Previously unpublished “memos for the record” by program’s first leader, John Yarbro, tell all

Soon after starting work on a book about the role the NCI-designated cancer centers have played in the National Cancer Program, Skip Trump and Eric Rosenthal got in touch with John W. Yarbro.

Yarbro got on their list because in 1971 he testified at congressional hearings about S.1828, the Act to Conquer Cancer, a bill that later morphed into the National Cancer Act of 1971.

At the time he testified, Yarbro was the founding director of medical oncology at the American Oncologic Hospital, the cancer hospital adjacent to the Institute for Cancer Research, which would merge to become Fox Chase Cancer Center in 1974.

Trump and Rosenthal also knew Yarbro as one of the founders of the Association of Community Cancer Centers, and they recalled that sometime in the 1970s he had attempted to earn an NCI cancer center designation for the Ellis Fischel State Cancer Hospital at the University of Missouri.

The authors didn’t realize initially that between 1972 and 1975 Yarbro served as the first director of the cancer centers program at NCI, and during that period, he presided over designation of five comprehensive cancer centers—that’s in addition to the three that were recognized as comprehensive at the time of the signing of the National Cancer Act.

“Unfortunately, in the midst of our interview, John got ill, and we never really finished anywhere near as a much of an in-depth discussion as we would’ve liked,” Trump said to The Cancer Letter.

Yarbro died on April 13, 2020, at age 88. After Yarbro’s death, his wife Connie H. Yarbro, one of the founders of the Oncology Nursing Society, sat in for an interview with Trump and Rosenthal and gave them several undated memos that Yarbro appears to have written in mid-1970s.

The documents serve as a basis of a section of Trump’s and Rosenthal’s book, “Centers of the Cancer Universe: A Half-Century of Progress Against Cancer.” Trump, Rosenthal and Connie Yarbro gave permission to the Cancer History Project to publish the originals of John Yarbro’s five memos.

“What we were really fortunate to be able to review, thanks to the kindness of Connie Yarbro, was a series of notes that John put together,” Trump said. “The notes are undated and it’s only by inference that one can estimate what they were for. They were titled notes to file.

“My hypothesis is that John wrote these notes in late ‘74, early ‘75, as he was preparing to transition out of the job as head of the cancer centers office at the NCI to become the director at the University of Missouri Ellis Fischel Program,” Trump said.

“When we first saw [the materials,] I said to Skip, ‘This is pure gold.’ We didn’t expect anything to unearth something like this. But we did,” Rosenthal said to The Cancer Letter.

The observations, contained in five documents, are undated and labelled “memorandum for the record” by Yarbro. They appear to be intended to provide Yarbro’s successor at NCI with his views of the capabilities of those centers aspiring to gain designation as well as his thoughts on the development of departments of oncology for successful cancer centers, Trump said.

“My fantasy was that John was writing these for his successor to give him an orientation opinion of John Yarbro,” Trump said. “If he did that, these were then copies of what he gave to his successor. So, I think it’s a fair hypothesis that this is the first time these have come to light, certainly publicly.”

The three comprehensive cancer centers in existence from the outset were MD Anderson, Roswell Park, and Sloan-Kettering.

At the time of Yarbro’s departure, comprehensive designation was given to five more centers: the Sidney Farber Center in Boston, Fred Hutchinson Center in Seattle, Wisconsin Center in Madison, Greater Miami Center in Florida, and the Mayo Foundation Center in Minnesota. (The Cancer Letter, July 18, 1975.)

According to NCI at the time, the following institutions were identified as developing comprehensive cancer centers: Fox Chase Cancer Center, affiliated with University of Pennsylvania; Colorado Regional Cancer Center; Duke University Medical Center; Georgetown University-Howard University Comprehensive Cancer Program; Illinois Cancer Council; the Johns Hopkins Medical Institutions; University of Alabama, Birmingham; University of Southern California (with the Los Angeles County Department of Hospitals); and Yale University Medical School.

The memos about relative strengths and weaknesses of these institutions are written in Yarbro’s swaggering, Churchillian sweep. Reading the memo on emerging cancer centers it’s important to know that some of the institutions he slams ultimately ended up doing quite well, while some of the ones he praises ultimately faltered.

Today, as cancer centers that are trying to capture their histories, the Yarbro memos offer a valuable opportunity to look back to the very beginning of the cancer centers program.

