The three comprehensive cancer centers that set the model for a nation

Directors of the first three NCI-designated Comprehensive Cancer Centers are learning from the past, starting with the National Cancer Act, and mapping an equitable future for oncology.

On July 29, 2021, the Cancer History Project convened panelists Candace S. Johnson, president and CEO of Roswell Park Comprehensive Cancer Center, Craig B. Thompson, president and CEO of Memorial Sloan Kettering Cancer Center, and Peter WT Pisters, president of MD Anderson Cancer Center, for a two hour Zoom session moderated by co-editor Otis W. Brawley. 

A summary of the event is published in The Cancer Letter, and a full transcript and video are available below.

Otis Brawley: Hello. I’m Otis Brawley of Johns Hopkins University and I’m one of the co-editors of The Cancer History Project along with Paul Goldberg, and we’re staffed by Katie Goldberg. 

I want to welcome you to this evening’s discussion, where we’re going to talk about cancer centers and the history of cancer in the United States, especially since the National Cancer Act. 

It was in December of 1971 that Richard Nixon signed the National Cancer Act. There was a lot of buildup politically throughout the 1950s and 60s in order to sign the National Cancer Act. And now 50 years later after we look at what many refer to as Nixon’s War on Cancer, it’s time for an after action report, where we sit back and assess where we’ve come from, what we’ve done, and that’s how we figure out where we’re going in the future. I want to welcome all the viewers.

We’re an international audience. There are people from the United States, people from Canada, people from as far away as Australia who are viewing us this evening. 

We have some wonderful guests. These are three of the leaders in oncology today, three amazing physicians, and—I know them all personally—amazing human beings who lead three of the great cancer centers of our time. They’re going to talk to us today a little bit about cancer centers, the National Cancer Act, and tell us a little about, maybe give us a glimpse as to where cancer research and cancer care is going into our future. 

And so you’ve seen the introductions of Dr. Candace Johnson of Roswell Park, Dr. Craig Thompson of Memorial Sloan Kettering, and Dr. Peter Pisters of the MD Anderson Cancer Center. Thank you for joining us today.

I must say, being with the three of you, I do feel like Forrest Gump. You are all incredibly distinguished in your own right, and you run amazing organizations that have contributed so much and are, and will contribute so much in the fight against cancer.

Let’s start out a little bit talking about the history of cancer centers. What is a cancer center and how did they get founded is where I think we should start it out. And let me start with you, ladies first.

Dr. Johnson, Roswell Park. I know Roswell Park himself was a surgeon, but I don’t even know if he founded the institution. I’ve heard it referred to as New York State Institute for the Study of Malignant Disease—catchy name, by the way—but tell us a little about Roswell Park and where it came from.

Candace Johnson: Roswell Park, you’ve got to remember, this was in the late 1800s. So this was 1898, somewhere around in there. And Buffalo, New York was the second largest city in the country. So, that’s obviously not true now, but we were the Erie Canal. I mean, this was a really booming place. If you look at our downtown, lots of incredible architects built wonderful buildings here and, with the Renaissance, we’re trying to bring that back. So this was a site of much commerce and activity. 

And so Roswell Park was a surgeon. He did found the New York State Institute for the Study of Malignant Disease. He was really a Renaissance man and, actually, Roswell Park IV just passed away during COVID. Not of COVID, he was a longtime multiple myeloma survivor and succumbed to the disease during COVID. But he was Roswell Park IV, he was a professor at Buff State. So we have a long history of Roswell Park, the family. 

And he thought out of the box. He really thought the way we’re going to understand this disease was to study it, sort of the beginnings of translational research, if you were. And in 1898, you were more likely to die of an infectious disease than cancer, perhaps, but he really saw a real need for this. 

And he also thought, and this was very revolutionary for the time, that the government should support this research. And it really goes to the tenet of how prominent a role Roswell Park played in that because he was very well connected to the president, to President Taft at the time, and really advocated for government support for, in cancer.

Brawley: Now over the years, you’ve had some amazing people there. I remember from a… You’re a basic scientist, so I’m going to dabble just a little bit. I remember a little about basic science about glucose being converted to glycogen. As I recall the Coris, a married couple at Roswell Park, won the Nobel Prize for that, right?

Johnson: Yeah, they did. And Roswell was supported by New York State, hence, significantly so during those early years. And really, there were a lot of very famous people that did their training here. 

We still have a summer program and little Roswell Park in Buffalo, New York has trained—people have spent summers at Roswell Park in this training program—and then went on to be leaders in the field. And so it’s really, we’ve played a big part in that. 

PSA was discovered here. Ming Chu and Dr. [Ming C.] Wang developed it. The same sort of test, if you will, that Hybritech uses today. In fact, the tech transfer people will say it was one that got away because we didn’t need anything else. I mean, can you imagine, we wouldn’t have to worry about the NCI because of the times. 

It was an invention that perhaps got away, but we have played a very prominent role in smoking cessation.

I don’t think people realize there was a gentleman in 1938, Dr. Levin—Morton Levin—who really made it his life’s work to [study] the evils of cancer and tobacco and their correlation with cancer. And we were very prominent in getting tobacco out of bars and restaurants in New York state. 

And then the Human Genome Project, where the back arrays that were sort of the foundation for the Human Genome Project were from a Buffalonian. And so a strong history in genetics. 

So, we’ve been a player. Two of the founding members that started AACR came from Roswell Park. They were Roswell Park physicians and scientists. And the first meeting of AACR was held here in Buffalo, New York. 

And so, we have our connection to the history of cancer and cancer research is strong.

Brawley: Now this idea of research and clinical care coming together, that too was done at Roswell Park, right? The hospital and the clinics.

Johnson: Most definitely. And I think we were probably one of the first centers to really not just treat cancer, but to really try to understand it and do research around it so that we could figure it out and treat it better.

Brawley: Dr. Craig Thompson, you’re at Memorial Sloan Kettering, the oldest private cancer center in the world, I am told. Tell us a little about the start of Memorial Sloan Kettering, because it started too at about the same time as Roswell Park, as I believe.

Craig Thompson: Oh, that’s right, Otis. 

So Memorial Sloan Kettering was formed actually in a slightly different way than Candace talked about. It was a group of physicians in 1880 that came together with some of the philanthropists in New York with the understanding that, even though this was, as Candace just said, the dawn of the microbial revolution, where we understood viruses and bacteria caused disease, that cancer seemed to them, as a group of seven physicians, to be somewhat different and that it needed its own research. 

And they got the philanthropic community because a number of well off families had been touched by cancer themselves. And it had this scare to it that it could occur, it seemed, in any organ. And there was dysfunction in that organ and it wasn’t attached to the microbial revolution. 

So we were able to raise, I think at the time, $3 million and proposed to build a hospital dedicated to cancer.

Now, I should say that because there’s international visitors, we weren’t the first private hospital in the world. We modeled ourselves off of The Royal Marsden, which was the very first, it was started in 1865, if I remember the year correctly. And they came together as a cancer research hospital over exactly the same reason, and New Yorkers believed we should have exactly the same thing in New York. 

So our mission was to understand this disease, to put it on the map. And we would do that through what is our tripartite mission, which is research, clinical care, and education—and then we met education in the broadest sense, trained those people that would do the research and the clinical care as Candace just said. And prove that by understanding the disease, we could provide better clinical care that led to our clinical trial efforts. 

And then the education, we are proud every year of the 3000 trainees that come through Memorial Sloan Kettering, and are exposed to the best of cancer research care and go out into the community and practice it throughout the world. We’re very proud of our alumni. 

The hospital was originally on Central Park West. The original hospital still exists on 104th, 105th street. It was actually built with round rotundas because they weren’t really sure that it wasn’t a virus or a bacteria, so they built a hospital with round rooms so there were no corners for microbes to lurk in. That was our proud first hospital. 

Our original hospital was led by surgeons and pathologists, just as Candace said. The leader of that group was William Coley. He was a sarcoma surgeon. He actually was the founder of Coley’s toxins and the idea that immunotherapy would make a difference. And in 1890, he launched our first dedicated research program into immunotherapy, starting with Coley’s toxins. 

We continued that continuously through its work on Lloyd Old and BCG, to our most recent work where Jim Allison realized checkpoint blockade, brought it into the clinic with other physicians here. And to its most recent iteration CAR T-cells led by Michel Sadelain and Isabelle Rivière.

So he was visionary at the very start, but he was at heart a surgeon. It was his care of a young woman who was 19 years old, who had osteosarcoma we believe, that led the Rockefeller family to be devoted to the institution. She was the closest friend of John Rockefeller Jr. and they were devastated with the loss of this close friend of their son. And they became the base of our philanthropy ever since, and brought people to the community. Ultimately Laurance Rockefeller became our chairman for many, many decades. 

Over the years, we started with surgery and pathology. Our first three chairmen are well known to everybody. I talked about Coley. The second was James Ewing, Ewing sarcoma. He was a pathologist. He put the pathology of cancer on the map. He wrote the first definitive pathology texts of the diversity of cancer.

And then the third was actually a practicing surgeon Peter [Pisters] will know well, and that was Allen Whipple, who’s best known for the Whipple procedure and pancreatic cancer as we went forward. 

We weren’t only surgery, though. In 1911, Madame Curie won her second Nobel Prize, which was really for the application of the understanding of radiation and its use in various modalities of therapy—and one that she championed was its use in medicine. And we hired one of her first trainees in the translation of radiation science to start a unit here at Memorial Sloan Kettering. 

I’m not sure where that would have gone, except that we were benefited by someone who took the opportunity to bring his daughter. He was a mining engineer from Denver. His name was James Wallace or James Douglas, excuse me. And his daughter had breast cancer. She had surgery out in the west. Didn’t go well. He brought her here to the surgeons at Memorial Sloan Kettering. Unfortunately, also didn’t go well. And then he took her to Madame Curie in Europe to see if radiation would help. 

