MD Anderson in Houston, Texas. And he did that for well over a decade. And so we both used Vermont in some ways as a springboard for subsequent careers, but when we both look back and think about those years, we had a lot of fun together.
JY: Well, it was. And also my formative years in Roswell, Jim Holland was my mentor and we maintained a good relationship over the years. And actually when I left the NCI, I went back to be the senior VP for clinical affairs at Roswell Park. So I came back where I came from in the beginning. But I still have ties in Vermont.
JY: Well, we’re helping them as much as we can. And the new center director, Randall Holcombe, came from Hawaii.
And actually, I was asked to look at the cancer center directorship job in Hawaii in the late ’70s before I went to the NCI. And I know what it’s like. And there are similarities, even though the geography isn’t the same. There are similarities. And what he’s doing is trying to put together programs that will be competitive in terms of a core grant. And that’s not easy. I mean, we did it way back when, because there were pharmaceutical chemists existing in the chemistry department in the university.
And so, one’s got to look at the expertise that’s available there, and try to put it together into programs that will have sufficient R01 or program project, or SPORE support—there are no SPOREs in Vermont—so that they will be competitive in terms of a core grant.
And so it was a good time for us because of the resources and the environment and the support we got from the university. And we’re trying to help him put that back together again in Vermont. And I’m confident Randy knows how to do it. He did it in Hawaii. And I think with the right kind of support, he can do it in Vermont.
JY: The approach, I think, is the same, no matter where you are.
You have to look at your environment. You have to look at the personnel that are available. You have to look at where the opportunities are, particularly now with the funding structure, because you could be tilting at windmills if there’s not external funding available to do this.
I think that you look at philanthropic funding that might be available. And in those days, the American cancer society was a major, major factor in developing fellowship programs. And then the NCI picked up the fellowship programs to train medical oncologists. In some ways, it was easier than it is now.
Now, because some of those funding sources have dried up for a variety of reasons, it’s a little tougher, but the approach is still the same. You’ve got to have a strategic plan for how you’re going to do it. And that’s what we did with the people that were available and the opportunities. And that’s what Randy is trying to do now in Vermont.
I think the rural environment is different than what you see in the major cancer centers, but it also tends to limit the number of hardcore basic scientists and the kinds of people that are pursuing R01s and P01s in the universities.
But the science in places like Dartmouth, which is in Hanover, New Hampshire, which isn’t a very big town, and in Burlington, Vermont, there’s still good science in depth there.
There just isn’t the patient volume and the density of patients that you see in large cities. So conducting large clinical trials depends on having memberships and networks that are going to allow you access to generate protocols and to be chairman of protocols and where the patient population may come from across the country. It’s a little different of an environment, but it just takes a little different approach.