“This program represents the major disaster area and possibly the major blunder of the cancer centers program to date,” he writes about the Colorado Regional Cancer Center. “Next to Denver, this is the worst we have,” he writes about Georgetown-Howard Cancer Center.

Yarbro offers pragmatic advice on handling the Hutchinson Cancer Center:

“The political problem with the Hutchinson Center revolves around the fact that the director of the center, Dr. William Hutchinson is a close personal friend of Senator [Warren] Magnuson [(D-WA), at the time chair of the Senate Commerce Committee] and he makes frequent calls to the senator often on relatively trivial matters which can result in a vast expenditure of staff time in solving the problems which he causes. As a result one must be exceedingly cautious in dealing with this cancer center and care must be taken to identify requests which Dr. Hutchinson has an interest in. I have found by experience that it is easier to surrender than to fight one of these battles.”

Hahnemann University, Yarbro similarly notes, “presents a particular problem in that they frequently work with Congressman [Daniel] Flood [(D-PA), a senior member of the House Appropriations Committee] and must be treated with extreme caution.”

The documents, labeled “Memo for the Record,” are being published in full here for the first time:

  • Trouble spots in Comprehensive Cancer Centers;
  • Developing Comprehensive Cancer Centers;
  • Comprehensive Cancer Center evolution;
  • Core Grant evolution;
  • Department of Oncology Development Grants;

As Yarbro left his position at NCI in July 1975, he gave a pithy exit interview to The Cancer Letter:

“Some of our centers are one-man operations,” Yarbro said at the time. “They exist only because of the leadership of a single, dynamic individual and are not established as viable academic entities. In such cases the loss of the leader can result in the collapse of the center into fragmented multi-departmental uncoordinated programs.”

Yarbro’s goal on departure from NCI was to build an NCI-designated cancer center in Columbia, Missouri.

In one of the memos, he lays out the vision for the cancer center in that state. An approach under consideration would create a department of oncology within the university “which will have departmental autonomy and which will be responsible for the staffing of the Cancer Research Center and the Ellis Fischel State Cancer Hospital.

“In addition, [there will be] a statewide organization involving two osteopathic medical schools as well as the medical school in Kansas City affiliated with the University of Missouri and the medical school at St. Louis University in a consortium for a statewide cancer control effort,” Yarbro wrote in the memo that doesn’t note specifically that he is planning to depart—or perhaps had already departed—for Missouri. “If this complex arrangement can be successful, and there is reason to hope that it may be, then this program will be a candidate for site visit for comprehensive status in 1976.”

Alas, Yarbro’s efforts in Missouri didn’t bring desired results, and he resigned as director, blaming political resistance to creating a coordinated cancer program.

“In three years, we’ve accomplished what I thought we should have accomplished in three months,” Yarbro told The Cancer Letter at the time. “I’m ashamed to go to NCI and ask for renewal of our grant. We have made some progress, but not enough. I have seen other center programs worse than this.

“We could put on a floor show and perhaps get renewed, but I feel too strongly about the centers program and I will just not do it. People here just do not want to work together. There have been too many picky roadblocks. It would not be ethical to try to cover it up.”

Trump and Rosenthal spoke with Paul Goldberg, editor and publisher of The Cancer Letter and co-editor of the Cancer History Project.

A video recording of the conversation is posted above.

Paul Goldberg: Well, gentlemen, thank you so much for agreeing to talk with me and congratulations on getting this book published.

It’s no small achievement. I thought there’s a lot to this book. And I thought one of the things we could discuss first, that I’ll really focus on, would be one of the chapter on one of the characters.

The characters is really why we all have stuck around in oncology, as long as we have. So, the character I’m thinking about is John Yarbro. And this is, to me, a fascinating chapter, because, of course, I knew John, and all of us knew John, but this is like, what is his job in 1971? What does he do? And when does he leave? So, let’s talk about him.

Skip Trump: Yes, we’re happy to be here, Paul, and we were really lucky to not only have spoken with John, as it turns out very shortly before he became ill and his death, but then in follow-up his wife, Connie Yarbro, who is a contributor to cancer history in her own right, as one of the co-founders of ONS and a distinguished nurse educator, and learning what John’s background was.

And then coming across documents that we’ll talk about in a little bit was a real treasure and a highlight for both Eric and I—I’m sure I could speak for Eric—in writing the book.