Unfortunately for that young woman, it also didn’t go well and she died of breast cancer, but he became devoted because his mining included radium mining in the Denver area. And he committed to Memorial that all the radium he mined would come to Memorial. And between 1917 and 1926 Memorial had more radium than all the rest of the world combined sent to us. 

It was ultimately Madame Curie’s visit, first to Candace’s center to our center to Fox Chase, where she brought the one remaining ounce. We had nine ounces, but she brought one more ounce that was bought by the US government who also wanted to play in this. 

At that point, we became known as a radium hospital and we dedicated a quarter of the institution to exploring whether radiation could improve cancer therapy.

First, it was whole body radiation. Patients were put in the room with radium, but fortunately one of our first faculty that was recruited in 1917, Edith Quimby, who is a legend in the early stages of radiation therapy, brought out the first radiation dosing tables and standardized what the doses were that each tissue could take. And from that, she also, because she understood you could encapsulate radiation, made the first brachytherapy program. 

So we’re very proud of that and what Edith did. It’s had a long tradition in radiation therapy since then. 

We were the first center to use computers to plan the ability to deliver radiation. And from that came IMRT in the later years and, more recently, proton therapy. And we’ve had a great tradition ever since Edith put it on the roll to the rational and scientific use of radiation. 

Medical oncology, like for many of us, came to us after World War II, with people that actually came back to New York having been in—unfortunately—in the chemical warfare research department and came back and said, “We want to do this research for something good.”

Using the example of nitrogen mustard gas, started experimental chemotherapeutic program as a result. And that has continued on to this day. 

And as the formation of our medical oncology, we are able at that time to recruit [M.] Lois Murphy to start our pediatric program.

And so we had all of those programs in full place when the National Cancer Act came and it allowed us to have all three of the major modalities to do our clinical research and to inform our basic science research at the time. 

We’ve been incredibly proud of also our ability, our scope, to be able to bring additional therapies to bear on cancer from Jimmie Holland’s pioneering work to start psycho-oncology and to build the understanding of the psychologic support that cancer patients need, the end of life work that Kathy Foley and others did around the use of opioids to deal with cancer pain, and the end products of that, and then more recently the basic research that got us to underpinning. 

I’ll just speak to one because it’s what everybody knows: One of our first chairmen of the department was in fact Charlotte Friend, of Friend leukemia virus, and she is actually the first person to ever show that differentiation therapy could actually reduce cancer. 

I think I’m really nervous about saying what’s currently going on. We’ve been proud to be with my two compatriots here, part of precision medicine, part of the immuno-oncology revolution, part of robotic surgery, part of proton therapy, and if I mention one faculty I’ll get in trouble because I won’t mention them all.

We’re very proud though, that they’ve received recognition as was just said by Candace. Seventeen of our faculty are members of the National Academy of Science, 25 of them are members of the National Academy of Medicine. Because in the end we balance the hospital, which is the here and now, to help and give hope to patients that actually face the disease, and our research is the future. 

It gives us the knowledge to engage in something you care about Otis, which is prevention. And to improve diagnosis and treatment, which is why freestanding cancer centers have existed since we started in 1884.

Brawley: As I hear about the early radiation therapy studies, you’re starting to rattle my definition of translational research because it really was translational.

Thompson: Exactly.

Brawley: We didn’t call it that in the 1920s. Of course, you and I didn’t call it anything in the 1920s. 

But anyway, Dr. Pisters, your institution was founded by a cotton man I understand. Tell us a little about MD Anderson, and the early history of MD Anderson.

Peter Pisters: Well, our history goes back to World War II when, presumably, the Texas legislature had been watching, potentially for decades, the innovation going on in New York State—in Buffalo and in New York. And the legislature at that time voted to create a state cancer hospital that would be devoted to research to cancer treatment, and positioned that cancer hospital under the jurisdiction of the University of Texas and its board of regents. 

And the hospital, as you alluded to Otis, received tremendous support from Monroe Dunaway [Anderson], who was a cotton merchant. And he dedicated his business fortune for a series of charitable causes, including cancer. And so following his death, the hospital was named after him in recognition of the foundation support and the wisdom of the legislature. 

MD Anderson himself is clearly recognized as one of the fathers of the Texas Medical Center—a center that is now viewed as the largest medical center in the world and includes institutions such as MD Anderson, Texas Children’s Hospital, and Methodist.

And the initial MD Anderson facility was housed at the Baker Estate, as in James Baker. This was James Baker’s grandfather, who was a lawyer in Houston, and he donated his estate to create the first location for MD Anderson, which was in downtown Houston. 

And then MD Anderson moved to its present location where all of you probably know, in the Texas Medical Center, in 1954 during R. Lee Clark’s tenure as president. My predecessors; Clark, LeMaistre, Mendelsohn, and DePinho have really transformed MD Anderson in ways that I think hopefully all of our viewers know and understand. 

We’re known for world-class cancer treatment, for research, for education, and also for the wisdom of Dr. LeMaistre, who inserted prevention into our mission statement. That was a quarter of a century ago, and we’ve made great strides in the science of prevention, in implementation science, and so many other aspects of how prevention could transform society.

All of us know that if we could succeed in prevention, we could put ourselves out of business. And so as we look at so many of the innovations that came out of MD Anderson, there are probably too many to summarize today, but I think one of the most important was the creation of multidisciplinary care centers that were organized around diseases. This was innovative. It aggregated groups of specialists around unique patients with specialized diseases, and that became a prototype for comprehensive cancer care delivery around the world. 

We’re also known for deep fusion, deep integration of clinical care and research. And that, I think, creates the opportunities for discovery. It supercharges physician-scientists who have opportunities to learn at the bedside and take questions back to the lab. And I think that is part of our secret sauce, and one of the reasons that we’ve been consistently identified as a top cancer center. 

When we look at the impact on society, there’s so many ways that that could be measured.

One measurement might be FDA oncology drug approvals. And if we look back over the last 15 years, MD Anderson has participated in one way, shape or form in the approval of 116 out of 251 oncology drug approvals. So it is literally the case that today, on Thursday, patients are receiving treatment at MD Anderson that will be approved by the FDA six months from now or a year from now. 

We’re proud of what we’ve accomplished, and look forward to taking a lot of the advances that Craig and Candace have talked about in driving an exciting future for cancer patients going forward.

Brawley: I just get a little bit emotional when you talk about your predecessors. Ron DePinho is a personal friend and John Mendelsohn and Mickey LeMaistre were also very good friends and mentors of mine. You come from a long lineage of just amazing leaders. 

Now, the three of you are at the top of your game, running leading cancer centers. I want to ask you, and you sort of delved into it a little bit Peter: Some cancer centers are matrix and very heavily integrated in university hospitals; some cancer centers are freestanding institutes as yours are. 

I’m about to ask something, this is sort of devilish of me, what’s the advantage of a matrix center versus a center that’s freestanding? Anybody want to jump in on that?

Johnson: Well, I’ll jump in because I came from University of Pittsburgh—very much a matrix cancer center. I think all of us on this panel would say the advantage of a freestanding center is you have more control. 

You’re not competing with all the other disciplines that are in a medical school for resources and you’re sort of… And the hospital, and matrix centers are many times owned by a different corporation, and so you’re fighting with that as well. 

But I think the advantage of a matrix center as you have all of us and especially for me, we’re in a small market. We don’t have perhaps as many deep pockets and endowments as my other two gentlemen here on this panel. And so for us, we’re sort of out there. So we have to survive and not only survive, we have to succeed and do really well on what we can bring to the table because we don’t have the luxury of being a matrix center and having the safety of the medical school or the university.

And so I think matrix centers are different. They have advantages too, because we’re all cancer here. Every person in this institution thinks, breathes, lives, cancer, regardless of where they come at it. 

The advantage of a matrix center is you have those engineering folks or those structural biologists where you can really, I mean, I always thought it was really fun to get into some of that stuff, because I was a pharmacologist in my research life and looking at how those structure function analysis happens. We don’t have that here at Roswell Park. So I think an advantage of a matrix center is you have more depth and breadth across all different disciplines. 

I’d still rather be a free standing center. And I bet you, you guys would agree with that.

Thompson: So I’ll chime in after Candace, because in fact, I started in the cancer center business as a director of a cancer center that was a matrix center at the University of Pennsylvania. 

There are a couple of huge advantages that speak to what Peter talked about at the end of his presentation. Particularly, academic medical centers that are with a matrix cancer center have one tremendous advantage that we don’t have, and that is a primary care network. And they have a public health mandate and usually a public health service such as the department that you work in at Johns Hopkins, Otis. And that gives you the ability to reach out with the knowledge, the understanding we have to get at all of our goal—the goal of all three of our freestanding institutions is to put ourselves out of business. 

And if we can do that through understanding and better therapies so that we don’t need to exist, our faculty and staff will be thrilled that they accomplished a mission that we’ve been at for 134 years. 

But that being said, there is a huge advantage to focus and that focus has allowed us, particularly in the field that you’re in Otis, to actually become the authority for our region. So when the city wants to have new laws on tobacco restriction, I can go to city council with the authority of our 137-year history to say we have got all the documented evidence that preventing tobacco addiction is absolutely an essential thing that the government needs to do, and be that authority. 

We can be the group that has the resources, as Candace said, to focus on, does it make a difference, now that we know that polyps are pre-malignant, to actually have a colonoscopy program, as Sid Winawer and Ann Zauber did? 

And so we can be the authority, and convene others to do that, to do a clinical trial that has gone on for 25 years, and we’re very proud. Just change the guidelines to 45 years, as the screening time is, sadly, we’ve seen colorectal cancer move earlier and earlier. We can pick our moments to do that.

And then, one of the most exciting projects that’s come out of that authority during my time as the president, was to realize that the largest health care workforce that is not coalesced around a major cancer that is increasing incidence, are dentists. Dentists see everybody in the city and everyone in our catchment area’s mouth. There are 40,000 dentists in New York City that actually are seeing people’s mouths. 

Coalescing them through our CME programs, through our research program that Jamie Ostroff runs, to train them in the standard of practice and do a trial, to do early detection and early prevention of oral lesions, has been tremendous, because it was an untapped resource. And as the convening authority, we could involve clinical trials like that, get the support of the NCI and make it a model for how to do it—and that’s an advantage of a freestanding institution.

Pisters: I think Craig and Candace have made great points. I can double-click on a couple of them just for emphasis. And my experience, obviously, comes back to being a CEO in a matrix environment with Princess Margaret, Toronto General, Toronto Western, a rehab institute, and an affiliation with the University of Toronto. And the clear benefit of the matrix environment, as Candace was alluding to, is that you’ve got a rich ecosystem, and you can be a beneficiary of the talent and the resources, the infrastructure, at the university, and that can foster tremendous collaboration and lots of opportunities.

On the other side of the ledger and the matrix environment, is the dynamic tension and funds flow, oftentimes between the health system CEO, the medical school dean, and the cancer center director, who have somewhat aligned agendas, but not always. And that can create tensions in an environment where the cancer center director has to compete with the organ transplant program, the cardiovascular program, the neuroscience program. And where, institutionally, at an enterprise level, there isn’t the fidelity and clarity on mission that you see in a cancer center. It is separated from the university environment.

When you look at the current situation I’m in, one of the benefits that we talk about internally is that we’re not a university and we’re not a medical school. And so, we can shed ourselves of many of the funds flow issues, the internal politics associated with that, and we can focus on making cancer history. 

And I think as we look closely, internally, we have the benefit of not having those politics, and we have the fidelity and clarity around what is it that we’re actually here to do. And as we think about that internally, and we talk about it, it’s symbolized by the cancer strike-through, it’s put into words by making cancer history.

Everyone in our institution, all 22,000 of our employees, understand why we’re here. It doesn’t matter if you’re a valet parker, a top-shelf neurosurgeon, a researcher, a laboratory technician, or a CEO, everyone knows this is why we’re here. And when you have that fidelity and clarity, you can drive deep engagement around purpose and meaning and work. 

And that, really, is a lot of the special sauce that exists in independent cancer center environments, where you’re freed from a lot of the politics, funds flow, and you can focus on what’s important.

Brawley: Great, great, great. Now I want to note to the audience, the Q&A function is open. And if you have any questions for any of our guests here, please go ahead and add, just write in the Q&A. I will read the questions as they come in, or we might bunch some of them together toward the end of our two-hour session here. 

I want to point out, we now know who MD Anderson is, we now know who Roswell Park. Since I’m from Detroit, I’m going to let folks know, this is a Jeopardy question, I’m sure. Sloan and Kettering were General Motors money. Kettering, actually, is the guy who created the modern-day automobile starter, so you didn’t have to get out in front of the car and crank the car up, as you might see in some old, old movies, the old silent movies.

Now, let’s get back to our point: cancer centers, at the time of the National Cancer Act, your three centers were consensus, comprehensive cancer centers, you need not apply. Everybody just accepted that you guys were the crème de la crème. 

How have cancer centers evolved over time? And I would actually, I’m going to say this—you guys don’t have to—many other institutions have tried to become like you. Just talk a little bit about the evolution of cancer centers and how they have changed over time.

Johnson: So, I think that one of the tenets of the cancer center program and the National Cancer Act was, cancer, it’s a complex disease. I think it was even acknowledged back in the ‘70s that this was not going to be an easy disease to treat. It was very multifactorial and different in every organ, and so forth. 

And so, you needed to have centers of excellence for innovative treatment, research, therapies. And so, it was thought that these centers should be within a day’s drive of every American. And so, if you look at a map, now in the early days, in the ‘70s, they were focused predominantly on the east because of the centers of activity. But if you look at a map today, there is, even in the west, even if you live in Montana, you’re within a day’s drive of an NCI-designated center.

And what it says to an American is that those centers, they’re going to know what to do with your cancer. So you may be treated in your community, but maybe you should go to one of those NCI-designated centers and make sure that there’s not something that you’re missing or there’s not some treatment that you could avail yourselves of. 

The other thing that I think is important is that, of those NCI-designated centers, we work very well together. I know, because Craig and I are not too far away, we’re at both ends of the state. And there will be people that we have sent to Memorial, because they have things that we don’t have.

But we have also gotten patients sent from Memorial to Roswell, because they live closer to us and we have things that Memorial doesn’t have, or they know that they could be treated here just as effectively. 

And so we do share. I mean, I get asked that from so many people. We do share, we do work together, and I think we do this for the betterment of all patients with cancer around this country. And so, I think that’s, to me, one of the real significance of the National Cancer Act is establishing these centers of excellence in cancer, because look at other diseases, you don’t have this

Thompson: Right. So our research mission, as Candace said, and you just alluded to Otis, was put on its legs, really, between 1935 and ‘45, when GM was the largest corporation in the world. Their headquarters were 10 blocks from us, and Alfred Sloan, their CEO, and Charles Kettering, who’s their chief engineer, turned their attention to an unsolved problem. And as Candace just alluded to, we knew it was too complex. 

Surgery wasn’t going to be the end-all and be-all cure. We needed additional things. And Charles Kettering was the proud man, okay, who not only had the starter, he invented the Slant-6, which was the successful car block engine for everybody.

They believed that if they funded our research institute, and we’d left the researchers alone, on their own, just like they invented a car, they would invent a therapy for cancer within five years. That’s actually what was in the document. 

Unfortunately—although we need, as both Candace and Peter have said, those colleagues who are engineers, and cellular engineering is the thing of today—we didn’t achieve that. Because, in fact, they both believed the research institute, a hospital, had to be separated. And it took us until 1960, 15 years of separate governance, but overlapping governance, to realize they were best together.

And so, in fact, in 1960, we formed the Memorial Sloan-Kettering Cancer Center to combine the Sloan-Kettering Institute and the hospital, Memorial Hospital for Cancer and Allied Disease, into one corporate entity, where we drew on each other. And that was timely, because in those next 10 years, we’re going to be part of the backbone, as my two colleagues are, of the reason we needed a National Cancer Act. 

And so what we really learned from that research is why all the other diseases had national institutes that were succeeding and were getting more funding, because they worked on an organ that had a physiology. So you could work on the heart and ask, what did it do and what goes wrong when you have a heart attack? When you have arrhythmia, what goes wrong with the conduction system?

But cancer is just too sporadic. It occurs in every organ. At the time, in 1960, it wasn’t amenable in most cases as patients presented, to surgical care. We didn’t have the diagnostic capability to do it early enough, and we were able to document that by having scientists who take the latest physiologic techniques come together. And so, the Cancer Act—we came together in 1960, the frustrations of coming… 

And I’ll give you our history. Our center grant, our cancer center support grant, started in 1964, four years after we came together. Because we just, simply, no investigator—this is Peter’s point of team-based science. So for us, team-based science started in 1960 when we realized we had to have the researchers and the clinicians working on the same platform, in the same… and bumping into each other in the lunchroom and having those conversations.

Our center grant came because we had 54 funded NCI grants. And the NCI said, “You’re driving us crazy, because you all want the same resources,” and made us bundle them all. We complained it was so much paperwork. We think about the paperwork today—they were complaining in 1964 there was too much paperwork. And the NCI, at least according to our records, threw up their hands and said, “Fine, put them all in one center grant.” And that gave us the resources to have cores that could support all of our clinicians, all of our researchers, to investigate human tissue, human biopsies, human cell line—our cell line program started then—and be able to focus on what now is the paradigm, the human as the subject, what the human natural disease is.

I embarrassed myself when I came 10 years ago to Memorial, when they told me, “We think cancer is 150 different diseases, because we’ve been part of the cancer sequencing projects.” 

And I said, “No, no, that’s way too complicated. We can’t have 100.” 

We unequivocally know there are over 400 entirely separable, need-to-be-treated diseases that are called cancer today. So there isn’t one organ. There isn’t one physiology. And the timing of the Cancer Center Act, the three of us came together and said, “We have to do this on a national level,” for the reason Candace said, so everybody has that hope that a freestanding cancer center is within a short distance of their own home. A network allowed us to take advantage of the revolution that started, also, in 1971, which was molecular biology.

We are the poster child of how much molecular biology can deliver to human health, with the TCGA, with the sequencing projects, the somatic mutations, the predisposition syndromes that have been figured out at a molecular level. That was all because of DNA sequencing, the understanding of molecular biology, and now the therapies that molecular biology provides us to treat this disease. 

It was just very timely for us to come together to understand that the research and the clinical care had to be hand in hand. We had to handle the tissues carefully to understand this disease, because it looked so diverse. And it allowed us to realize advantages that happened in our basic research. Rous sarcoma virus—I’m looking at the building that Rous sarcoma virus was discovered in at our sister institution, Rockefeller University.

My predecessor, Harold Varmus, with his colleague, Mike Bishop, cloned the gene, which was a homologue of a gene to launch the molecular era in the 1970s. The benefit of funding, that doubling of funding, because the National Cancer Act doubled the NCI’s budget—for our junior colleagues, they’ll be horrified, it went from $100 million, to $200 million.

That was a revolution that allowed the molecular era of cancer research to start. We, all three of us, and our colleagues, and all of our patients have benefited from that revolution over the last 50 years. Why do we see cancers’ mortality going down 1% a year, every year since 1990? And now it has accelerated in the last decade to 2% a year.

Brawley: You brought up a very important point. The NCI budget in 1971 was $200 million. Today, it’s about $6 billion.

Thompson: That’s right. 