Eric Rosenthal: What was interesting, Paul, was when we identified John originally, it was as one of the people who testified in favor of a National Cancer Act. And we weren’t that familiar with his background at that point in time.

Through the digging, we saw that at that point in time, when he was testifying, he was at the precursor of Fox Chase Cancer Center, and testifying on their behalf.

It was only after we spoke to him and Connie, we found out that he also had been the first director of the [NCI] Cancer Centers Program, which made his value even greater than before.

And we were able to speak with him, as Skip said, and Connie, right before he took ill. And we continued our conversations with Connie, who also shared really valuable information from John’s archives about his observations, about the original cancer centers when they were actually trying to put in for designation.

Well, when you think about the National Cancer Act, people think, well, it’s about cancer research. Yeah, it is. But it’s also a public health measure, and it’s easy to forget that it is that. So, here’s John as head of the first cancer centers branch, whatever it was called then. What was it called?

ST: Among the things, it’s hard to pin down or a lot of the details of the early history of the National Cancer Program, Paul, I believe it was the Center for Cancer Centers or the Branch for Cancer Centers, but it’s not entirely clear.

ER: The nomenclature as you know, Paul, changes quite a bit over the years, with each subsequent bureaucracy at NCI, and they’re constantly renaming their different offices into different variations.

So, what’s John’s job? Back in ’71, ’72; right? When did he come in? Do we know?

ST: Well, I think it’s important to start even a little before then, Paul, because a point that I think very few people know I would hazard a guess, is that, as Eric mentioned, John testified in the hearings leading up to the passage of the National Cancer Act.

So, John was one of the experts called, because at that time he was head of medical oncology at what was to evolve to be Fox Chase.

But, at that time he was head of medical oncology at American Oncologic Hospital, closely associated physically with the Institute for Cancer Research. And John was obviously an advocate for the NCA and cancer centers and all that the NCA was hoping to accomplish.

But John pointed out that it’s time that the public and the federal government paid more attention to cancer, because he noted, and he did the calculations of abstracts presented at the federation meetings in Atlantic City, noting that cancer was disproportionately underrepresented as a discipline disproportionate to the mortality rates from cancer, compared to heart disease.

So, John was one of the first I came across, who pointed out that in the ‘60s and early ‘70s, inadequate attention was being paid to cancer and targeted to this relationship between number of abstracts on heart disease versus cancer research at the federation meetings.

That’s called Disease Olympics, I believe.

ST: Yeah.

He is one of the founders of Disease Olympics?

ST: Yeah.

But, so he comes into this job. Here’s this guy sitting at a government desk in Bethesda, and he’s a former cancer centers guy, even before there is a cancer centers program. And his job is to do what? To identify cancer centers?

ER: To evaluate whether or not they will have what was essential to become a cancer center as the National Cancer Act had defined it.

Just one thing I want to say, Paul, just backing up a little bit. One of the challenges we had was, we wanted to speak to as many people as possible who were around when the National Cancer Act was being passed. And that became a challenge, because you had to be relatively senior at that point to be involved in this, which would place most of those individuals in their late ‘80s or ‘90s.

And John was one of the few people we met. Joe Bertino had been another who was around at that time.

But the other thing was, I remember conversations I had with my good friend Jim Holland, 11 years ago about the National Cancer Act. And I never took notes back then, because I never knew we would be going to this depth.

And I think Skip and I both have that experience, having spoken with so many people who were involved at the beginning, but who are no longer with us, and we have a memory of what they said, but not exactly what they said.

I know exactly what you’re talking about, because I’ve done the same things, and I didn’t have the foresight to keep notes, but we still had pretty good view of what happened.

And having just seen the people involved means a lot, but let’s go back to John. So, his job is to sit there and figure out which cancer centric gets the designation. So, his first were… I know we’ve sparred on the subject. What were the first ones, as far as you could tell based on that memo? I think it’s three.

ST: Well, yeah. And the sparring you refer to, Paul, gets back to the uncertainty Eric alluded to as to records at the NCI.

What we were really fortunate to be able to review, thanks to the kindness of Connie Yarbro, was a series of notes that John put together. The notes are undated and it’s only by inference that one can estimate what they were for. They were titled notes to file.