Brawley: Did I step on you, Dr. Pisters?

Pisters: I’m going to say, Otis, taking into account that we have an international audience, and looking at the benefit of history, I really believe one thing that should be emphasized today is that, by starting out with three exemplars, and then by putting into place a set of criteria, this then became an aspirational goal through university presidents, medical school deans and health system CEOs. 

And oftentimes, that is really what led them on a pathway to create an NCI-designated Comprehensive Cancer Center. It infused the understanding of many of the complexities of cancer care delivery that Candace has really talked about, and that Craig has really elaborated on.

And it helped, really, to create geographic distribution that has been so beneficial to cancer patients. And I think that in the modern area, this has led to a degree of consumerism where the term cancer center is understood by lay people in fairly detailed terms, as a result of the fact that so many universities and medical schools really chartered a pathway and put into strategic goals, spoke to philanthropists, talked to their community, and now, we have an unbelievable network of 51 NCI-designated Comprehensive Cancer Centers that benefit society in ways that don’t exist, frankly, in other countries.

Brawley: Is the expectation of the American people that a cancer center is both a place that treats and a place that does basic and translational research? Am I right that people have come to expect that?

Pisters: I believe so. It’d be interesting to hear what my colleagues think. I really believe that increasingly, particularly as we move past the AIDS epidemic and into, now, a pandemic, people are understanding the value of medical research. 

Now, we’re in an era where we can get a COVID vaccine generated and into people’s arms in six months. These are unbelievable triumphs of science that the general public is becoming much more aware of, and therefore, hopefully, continuing the long-standing, bi-partisan support for NIH funding.

Johnson: I agree with that. I think, actually though, I’m not sure we’re always as effective lobbyists for getting more money from the federal government for the NCI. 

I mean, if you look over time at the NCI budget, and the paylines and so forth, it’s gone up, it’s gone down in my career. I’ve seen lots of that, sometimes it was stable. And if you look at who was president, who was in charge of the Congress at the time, you can’t really correlate excess research dollars with any political affiliation.

Because you could see on both sides of the spectrum, you can find where we had prosperous times. And I think that when you talk to people in the federal government, they all support us, they all think what we do is wonderful, they all want more money. It’s prioritizing—and it’s too easy to cut our budget. 

And I think we need to be more bold, and maybe the general public, especially coming out of COVID, where research is so important, can help us with that. Because I think we’re not as good an advocate as we could be to advocate for more dollars.

Thompson: So, I agree with that, Otis. And just to add a little bit of color to what both—and I completely agree with what Candace and Peter said—I think the public does understand what comprehensive cancer centers [are].  

My chief operating officer, when I first came here, John Gunn, used to say the biggest value of our cancer care is actually people seeing how many people are committed to the team that will make them better and find a new therapy. 

You come on our main campus, and you see the number of people involved in research, you see the number of people involved in clinical care, and it gives patients and their caregivers hope. And that is a message that gets out into the community, and it matters.

Because we still don’t—and it’s to Candace’s point—we haven’t done a good enough job of explaining, yes, we have all these new tools, but we only have half the tools we really need to make cancer history, as Peter just said, in his dialogue. 

We still need funding, we’ll still need research, because of the complexity of the diseases that come under the rubric of cancer. We have to exist for rare cancers that no single community hospital or regional hospital even sees one of in a year. We have at each of the three centers, a clinic every afternoon of the week, seeing people from around the country to come for that combined expertise.

At the same time, we have to see the common cancers for our training missions. And that often confuses people, “Well, if I have a common cancer, why can’t I go to my local cancer center?” I can come to a comprehensive cancer center, because you’re participating in improving our knowledge about that. 

And we do need to be better at getting that communication. As Peter said, sometimes people think of cancer treatment just as a commodity. It’s odd it happens in these conversations that Candace is talking about, rather than when you actually talk to patients and their families. They really do understand the importance of this.

The public’s ability for philanthropy—we have averaged over my presidency, a million donations a year. But the average donation is a couple hundred bucks, and that’s the [public]. We don’t touch that many people—people believe in the mission. 

George Gallup told me in 2008, that the leading thing Americans now fear in health for their family, is actually getting cancer. The World Health Organization doubled down [on] that in 2012, it’s the leading fear around the world in developing and developed nations. 

And so, our opportunities to give hope through combining that expertise, the team-based research, is a tremendous benefit, and we don’t do enough to shine a light on it. I hope the Cancer History Project actually shines the light on that as we go forward.

Johnson: Yep.

Brawley: Thank you. I’ll take that as an opportunity to do the one commercial of the two-hour interview. The Cancer History Project, at CancerHistoryProject.com is a website free to anyone who wants it, that allows people to go look at some of the sentinel events that have happened in cancer medicine, not just in the 50 years since the National Cancer Act, but in the history of cancer. You get to see things donated from various cancer centers and universities, various distinguished scientists, archives of records. So you can actually see the first protocol that looked at lumpectomy and radiation versus mastectomy, for example. You can read the actual protocol. Now that’s for the commercial, CancerHistoryProject.com.

Craig, you really want me to go in two directions, or you’re encouraging me to go at two directions. What I want to talk about, how, over the last 50 years, we, and we as the cancer centers at the lead, have really changed the definition of what cancer is. People didn’t realize it was a genetic disease in the 1950s and ‘60s. Many people thought it was metabolic. Talk a little bit about that. You’re a true basic scientist. Talk about how the definition of what cancer is has evolved. You mentioned the 400 different diseases, explain that to the lay person a little bit.

Thompson: So, I think a couple of major insights have come in the last 50 years. First of all, the discovery, as I’ve mentioned, by Harold Varmus and Mike Bishop, of oncogenes, genes that drive proliferation and survival of cells, that are recurrently mutated to define certain classes of genes. And so they come as a large group, the kinases, but each individual cell and each individual cell type relies on a different member of that family. And so, you have to treat relative to what’s driving this accumulation of cells.

When I started in medical oncology, I was taught that every cell had a risk of becoming cancerous. That’s not true. We now know that every tissue in our body, as a long-lived animal, a mammal, we have regeneration. When you cut yourself—I cut myself this morning on my hand—I know it will heal over time. But that regeneration activates lineage-specific cells of my skin to repopulate the tissue. And that duplication, because it is a genetic disease, inherited in the DNA that you’ve talked about, it’s those mutations, that accumulate over lifetime, that make cancer a disease of aging. And because we are constantly damaging ourselves and regenerating, we understand why things, like tobacco smoke, like UV light or radiation, increase our risk, because they damage DNA during that repair process.

We understand why Hepatitis B and Hepatitis C cause liver cancer. We understand why HPV over a long time causes cervical cancer and head and neck cancer, and we can build preventative strategies, HPV being one of the biggest opportunities going forward. 

We had to have a molecular understanding, because it wasn’t one organ. Every organ can get cancer, but it’s the regenerative cells of that tissue that make a difference. 

That leads us to our last frontier of why all three of us continue to believe in freestanding cancer centers. We’re terrific now at treating anybody whose cancer is caught early enough, that it’s only in the local organ that it starts in.

Peter’s surgeons, Candace’s surgeons, my surgeons, radiation oncology surgeons, any major cancer center—all of them that participate in the comprehensive [designation] can cure that person with the modalities they have. 

The problem is cancer metastasizes, and that’s the last frontier. If we can understand why it is that cancers acquire the ability to metastasize, because it’s not a simple mutation. We’ve now sequenced thousands of metastases. Yes, they have a little more diversity than the cancer, but there aren’t oncogenes of metastasis. There aren’t tumor suppressors of metastasis. And so we’ve got a whole new frontier, because that’s, unfortunately, why there’s still residual cancer that we can’t handle. And, ultimately, when we understand the biology of that, we’ll get to the future.

And so, we had this tremendous advance that gave us precision medicine. Charles Sawyers who leads the program here, and his work on Gleevec with others at Peter’s institution, as well as at the University of Oregon, really proved to us that understanding mutations, and treating for those mutations, would give us better outcomes. And so, the use of Gleevec and CML revolutionized the disease that I used to take care of and had fatality within 36 months. 

Now, the cohort that they studied in a phase I study that was never closed, those patients are living longer than their age-matched controls, as Brian Druker continues to follow them at Oregon. And that’s amazing that precision therapy delivered that.

And then, we understood that to be able to be successfully metastasized, they had to fool the police of our body, the immune cells, and that led to Jim Allison’s insight about checkpoint blockade. Those are two revolutions that given us tools for the metastatic disease, so we can see melanoma be cured, lung cancer, which I never thought in my lifetime we’d see cured, but it doesn’t work for everybody. So there’s lots more we need to know. And that both demonstrates the promise of things we didn’t expect, from the discovery of oncogenes and tumor suppressors in molecular detail, with the sequencing of the human genome, and then the sequencing of cancer genomes compared to the germline.

And then, this discovery that the rest of the body is co-opted by the cancer cell of the metastasis problem, and if we can reactivate the cops, we’ll do well, but there’s other cells involved in helping a tumor be successful, that we’ve got to learn how to get them to stand down or fight back against the cancer, which has fooled them. 

And so there’s a tremendous need for this network of comprehensive cancer centers to solve that problem, and then deliver that answer in a way it can be practiced everywhere in the country, for every oncologist, every patient that has the disease.

Brawley: Dr. Johnson, you are a world-renowned pharmacologist, a drug developer, what’s the future of the cancer center and drug development?

Johnson: So, I think drugs have taken a different turn than from, well, when I started in this business, because they were all poisons, [with] their side effects. They still have a place today. But I’d like to think that pharmacology, we’ve gotten a little more sophisticated. And some of our drugs, pharmacologists would even say that a checkpoint inhibitor is a drug, and there are pharmacologists that work on those sorts of areas. 

But I think the future for us is more targeted therapy. As Craig said, the genomic era has really offered us such an opportunity to identify genomic signatures. And there are, really, only about a handful of drugs that recognize certain genomic signatures, where you can actually see a response in a patient.

Now, if you have that, if you find that gene where there is a companion drug for it, you have a good chance to see a response, and it’s a wonderful thing—but it’s limited. And so I think there’s lots of room for new drug development, and for drugs that are attacking and looking only at that specific target. So I think, there’s still a place. 

Pharmacologists, in the old days, when you’d go to an ASCO or an AACR meeting, there’d be lots of pharmacologists, lots of drug-discovery efforts, and so forth. And now, it’s all immunology, and the pharmacologists are sort of sitting in the corner.

But I think that immunopharmacology is a really important area. And I think that what all of us are doing in the immune space, in the immunotherapy space, is really exciting. I mean, we’re seeing the “C-word”—cure—in patients that you just wouldn’t have seen this before. 

As we’ve all said, this is a very complex disease. We’re not going to solve it with just drugs alone, and we’re not going to solve it just with immunotherapy alone, where it’s going to take all of this. It’s a complex process.

Brawley: Yeah. Dr. Pisters, you’re a surgeon—you already knew that, I guess. The minimally invasive surgery, when I first started in medicine in the 1980s, surgery caused a lot of morbidity and there were efforts, tremendous efforts to decrease morbidity from surgery. Limb sparing sarcomas surgeries, and that sort of stuff. It seems like surgery has progression and minimally invasive surgery with robotics, with scoping, and that sort of stuff, has become more and more on the forefront. 

Can you tell me just a little bit about cancer centers and developing those sorts of things, and convincing the FDA and the American public that you really don’t have to be totally unzipped in order to have a good colon cancer operation?

Pisters: Well Otis, your question really makes the point that minimally invasive surgery has transformed many aspects of surgical care, not just cancer surgery. It was brought to cancer patients and done so in the ways that your question really illustrates, that it really reduces morbidity. It has comparable mortality rates, where mortality is often driven by the other comorbidities rather than the surgery itself. 

And over time, we’ve been able to demonstrate that on oncologic outcomes, in some but not all cancers, are comparable, and this has really created advantages. Unfortunately, those advantages don’t extend to cost, where increasingly the costs of the reusables associated with this drives up the cost of a given operation, and as we all become more cost-focused, this will become an issue over time. 

We also have seen that in many cases across the nation, a lot of aspects of minimally invasive surgery had been driven by the industry, and this has created a situation where there’s been really a dearth of randomized data, particularly in cancer.

When you look closely at subsets of cancers and you look at the randomized data, or the trial that we led in gynecologic cancer, we found contrary to the hypothesis, that patients who had open surgery had superior oncologic outcomes. This was practice changing. It prompted lots of questions over time, and really demonstrates the point that when new technology is introduced, particularly expensive technology, it has to be subject to randomized controlled trials that look at all aspects of the short-term morbidity, look at cost data and look at oncology outcomes.

Brawley: Thank you. The cancer centers as a group, the NCI-designated Cancer Centers, have gotten a mandate to do community outreach and engagement recently. Now, the original National Cancer Act in 1971 told the NCI that it needed to do public education regarding cancer, and this COE, or community outreach and engagement mandate, is really a follow through of that. And it’s actually manifested itself in a number of different ways. 

The three of you were co-signatories of a very powerful, incredibly powerful letter—I wish we had some similar thing for coronavirus vaccine. A letter encouraging every parent in the United States to get their children, boys and girls, vaccinated against HPV. 

Just tell me a little bit about what your cancer centers are doing for other aspects of education beyond that—diet, exercise, smoking cessation, so forth. Just give us some examples of what your cancer centers are doing and what other cancer centers ought to be doing. I’ll start with you Candace.

Johnson: Our catchment area is characterized by poverty, obesity, smoking. We’re the second poorest city in the country, and so it’s a real issue for us. We have a large number of African-Americans, Hispanics in our community, and also we have the indigenous population. There are many Seneca reservations that are around our catchment area as well. 

And so it’s something that we really pay attention to. And I think that even before the community outreach and engagement component of centers’ grants, this was something that we put center stage, is reaching out to our community. I applaud the NCI for focusing on this because it, and quite honestly, many of our efforts that we’ve done in cancer, really helped us to reach folks for COVID vaccines because they trusted us, because we’ve spent a lot of time in trying to develop trust in many of these groups that don’t trust us. It’s helped us in so many ways, education, screening, and so forth.

We have, Christine Ambrosone leads a very distinguished group and is interested in molecular risk factors in breast cancer, and has really reached out in the African-American community and collaborated with many centers around the country to look at a number of factors, including breastfeeding to decrease mortality in breast cancer. And in prostate cancer, we have outreach in many of our African-American communities here as well. 

One of our faculty members is a member of the Seneca tribe, so we have a big study and looking at obesity and trying to make connections in the indigenous population, and I want to tell you, it’s a whole other level of mistrust, if you will. And so we’ve made great strides in helping to, in our screening programs, to get these folks in.

I think that it’s one of the most positive things that we can do, as a cancer center, is to be that nexus, not only for screening, but for education, as it relates to a whole variety of diet. 

I’ve already mentioned our footprint in smoking cessation, but now that’s also expanded into, I mean, vaping, which is a huge problem and looking at the effects, and it’s not without its issues. 

And so I think that the community outreach and engagement has really made our centers. We talk about, those of you that know about the CCSG, excuse me, the depth to be a comprehensive center. You have to have depth and breadth across all of the basic science, clinical and population science, and education. And I think the community outreach and engagement really has given all of our centers depth and breadth, because it shines a light on these so important things that we do for our communities. So I could go on and on, but I’ll turn it over to Craig or Peter.

Thompson: So I’ll just pick up where Candace said. I think each of us serve major cities, as Candace said. When their center started, Roswell Park started, it was the third largest city in America and had a booming economy. As small industry has moved away, she’s faced the economic challenges. 

For us, we are still the largest city. We have 34 million people within 100 miles of me right now, so that’s one in 10 Americans, and we have to serve, to get through that whole diversity. So for rare cancers, things like that. 

But in terms of the outreach to the community, Otis, the critical things that we’ve seen, that we uniquely can do, are some of our aspects of immigrant health and cancer disparities that Fran Gany leads. We have a very active program that reaches out into the Hispanic community that’s moving up from the Caribbean, from Central and Latin America, and reaching out because they don’t have that kind of cancer information that they need.

So we have a big program in getting HPV vaccine into that community. Signing that letter didn’t impact that community as much as I would like to have. So we have a terrific program around that. 

We have a huge obesity problem that Candace mentioned and it is socioeconomic—it goes across America, America is the fattest nation. And today, at least in our city, tobacco is not the number one preventable cause of cancer, it’s actually obesity, type 2 diabetes, and poor diet and lack of exercise-related cancers as seen by the statistics published by the National Cancer Institute. So I was really proud among… We could all talk about ratings, but I was really proud of our, the recent ratings come out, the US News and World Report, because we’re 18th in the country in our diabetes program. Because we need to understand why is this cancer incidence going up in the obese population to serve our community. 

But at the other end of the spectrum, because of the socioeconomic challenges that Candace said, we have a huge number of patients we deliver care that are food insecure. So we have a hospital-based food security program to make sure our patients have the nutrition to successfully get through their therapies. We reach out and make sure that all of our patient population is doing that. 

For prevention strategies, we’ve learned, as I said earlier, to partner. So right now in northern New Jersey, we’ve got to get people back to their cancer screening. We have a public service message announcement going out with our partner there, Hackensack Medical Center. They have 20 hospitals that serve all of northern Jersey. They have the screening facilities, we have that imprimatur to say, “You have to go and do that.” Those partnerships with all the community-based organizations really work to get the word out on our community. 

And then finally, COVID has allowed us to reconnect because, in fact, cancer exposed you at greater risk to COVID.

We reached out to the communities, at the request of New York City, to stand up vaccine centers with our colleagues in Harlem. We partnered with the Abyssinian Baptist Church. Tremendously successful program that’s vaccinated over 10,000 people that were otherwise vaccine-hesitant. Reverend Butts has been amazing in leading that program, and we were proud to be a nation center where the First Lady, Dr. Biden came to visit with Tony Fauci to actually talk about why we had to be engaged in the communities. 

We’re really proud of those efforts, we’ll never be able to… I mean, we’ll keep doing as many as we can, but connecting with the community, becoming that trusted authority, which COVID has allowed us to reinvigorate, because of our response, is something that all the cancer centers really do embrace. 

But each of our areas and the service we can provide is unique, and it’s different as we’ve talked about for a matrix center, which has a public health score in primary care network, versus a Comprehensive Cancer Center, that needs partnership to get to those primary care givers or the dentist that I talked about earlier.

Pisters: Otis, just to add a little bit to what Candace and Craig have said, and for our international audience, I think COE is a uniquely American adaptation to changes and interventions that have occurred in the jurisdictional level in other developed countries that have single payer systems. 

Other developed countries that have better health outcomes than the United States use a jurisdictional approach to cancer prevention and screening. That’s what we had in Ontario with Cancer Care Ontario: an entire provincial agency that sent letters to everyone in the province at a moment in time when you needed to have colorectal cancer screening or a mammogram. 

And what we’ve done instead, for a variety of reasons related to structural issues in the American healthcare system, we’ve created this construct of COE as a best practice, or as an adaptation, to try to extend prevention and screening benefits, as well as anti-cancer living benefits, to larger populations, not just those who enter our organizations. 

So it would be important for us at a policy level to learn lessons from other countries that are, frankly, better at this than we are. Yeah.

Thompson: I want to double down on what Peter said, because that international program… For us in New York, if we look at the patients that come to our hospital, to be able to adequately inform them of their healthcare, we need to engage with them in their primary language. 