My hypothesis is that John wrote these notes in late ‘74, early ‘75, as he was preparing to transition out of the job as head of the cancer centers office at the NCI to become the director at the University of Missouri Ellis Fischel Program.

And when one looks at the documents that are available, our best estimate is that at the time the NCA was passed, the National Cancer Institute judged that the Roswell Park, Memorial Sloan Kettering and MD Anderson met the criteria for comprehensive cancer centers.

So, they existed at the passage of the NCA. The sequence in which others accomplished that goal, or that title, is a little bit murky.

So, I guess we were in complete agreement, sparring notwithstanding. That’s exactly what we saw, based on very different sources. And that’s another question. People forget that 1971 there weren’t that many oncologists.

ST: And, and most of them weren’t oncologists, because that discipline really didn’t exist in 1971.


ST: Pathologists like Sidney Farber and radiologists like Henry Kaplan. So, yeah, another part of this story is the evolution of the various specialties. And now we’ve segmented ourselves into sub-sub-subspecialties, but we forget that in 1971, there were only a handful of people who bothered to focus their career and energy on cancer.

ER: And then there was all the politics involved within medical schools and medical organizations, resistance to having cancer centers or cancer come forward as a separate discipline.

The hematologists were opposed to that, as having cancer centers versus what’s they called cancer programs. And it was just an uphill battle. There were organizations which are great, great supporters today of the National Cancer Act, such as the AACR, which was opposed to it at that point in time.

However, what was interesting was, its president at that time, Jim Holland, was one of the people who… Even though he’s president of AACR, he was on the other side of the tabulation who was voting in favor of it. So, it was just a lot of strife in terms of the medical, preceding oncopolitics, and the politics that was actually going on in Washington to get the act passed.

I think one of the other obstacles we found was the lack of records.

We contacted NCI a number of times to find out when various cancer centers were designated or when they had received their planning grants. And what we learned was there was a federal records management mandate destroying all records every seven years in federal offices, including HHS and NCI.

And we really couldn’t believe it. And we kept asking different people, including we even asked Ned Sharpless in one discussion, he was unaware of that.

So, we had to go back to the cancer center program directors in the past and rely on their memories as to what actually happened. And one of those people was Linda Weiss, who gave her observations about the cancer centers and what was happening with them and the formation of them.

And she basically also said that NCI fudged on certain issues in terms of answering the question, they didn’t know who was first, or what was a cancer center. Again, most of the cancer centers that evolved later, many of them started out as either independent hospitals or research centers.

There were very few that were combined as academic medical research centers or comprehensive cancer centers. Memorial Sloan Kettering, Roswell Park, Fox Chase. Many of the earlier ones were different institutions that came together to form a cancer center.

Right. Let’s go back to John. Everything you’ve just said makes that long memo that you’re quoting at length and that we would love to be able to post in the Cancer History Project all of the more valuable, because here’s this guy who is sitting there and saying, “Well, I have real problems with this place, or this place has this potential to do this, and this place doesn’t have any potential for anything.”

It’s just a fascinating memo. Can you talk about the memo more?

ST: One of the striking things, if you reflect on some of the things John said, and what the stated purpose of the centers program is, folks often forget that the cancer centers are designated because they achieve a certain level of excellence in cancer research, clinical research, population research, and there’s never a measurement or a specific evaluation of the care of cancer patients.

It’s expected that the care would be great, and it’s expected that the region would be impacted, but John on at least one very clear occasion in his series of notes made the observation that if a certain center that he was criticizing disappeared tomorrow, there would be no noticeable change in the terrible cancer care that was being received by the patients in that region, implying with or without the center, the care was not so good, and that the center needed to get its act together.

ER: And he also indicated in certain cases that if certain cancer center directors were no longer at the helm of that cancer center, that cancer center would cease to exist.

Give me some examples; or what’s your favorite part of it? Is there anything you want to highlight?

ST: I think that [G. Denman] Denny Hammond and USC, John basically said if Hammond were to leave, the center at USC would dissolve.

He also recounted the story of Rochester and its attempts, which apparently were fairly vigorous in the late ‘60s, early ‘70s, to develop a cancer center, but then Dr. Tom Hall left Rochester and in John’s words, of the effort dissolved, and there was nothing left of the foregoing organization.

“Leadership matters,” to quote Joe Simone, as one always should.

ST: Yes.