In many parts of America, that will be English, and increasingly Spanish. For us, we have five languages where more than 5% of our patients, it’s their primary language at home. And so learning to get that content and how to communicate it, we can do through our international collaborators, to learn how to interact in different dialects of Spanish. We’ve used the UN, a unique resource we have, to do reverse translation, because just translating in one direction, you often don’t… When it’s [not] reverse translated, you didn’t say what you meant to say.

And language, because America is this great melting pot of diversity, language is something we have not embraced enough in explaining the complexities of cancer to patients, so they feel comfortable with the authority that we’re providing. So language is a huge barrier in the metropolitan areas in the United States, but I think it’s everywhere. Every community has a language of the immigrant population that came there, right?

Johnson: Do you know Craig, even in Buffalo and we’re a very small market, we have over 70… We translate over 70 different languages and have capabilities for that. So it’s difficult, but you have to be able to do it. It’s so, so important.

Thompson: And increasingly we could draw on an international community where they have that language content, and we could adopt it because many times that reverse… We were shocked when we started this reverse translation system, that our translation into these guys… We have 80, like Candace, 85 languages we provide interpreters versions, but when you translated it back, it didn’t come back exactly in what the first English version was. 

So we have lots to learn in the community delivery of that care, in our messaging, in our prevention strategies, and that’s why we need to engage the community and provide research into what makes a difference. Because for us, the biggest thing that drives disparity is not understanding, and it’s that language barrier.

Brawley: Now the NCI doesn’t call this community outreach and engagement, but I think it’s one thing that cancer centers might be able to do. Can you speak to what you’re doing to influence how people are treated in your catchment area who don’t come to the cancer center? Whether they get… How doctors are recommending mammography screening, or how doctors dose chemotherapy, or how doctors might even perform operations, or when. Are the Cancer Centers really involved in trying to drive quality of care? And here, I’m thinking about your involvement with NCCN as well, and so one of you may want to explain to the population here, what NCCN is.

Pisters: I can just start this one just with our example. Houston is situated in Harris County, and Harris County, Texas has the largest number of uninsured citizens in the country—1 million. And what we’ve done is to look at the county hospitals, and to partner. We have two county hospitals, Ben Taub and LBJ. Baylor College of Medicine provides oncology care at Ben Taub, and MD Anderson provides oncology care at LBJ Hospital. 

And the way we’ve done that, is to really bring the doctors to the patients, and so our faculty have a clinic at LBJ. We provide the services there, at our standards, with our doctors, and we bring, increasingly, our clinical trials to that environment so we can enroll a larger population, a much more diverse population of individuals, into our clinical trials. 

We’re working now with the UT System to increase our investment and build an MD Anderson facility at LBJ Hospital with donor support and with support from the University of Texas Board of Regents. So I’m really excited about these changes. It’s an excellent example of what other cancer centers can do to really make a material difference in their own regions.

Johnson: I mean, NCCN has really played a huge role in standardizing things across this country, and all of us are members of NCCN and on this panel, to improve quality across the board. We also try, with pathway-driven care, to try to standardize the way some of our physicians in the community—and sometimes that’s embraced and sometimes it’s not. But I think we owe it to our community to be the leaders and be the gatekeeper if you will, of this high quality care at every turn. So I think it is a really important thing that we do.

Thompson: Right, so I’ll just double down on NCCN, which is where the comprehensive centers came together to set common standards, so that everywhere… 85% of oncology care is still given in community hospitals throughout the nation, and to have a standard reference to go back, to have a compendium of recommended therapy that is kept constantly updated, is what NCCN has started, and that’s been a great offshoot of the Comprehensive Cancer Center network. 

I do want to say that the biggest hit that we’ve seen in COVID, and in our mission, has actually been our ability to serve as the CME center for cancer in our catchment area. We never had a week go by without at least two groups of three or 400 physicians coming to be re-educated on their part of cancer to this institution. I’m sure Peter and Candace would say the same thing. And we haven’t been able to convene them, and it’s not the same thing as them coming and talking to our experts, finding out that insight, understanding why that new treatment makes a difference, that communication.

When immunotherapy came, the average person didn’t know how to deal with the side effects. That was a way we communicated it, and that ability to come together with CME, we’ve all got to reinvent. 

And then I just want to speak to something Candace mentioned and Peter reminded me of, which is that we have a huge and wonderful—you heard a lot about from them—of safety net hospitals in this city, that in COVID were amazing in how they stood up here. We partnered with them to take their cancer patients who shouldn’t be exposed to COVID. It was a great partnership. But the real important, long-lasting thing is that those safety net hospitals don’t have the molecular testing that allows them to decide whether they could achieve NCCN guidelines because they don’t have the molecular testing.

And so Dr. Carol Brown, who is our chief health equity officer, has been standing up programs in partnership with health and hospitals to get those people tested through our impact testing. Those people that get a cancer diagnosis, now the hospitals can find out if they’re eligible for a clinical trial, if they can get that molecular testing. And we have that at a number of pilot programs in Queens, in Brooklyn, throughout the city, to be able to do that. 

That’s where we become that authority, that Candace is talking about. We have to make those trials available to everybody, the latest recommendations. You have to have the diagnostics right to do that, and that’s where we are falling down, and why we’ve got to convince the Federal Government that molecular testing is the right way forward with cancer. That’s not yet fully approved in terms of reimbursement.

Brawley: Cancer centers have always had a lot of political support. One of my old bosses while I was at the NCI, an NCI Director, used to always say, “The thing about cancer centers is every one of them has two senators and at least one congressman.” I don’t think that the cancer centers are going to be removed from the NCI budget in the near future, but we still have a payline that’s hovering between 9 and 10%. I worry about the investigators who work in the cancer centers. How are we going to fund the future? How are we going to keep young people in research? 

And I ask this question, knowing that the three of you do an amazing job of finding alternative streams of money to support young investigators. But how long can we keep doing this? And what are some of the ways—you might want to mention some of the ways that you’ve been working to support young investigators, because I don’t think many people outside of the community of cancer center executives know the work that you do, the hard work that you do to support, especially young investigators. I’m talking about the people who are in their 30s, who are just building their career.

Johnson: I mean, I can start. I’m the small fry here, but I actually think Buffalo, Roswell Park, we’re sometimes the last bastion of the clinician-scientist, because the young clinician-scientist, we really try to incentivize them and support them early on in their career, especially to push that translational envelope, as well as our basic scientists, the young folks who get very discouraged at a 9% pay line, that’s for sure. 

Our philanthropy is a lot smaller, I’m sure, than my colleagues on the panel, but we do a really incredible job at raising money in Buffalo. And we use that philanthropy very judiciously to help support some of these programs, and to help give some of these young individuals a chance for pilot studies to be able to garner bigger and more comprehensive grants from the NIH or NCI or DOD or other mechanisms, but it is a challenge.

We also utilize our clinical revenues to help support our research mission. Hence why it’s so important for us to drive that, because it helps to fund these young investigators. But you have to be committed to it. And I think cancer centers are the place to do this, and I know my colleagues agree with me. It’s what distinguishes us. Our innovation and our ability to generate these incredible discoveries is what distinguishes us from a non-NCI-designated Cancer Center, a cancer center who is more of a community center. That’s what designates us and distinguishes us, and so I think it’s really important that we don’t lose that. 

And it will become more and more of a challenge Otis, you’re exactly right as we go forward, because those dollars are going to be harder and harder to come by.

Pisters: I think that, just to add briefly to what Candace said, as we think about it and our diverse faculty, it’s very important that we value all contributions to the mission. 

Research is very important, it’s a very important component of our societal contributions, and we want to create dedicated protected time for a subset of our faculty who engage in research. We want to give them all the resources, all the time, access to the platforms. 

And then, as we talk about it internally, we make investments in three specific areas to fuel the kind of production that we need and to enhance the ability to come above the payline. 

One of them is investment in talent, where we’re recruiting the right kind of collaborators. 

Second area is investment in partnerships, very important, academic partnerships illustrated recently by Breakthrough Cancer, and industry partnerships that are very, very important to our research community.

And the last area of investment, very important, is the facilities and infrastructure. Not just cores. I’m talking about ideation space, new research buildings, different way of allocating space over time so that highly productive researchers get rewarded for that and they get more space over time. And that we help researchers who, for whatever set of reasons and circumstances, can’t achieve reasonable research productivity to find other ways to contribute to our mission. 

So it’s really understanding that not everyone needs to be engaged in wet lab-based research, those who are engaged need to be supported in [every] possible way, so that they can be successful with the investments in the talent, the partnerships, and the infrastructure.

Thompson: Yeah, so I’ll just re-echo what both Peter and Candace said. We have a big program to fund at the junior investigator level, new pilot ideas, new grant ideas, that will give them the opportunity and the resources to be able to develop a portfolio of results at every level, whether it’s basic, translational, or clinical science, to move forward to getting funding from a federal agency or a patient interest group. And those funds are absolutely essential for success at the junior level. To have that chance, that satisfaction, that you can investigate your own new idea. 

The new thing is, what Peter said, translational research is the mantra of today. Demonstrating it can happen, that’s much more team-based. You need to bring together the expertise. That means we have to have promotion systems that recognize people are going to share the credit. It’s not what the movies show us, as one doctor sitting in a laboratory coming up with something. And so we have to change the standards of team-based research, of embedded investigators junior in their career, so that they can explore their ideas in the framework of a larger group of people working on that. 

So team-based science, collaborative science is really something we’re pushing hard to support our junior investigators, and get them to understand the complexity of modern biomedical research.

Brawley: What about investigator-initiated research versus directed research? There’s increasingly, I’m seeing… For the audience, over the last 50 years, a lot of our learning has come about because people in the laboratory or groups of people in laboratories at cancer centers, universities, have written grants, sent them to the NIH, said, “This is my idea and this is why it should be funded.” That’s an investigator-initiated grant. More and more, there are movements by certain elements to have more directed research, where some smart person somewhere says, “I want to give you money to do this or that.”

Are you seeing… I think this is becoming more and more prevalent. Are you seeing this, and do you think this is a good idea? Because we’ve learned an awful lot through investigator-initiated research in terms of what’s going on in the cancer cell. And I’ve even gone off and said, for example, the mRNA vaccines for coronavirus, they weren’t created in six months. It was huge investments in basic research over several decades that all came together and happened to be applied in a short period of time to develop those vaccines. But it was primarily investigator initiated research that brought us that—and I’m talking too much. Do you see a problem here?

Thompson: So Otis, let me just speak to this because in researching, and this is relevant to the History Project, one of the real debates and what started the National Cancer Act was the commission that took place in the Senate as Nixon came in and Johnson left. Mary Lasker convinced the Senate to have, along with Sidney Farber, to have a commission that looked at what should happen in cancer. 

The biggest debate in Congress, if you read those records, was whether the new money should be a contract or a grant. And thank goodness, the scientific community stood up and said, “It cannot be a contract. This is not just delivering this number of doses. We need to investigate the science of this and to have those investigator-initiated ideas, and a way to do that.” 

It’s a time where that debate’s happening again, Otis, and that’s what you said. And so I think we need to look at what happened for that 50 years, because we stuck to the idea that these are grants, that people get to follow their new hypothesis driven idea with the new tools of science, with the new tools of medicine. And we have to really double down that. And we need to use, collectively, our authority as cancer centers, say this is critical in driving cancer forward and keeping the talent that’s involved in our education, our training missions as we go forward.

Johnson: Agreed. Totally.

Brawley: Yeah. Peter?

Pisters: I think that it’s very important for us, in each of our organizations, and I presume colleagues across the country and around the world, are trying to find the sweet spot. In other words, you need to support a curiosity-based discovery research, exemplified as Craig said, by Jim Allison’s work on the fundamental biology of the immune system and how it can be used for cancer. And that’s had massive impact on society. 

You also need to see the opportunities that are created with team-based science. And that when we solve for a problem like a breast cancer, or glioblastoma, by putting research teams together from different institutions, or partnering with industry, team-based science creates tremendous benefit. The poster child for team-based science on a foundation of curiosity based science that you pointed out, Otis, was the development of the COVID vaccine.

And so we need in our institutions to have both. And really the challenge is to define the sweet spot, so that individuals feel like they can pursue their own hypothesis-driven ideas in a rich resource-based environment, and other individuals, or perhaps the same individuals at different points in their careers, can join teams that are doing great things together.

Brawley: Wonderful. I’m going to ask a couple of the questions here and anybody who wants to add into the Q&A session, please go ahead. One person who worked for the NCI said that they’ve witnessed examples of discretionary resources being directed toward achievement of cancer center metrics rather than toward the most exciting science. That’s their opinion. Do you have suggestions for improving the NCI designation process? Anybody?

Johnson: I hope we go back to in-person site visits. 

I’ve done a bunch of those site visits and it’s difficult to sort of get the chemistry of the team. I don’t want to joke around, obviously, the person that asked the question.

I would like to think at our center that we don’t spend—if it’s directed towards the CCSG metric, it’s actually going to help the institution and it’s going to incentivize the best science. So I don’t know the specifics of that question, but I think that, most of us, the metrics actually are positive ones too, that we achieve.

Brawley: Yeah. I will say, having sat near the front office at the NCI, there is a concern about unfunded mandates on the part of the NCI. There’s a desire not to do unfunded mandates, near oftentimes pressures for certain mandates that are from places you would never, never dream of.

From one of our Canadian friends, please comment on the cancer centers’ global mandate. Should the US model be replicated in every country around the world? And what’s the nature of cancer centers, US cancer centers global mandate?

Johnson: I can start out. We are probably not as global outreach as my panelists, but I think it is important for us to be in the global scene. They have a lot to offer to us. 

We have a longstanding collaboration with Cuba. And the Cubans are really an incredible group of scientists and have achieved much with very little. And so I think we at Roswell Park have been enriched through our collaborations, and I think we are bringing things to Cuba, and they are bringing things to us.

We have some outreach in Africa, where there is much needed attention to quality and care for those individuals, and in the Caribbean, and so forth. So I think a global presence is really important for every NCI-designated center, because I think it enriches. It’s just like diversity. It enriches us, and it enriches them because you’re bringing a different culture and you’re learning more things about them. 

Thompson: I just want to echo what Candace said, and not talk about specific programs. All of us, and everyone at our centers, wants to reduce to practice advances in cancer prevention, diagnosis, and treatment, that won’t be just practiced in our center, but will be adopted—are capable of being adopted—for every one of the 8 million cancer victims every year throughout the world.

But what we have to appreciate is, which has been a very important part of our international program is, that there are cultural differences in how people approach health. And we need to be sensitive to that and knowledgeable about that. And that means a partner that is involved in the primary delivery of care throughout the world.

So our global missions are almost always in partnership in all the continents where we have major programs, to find a partner hospital similarly dedicated to elevating the quality across their nation or their region’s cancer care, and deliver that in a culturally sensitive way, that actually makes a meaningful difference.

And we can become, as I just said—as we do in the US in our local region—we become the authority that they can exercise to say, here’s the science of it, here’s how we can adopt it within our healthcare system to make a difference. Because ultimately, all three of us and the cancer centers that are in the conference right now, are incredibly proud of the quality we deliver to the individual patients that come to our care.

But that’s only a small fraction of the US cancer patients that we need to help, and the international patients, because cancer is a disease in every country in the world. And so we really want to understand how to best do that.

And this is an unfunded mandate, but one thing we need to do is share best practices and learning how to do that. And we will often learn as much as we give back for the language issues that I talked about before, for understanding what often that partnership says; “you guys are too academic. You have too many visits that have to be done in a clinical trial.” We could do it with four, and we learn to get simpler, and that’s more patient-centric and more focused.

So the partnerships are good when they are a partnership with the primary caregivers of cancer delivery throughout the world, in our global initiatives.

Pisters: Otis, this is a great topic for discussion. And, in fact, the question you pose is one that was part of our strategic planning and conversations in many meetings. And it comes from experience that we have: we operate a cancer center in Madrid, we do work in partnership in Sub-Saharan Africa. 

And the net result of our strategic planning conversations is that we reached the conclusion that single institutional efforts are highly inefficient. And our resources are probably best allocated in partnership with the WHO, with UICC, where we can come together and take full advantage of their talent, their infrastructure, their footprint, in some of these areas of the world where there’s massive unmet need.

So I think as you see us moving forward, you’ll see us working to expand our partnerships with organizations that already have a global health mandate, and helping them with oncology care delivery and new ways of extending prevention and screening into the developed world.

Brawley: Question: does each institution have an institutional historian, number one; if so, do you know what year you became an NCI-designated Comprehensive Cancer Center? Did you have to apply? And was there peer review, and what did peer review look like at that time? 

I should point out to the people who asked those questions that all four of us were not in grade school when this happened.

Johnson: So yeah, I could start. So, we don’t know the exact year. We’ve tried to find it. We were one of the first. We did not have, because we were, as I’ve said before, we were a large city for its size, we had preeminence of this longstanding cancer center.

And so we got designation without even applying, and we were one of the first of just a handful of centers that got designated initially. We were also, when we did have an application, we were one of the first folks to get comprehensive status officially, and so forth.

But we do have an historian on our staff. Roswell Park, as you could well imagine—I mean, this, I don’t know if you guys can see this. This is a tobacco box that was Roswell Park’s. It sits on my desk. And I don’t use it for tobacco anymore.

We have a lot of his: his desk, his file folder, x-ray folder, all wood, very beautiful furniture, still sits at Roswell Park. We have it where people can look at it. We have many. We have his death mask. We have archives of records and documents.

And so we have, yes, we have an historian who pays attention to all these things. So a very rich history here.

Thompson: So I will say I envy Candace. We do not have an historian per se, but we have a tremendous library service with a number of people with PhDs in information science, so they’re good at finding that, and we have tremendous archives that we keep that we can draw from the record.

So I can tell you that our first grant that is a cancer center grant was the one I talked about in 1964, that our team was able to drag out. 

What I understand is that there were three outcomes that were relevant to us for the National Cancer Act:

The first was, the chair of our board became the head of the National Cancer Advisory Board—that was Benno Schmidt because Laurence Rockefeller didn’t want to serve. So that’s the historical record. And he nominated Benno Schmidt, and Mary Lasker and Richard Nixon picked him to be the first head of the National Cancer Advisory Board, which started as part of the Cancer Act to oversee this issue and continues to oversee the NCI.

It allowed three cancer centers—because in the act it was anticipated that there would be comprehensive cancer centers—three cancer centers passed through until 1973 to actually be the founding ones without a further application.

And the current directors were in grade school then—Candace, Peter, and myself—because we represent those three institutions that were already considered without an application to do that. That doesn’t mean every five-year since then we had to do it.

Johnson: No, it doesn’t.

Thompson: Exactly, but we were allowed to do that. 

And the one thing that I just want to say, because it’s a very proud part of our tradition that Benno Schmidt brought as part of the NCAB, because there was great concern.

What you may not know is that the director of HEW, which is where the NCI was under at that time, was against the National Cancer Act. And there was a large number of really high quality scientists, some of whom ultimately were chosen to go into the NCAB, who believed, because cancer didn’t have this physiology history, that the money would be wasted on trying to do things that were too close to the clinic and not fundamentally grounded in science.

And the one thing that happened for every center, and it came because Mary Lasker timed the National Cancer Act ask perfectly—you may not know this, but she started the ask immediately after the landing on the moon. And she said, “This is the next thing we’re going to do.”