So, that explains then, when you’ve seen one cancer center, you’ve seen one cancer center.

ST: Right.

ER: Joe looms large in our book, also. We have interviews with him. The other thing is… And Skip, we’re not really sure who has ever seen these [Yarbro’s] notes. Isn’t that true? As far as we’re concerned, we may have been the first to unveil it. And, Paul, if you put them into your History Project, that may be the first time they all see the light of day, because we’re not sure where they went or if they even made it to the NCI leadership afterwards.

My guess is that nobody ever saw them. Because something like this, it’s a note to file. Why would you show it to anybody? It’s just something that you do out of just probably act of frustration; right?

ST: My fantasy was that John was writing these for his successor to give him an orientation opinion of John Yarbro, but you’re quite right. If he did that, these were then copies of what he gave to his successor. So, I think it’s a fair hypothesis that this is the first time these have come to light, certainly publicly.

ER: Even if these observations were subjective. And we don’t know whether they were or weren’t. We do know, at least they’re coming from somebody who is in a position to view cancer centers. So, it’s fascinating just in and of themselves to see what he was saying and what he was saying about different centers and different individuals.

I knew him when he was one of the leaders of ACCC. So, he was really more interested in community centers, which is a fascinating idea, because I would’ve met him around, I would say in 1986. So, it’s a whole different phase.

How do you go from that phase, from the academic cancer centers phase to the community cancer centers phase? Did you get that sense about him, why? What’s the… Or how…

ST: No, and that’s a very important concept, Paul, I think, because originally the main reason I wanted to talk to John was to explore his transition from the NCI to Ellis Fischel and Missouri, and what the barriers and hurdles he found at Missouri in achieving NCI designation.

Unfortunately, in the midst of our interview, John got ill, and we never really finished anywhere near as a much of an in-depth discussion as we would’ve liked.

I can only imagine that the difficulty in assembling the support necessary for an NCI application at Missouri and Ellis Fischel that John ran into that seems to persist to this day led him to focus rather than on academic, scientifically oriented cancer center on trying to organize cancer care in the community and to develop a strong community-based program.

That’s an interesting bit of insight about his evolution, because I never would’ve even thought that he was the director of the Cancer Centers Program at NCI. I knew him as this guy who was pretty funny, but in a very also prickly and scary, in a sense, if you don’t know whether he’s a good guy. Because he had that sense of humor.

ER: As I noted earlier, when we spoke with him originally, we didn’t know that either, versus having testified for the National Cancer Act and then knowing his background at the American Oncologic Hospital.

But when that came up, all of a sudden, lightbulbs started blowing up all over our heads when we found that out, because that was a dimension that was more critical than anything else that we had known about him or most people we spoke with. If he had a bird’s eye view of the Cancer Centers Program, as it was being created.

My God. And here you are. You find an amazing document that nobody even people who knew him knew about.

ST: The striking thing in the document, Paul, is that in 1974, ‘75—almost certainly that was the timeframe—John summarized the challenges and problems that confronted those seeking to develop cancer centers for the next 50 years.

He pointed out in several of his commentaries that lack of support by the dean was going to be a problem at this center. Lack of resource commitment to establish independent space was going to be a problem.

He criticized one very prominent center early on, Johns Hopkins, noting that Al Owens, who was the founding director at Johns Hopkins was not thinking sufficiently broadly to develop a broad cancer research program and was focused on more narrow topics, which I think is a fair criticism, looking back at the history of how Hopkins developed. So, if you read what John wrote carefully, he captured the zeitgeist of developing a cancer center very early in that history.

ER: And he didn’t pull any punches when doing it. He’s very explicit about how he thinks and how he feels, which makes it all the more… Well, it’s colorful, but it also seems much more real, because it’s not a bureaucratic rendering of an analysis. It’s basically his observations on what he’s seeing and what’s coming to him in terms of proposals for cancer centers.

Well, also, we just skipped right over it. But this whole genre of a memo to a file is… You’re writing an intimate note about programs to your filing cabinet and putting it under probably misfiling it deliberately, so nobody would find it, God forbid; right. So, he found a Rosetta Stone or some such.

How often do you ever see this? I know only one memo to file that I’ve ever read. And that was about in the midst of the NSABP scandal; right? Skip never wrote one of those. Have you ever written a memo to file?

ST: Well, I have on occasion, but it’s usually for HR concerns, not historical or organizational concerns.