It was the way we channeled the excitement of going to the moon that Kennedy launched into the Cancer Act, and every center increased their funding over the next decade.

And so, not only did basic science funding—because there were grants increased for cancer—not only did cancer center grants happen, but it raised the molecular biology revolution, and the US’s ability to lead it in every discipline, because Congress got the message that this was an opportunity.

So it’s a tremendous celebration, this 50 years, of what it’s delivered and that delivery, I’m proud to say, happen at every field because cancer touches every organ.

So the other institutes that are dedicated to organ-specific disease benefited as well. And we’re really proud in our history with our role in that, around Benno Schmidt’s role in the first NCAB and making that message clear to Congress, as he did.

Pisters: We’re very much like Sloan-Kettering in the sense that we don’t have a historian, but we do have archives and excellent librarians. I think the flip side to your question, Otis, is, a lot of old history can really be put together with memos and letters that are in paper files. And now we’ve moved to a digital environment—I’m completely paperless myself.

And every now and then I’m wondering, how is the history of this period ever going to be documented? Because it’s in a bunch of deleted emails, it’s on a bunch of servers. How are we going to take the archivists of the modern era and help them to chronicle today’s history?

Brawley: That’s a really, really good point.

Johnson: We have a book that I have to mention that’s pretty special. So it was a bound book that had blank pages in it. Roswell Park started it, so it starts back in 1898, and every time a visitor came and gave a seminar, you signed—or a dignitary or something.

And so, we still have that book. And we’re not using it for people that are coming now anymore for seminars, because we want to preserve it, but, to page through it, it’s remarkable the people that came through, and it’s a very treasured item. So I think it’s important to—I agree with Peter—we don’t want to lose our past.

Brawley: We have 10 minutes left. There’s a couple of questions here about “what are your cancer centers doing to advance health equity,” or “what are you doing to overcome health disparities?” 

I’m going to take the moderator’s prerogative and say that I believe that that’s not just the cancer centers’ obligation—that’s more of a global obligation for society at large. And I’ll even invoke my own personal belief that the cancer centers have done a lot more than a lot of other people in terms of this. 

But anyway, let me give you the opportunity to address that, and, at the same time, because this is probably the last time we go around, what do you expect for the future of the cancer center? I don’t know who wants to go first.

Johnson: I can go first. I think one of the things—we’ve talked about some of the things that we’re doing in our [centers], for our disparate populations across the board and all, both Peter and Craig, we’ve all done and, Otis is exactly right, it’s sort of the mantra of an NCI-designated center.

But I have to tell you, the recent times, with what’s happened in our country, has made me reflect even more on this. I don’t think it’s enough just to go into our community and do the kinds of community engagement kind of things that we’re doing, as it relates to CCSG.

I think that the way we’re going to really make connections is we have to have more physicians, nurses that are African American, or indigenous population, or LGBT.

We need to be more. You know, all of our centers are very diverse. That’s the thing I love about this field is you meet people from all over the world, diverse backgrounds, religions, gender, everything. And it really adds to the richness of each one of our organizations, but we could do more.

And I think that I’ve been very sensitive to trying to make sure that Roswell Park is a place of inclusion, where people can come here and feel safe and be able not only to work here, but also to be treated here.

And I think it goes to—it’s a little bit bigger than just some of the community engagement things that we have. And I think it’s important. I feel a responsibility in this area, and in our community.

Thompson: So, I’ll just echo what Candace said. I think the recent events have reminded us of how important, as part of health care delivery, that people come to see commonality with their caregivers, so that they feel that trust. That convenience is that we’re seeing that’s driving vaccine hesitancy and other things about.

We probably already had a chief diversity officer, and across our whole workforce, we do mirror New York. And we’re very proud of that. We needed to reach out to the populations that were underserved in every way, shape and form in New York to even a greater extent than we’ve talked about. 

An example:

I was very pleased that last summer we were able to have Carol Brown take our chief equity officer position, that we started as part of this, to redouble our efforts, as Candace just said. We needed to understand that we don’t have enough diversity in our senior ranks, particularly of our physicians and our senior researchers. 

We are not as diverse as the community we serve and we need to do better. So we have tremendous programs that, quite honestly, The Cancer Letter has profiled in the last bit of time about our educational mission at high school, at college.

They reach out to diverse communities, but we also needed to do that at the top of the organization. 

We’ve done that for women—more than 50% of our leadership is now female. So that’s worked nicely over the last decade, but it doesn’t mirror the rest of the diversity that we need to achieve.

And so we have asked, and had our diversity council that we stood up, that represents all aspects, in order to set real stretch goals about how we as a leadership match the diversity of our community. We are going to do our best to match that.

I think this was, as Candace said, a wake up call for all of us, that we were not doing enough. But, as you’ve said Otis, this is central to our mission. If we’re going to get the trust of the community to drive cancer care forward, to have people take prevention strategies, which we’ll never know whether they worked or not, we’ve got to be able to represent them in every way in which they feel we are their community. And that’s what we’ll do over the next few years.

Brawley: Peter?

Pisters: Yeah. Just to build on what my colleagues have said, I think that, as we formulated our strategic plan, we spent a lot of time looking at these societal issues and things such as our carbon footprint or a commitment to diversity, equity, inclusion received tremendous internal discussion during the process of co-creating our strategic plan.

With respect to DEI, what we didn’t want as a landing spot was an archipelago of tiny initiatives within the organization that could be at the sub-unit level or in an academic department. But we needed an institutional approach. 

By building it into our strategic plan, we know that resources will be allocated, there’ll be an executive committee that reports to me with defined metrics, and we can really drive change that’s meaningful over time.

As we really look at the issues of health disparity, we have an entire academic department that’s focused on the elimination of disparities that is very, very important to us. And we want to really conduct systematic research to better understand the drivers of disparity, and what our role is in addressing those gaps.

So I think that the issues that our country has faced in the aftermath of George Floyd, a lot of the discussions that have taken place, and the COVID pandemic, have highlighted the disparities that are present in our own country. And it really galvanized academic medical centers around the country to really lean in on this topic.

We know how important it is to our workforce. We know how important it is to our community. Houston is the most diverse city in the United States. We need to reflect that diversity, we need to embrace that diversity, and we need to define how we’re going to get all elements of diversity and inclusion.

Diversity and inclusion are not the same. Diversity is a descriptive fact, inclusion requires acts—and deliberate acts, and strategy. And that’s the conversation that we’ve had as we embark on a big institutional effort on DEI.

Brawley: We only have a couple of minutes left and, the issue of disparities—one element is cost. Costs are going crazy. I prescribed a drug yesterday and patient, told me that it was $15,000 a month for his oral medication. How are we going to overcome this—we don’t have time for that. 

Tell me, are you optimistic? And if so, why? Overcoming disparities, overcoming costs, getting increased access? Are you optimistic? Yes or no? And if, if yes, why?

Johnson: Yes, because—I will answer it immediately—I’m a very optimistic person. And I know the challenges are great, and cost is a big one. And that’s a whole—we could spend a whole other two hours just on that. But I’m optimistic that the future is bright for us, and we will find a way.

And I think some exciting things are going to be coming around. I think science, I think there’s so much exciting out there right now, that I think I’m very optimistic about the future for us in cancer, in cancer investigation.

Thompson: So I’m of two minds. I, like Candace, I think that the science and the advances are going to deliver and the healthcare costs of actually being in the hospital or receiving chemotherapy. It shouldn’t be that there’s a higher copay for an oral medication when you don’t need infusion. And you can do that Otis, as you just pointed out. I think that’s going to happen and it’s going to quickly come down. Right now, the costs are too high. 

What I am worried about is the financial toxicity as we recover from COVID, and we go through all this, that are not part of the health care costs.

To get the best out of cancer care right now, you need a caregiver, you need somebody else that can take it. In a family that’s living close to the poverty line, that’s losing two incomes if both members of the household work: the caregiver and the patient with the disease.

We find the financial toxicities of loss of time from work, loss of pay, the cost of transportation, of food security, are really the things we are going to have to struggle with going forward.

We have institutional resources for all of those, but they are just not sufficient to meet the toxicity that people are facing, as they face a cancer diagnosis right now. And, oddly, the government rules don’t allow us to supplement on certain levels, as you may know.

Brawley: Yeah. Dr. Pisters?

Pisters: Otis, let me just say the obvious: I am wildly optimistic. When you look at four of us on this panel discussion today, it’s accurate to say we’ve all been in this business for decades. And the reality is that the last decade has been like no other decade in our professional lives.

When you look at the strength of our institutions, you look at 51 Comprehensive Cancer Centers across the United States, there couldn’t be a better time to be in oncology. The kind of innovations, the discovery, the amazing things that are going to happen in the next 10 years… I can’t wait to see it happen.

Johnson: Yep.

Brawley: I’m just going to end by saying, you know, I saw a guy yesterday. He’s had stage four non-small cell lung cancer for 12 years. I don’t think I would have thought that possible 20 years ago.

Johnson: Yeah, I know. Amazing, I know.

Brawley: This has been a great conversation. I want to thank Dr. Candace Johnson of Roswell Park, Dr. Peter Pisters of MD Anderson, and Dr. Craig Thompson of Memorial Sloan Kettering.

I really enjoyed this conversation. I want to thank you, not just for being the leaders of incredible cancer centers, but for being incredible scientists, and for your contributions, and also being incredible personal friends of mine.

I want to thank you and have a good evening. This is a recording for the Cancer History Project, and it’ll be available on CancerHistoryProject.com. 

I want to thank Katie Goldberg, who has orchestrated this whole thing. And I want to acknowledge my partner in the Cancer History Project, the co-editor Paul Goldberg. So, good evening folks.

Thompson: Thank you. It was a privilege for all of us to participate.

Johnson: Thanks, Otis.

Pisters: Thanks a lot.

Johnson: Thanks Craig, Peter. Great to see you.