ER: But then, when we were talking to him and Connie—and by the way, it was during that initial interview that he had his first episode, and we had to get off the phone—and Connie said to us, “John is ill, we have to get off.”

We followed up with Connie the next day, to see how he was doing, and she was doing, and we found out he had been hospitalized, and it was a few weeks later that he passed away.

So, Connie wanted to continue, and she, as we said before, not only as the spouse of somebody who was walking through history, by his side, but somebody who was also involved in the history of oncology nursing, which also followed the history of oncology in those days, continued talking to us. And she was the one who shared these things.

When we first saw that, I said to Skip, “This is pure gold.” We didn’t expect anything to unearth something like this. But we did. And you’ll help bring more of it to light.

This will be amazing. Tell me more about what did he die of? What was the episode?

ST: Well, we didn’t delve into detail, but I think it was a cerebral vascular accident that caused the termination of our phone call. And, presumably, it was continuing neurologic difficulties from that.

Oh my God. So, you really got him at the right moment, literally.

ST: Well, as Eric alluded to, it really is a striking illustration of how the history of the centers program and the NCI is slowly—well, maybe not so slowly—ebbing away as these founders and giants who were there at the beginning are no longer with us. So, that plus the observation that Eric made about the lack of documentation…

One of the points that we emphasize whenever we get a chance is that institutions should keep track of what they’ve been doing, because some day somebody is going to want to look back at it, and it’s interesting how little attention most places spend on the history of their entity.

ER: The three of us are also very, I will say, blessed and honored to have been in contact with so many of these individuals over the decades, knowing firsthand, becoming friends with many of them. And that’s really helped in us enrich the book, because we knew the people we were writing about, even if they were no longer with us.

But it’s also serendipity, aside you and I, Paul, among the very few people who have written over the years for a larger audience about the biographies of these founders of oncology.

And a lot of the serendipity. I remember when I last spoke with Jimmie Holland, which is probably her last interview. At that point she told me… Jim, before I interviewed her, because she didn’t think Jim Holland was going to last that long. And then she predeceased him, but it’s just a matter of the timing that makes it so fortunate and unfortunate at the same time.

Well, but definitely a privilege for all three of us, that we did know many of those people, because you’ve seen the person, you can actually have a better sense of how to write about them.

ER: Joe Simone is another example of somebody who died during the course of our writing this book.

Joe… Well, let’s go back to Joe for a moment. And this is picking up also on something Skip just said. Joe’s line that “If you’ve seen one cancer center, you’ve seen one cancer center…”

Is that becoming more homogenized? Is there more of a standardization, are they becoming… If not one cancer, you’ve seen one type of a cancer, so one group of cancer centers. Is there a homogenization of them?

And, of course, Skip has run many cancer centers of many different kinds. Tell us.

ST: I guess my view would be that the Simone maxim persists.

The models continue to evolve and yes, there is standardization. Some of which is good and has been incited by the desires of the NCI, some of the standardization, maybe not so good, but all in all, I think each center has its own ethic, its own pressures and challenges.

In general, you’ve got to have the support of the dean in order to have a successful cancer center, but that support can be developed in many, many different ways, and using various forms of persuasion that can be developed in other parts of the community. So, I think the Simone maximum continues to be a truism.

ER: Well, I agree, but I think there are more cancer centers being created, which are similar to other cancer centers. You don’t have some of the vast differences. One of the things that the National Cancer Act talked about was creating 15 new centers, and the model they were looking at was the model of Roswell Park, Memorial Sloan Kettering, and MD Anderson in those days, which were really freestanding institutions that combined basic, clinical and prevention research under one roof.

As Skip has noted, very few institutions have been created as freestanding since then, most of them have been matrix of one sort or another, but they also seem to be working.

The other thing that John kept pursuing and we’ve mentioned this several times is the need to have independence of a board, independence from the dean, and basically a ranking among peers of the cancer center director with other authorities within the medical complex. And that has absolutely proven to be true over the years. If you want to get things done, you have to have some control.

But there was also in his era, the beginnings of a lot of consortium cancer centers. And that’s an interesting idea, too.

ST: Attempts.


ER: Yes.

Attempts. Well, it was about 10 years of attempts, and NCI put a kibosh on that, pretty much. About 15 years, actually.

ST: Well, but in John’s original notes. He notes both the potential advantages as well as the challenges of the Illinois Cancer Council, which was a consortium of Northwestern, Chicago and Rush, and an example very early on of an attempted consortium model that two of those three institutions subsequently fairly quickly went on to get the independent designation, but shortly after the passage of NCA, they were working on a consortium model that didn’t work out.

Then there was California; right? Northern California?

ST: Later.

Yeah, later, a little bit, but the Illinois Cancer Council ran out of money, basically. That was the problem there. The state money dried up.

ST: I think that’s right. And again, it emphasizes the critical importance of ongoing support, often political support. With that model, it required somebody extra-institutional to maintain the support, which didn’t happen.

ER: And you also… So, I think Michigan Cancer Foundation, and the consolidation of the Wayne State and others, and what it took. Even in Philadelphia. And [John] was familiar with what became Fox Chase, he talks about the fact that… It was originally the Fox Chase-University of Pennsylvania grant that was going in.

And he also noted that, did many of these cities need more than one cancer center? But he also noted which entity of these conglomerations had strengths, and which had weaknesses, which may have had strong clinical presence, but no basic research. And so, in today’s light, it really was very insightful in terms of how he looked at what it took to become a full-fledged comprehensive cancer center.

Yeah, that’s what I loved about that chapter, but is there a reason, is there a need for more cancer centers right now?

Because the original idea was to have regional representation of these cancer centers that are going to be taking care of people as we find the cures and they’ll just be curing them and they’ll be going on along their way. But right now, 50 years later, do we need more cancer centers? I know there are lots being considered right now, at least by their directors, applications are going in, will they be approved?

ER: We have a chapter, that we call the newest kids on the cancer center block. And we looked at the last five cancer centers to get designation. This was from, I think 2012. Two of them had been designated as comprehensive in the past, lost their designation. And that was Mount Sinai and Sylvester Cancer Center, and then got a designation back, but not a comprehensive designation.

But three of them Kansas, Kentucky and Oklahoma, all of which had been underserved areas, all of which had large areas that had no NCI-designated cancer centers, but it wasn’t until they could meet the criteria that was necessary in the basic prevention and clinical size that they got that designation.

So, we chronicle a little bit how they built up those different divisions to come into compliance with what it took to become designated.

ER: There are other areas of this country, which have a lack of any identity of any cancer center nearby, and where cancer… But part of that was… When Mount Sinai tried to become designated again, it was back in… When was that, Skip? In the early 2000s?

ST: Yeah, I think so.

ER: Yep. When they were trying to get designated, there were times when they were running up against the fact that there were a whole bunch of cancer centers already in New York. And we have a story in there when some cancer center directors bumped into [Harold] Varmus when he was still at Memorial Sloan Kettering.

And he thought that they would have a hard time gaining designation because they were New York City based, but to a large degree, they got that designation because they served an underserved area, anyone else was from New York. And that’s part of the mission to be able to reach out to those communities.

Right. It’s very important. The most important thing that’s probably happened in cancer centers is the outreach and engagement component, because that was there, but then suddenly it became very important. Skip, whom would you give credit to for that too, for that rather? Who made it happen? I think it’s Doug Lowy.

ST: Well, certainly, Doug has played an important role in the contemporaneous with the development of the emphasis on outreach and engagement. So, you’re probably right, Paul. And it’s interesting to reflect on the history.

There are still swaths of the country that are not covered by a cancer center, and whether it’s cause and effect or not, but some of those parts of the country are among those that have the worst outcomes in some cancers that we clearly recognize as preventable, like cervical cancer.

ER: And two cancer centers were the newest kids on the block, Oklahoma and Kentucky, both through their cancer center directors had noted they were among the poorest states with very high mortalities in a lot of cancers.

So, those are states that really could use that presence. The question is, in those other states that are still without a cancer center, what can be done to bring that type of excellence to that state or that community?

You could expand catchment areas. You could play with catchment areas. But I’m not smart enough to suggest anything about the way to deal with it. But what I am wondering about is whether the program has reached the point where there is not much need for cancer centers, or my own instinct from just covering the field is the more the merrier.

ST: I think that’s true, Paul, your latter statement, the more the merrier, because as long as a candidate new center, has the requisite scientific excellence and provides a unique component to solving a regional cancer problem, I don’t think there’s any reason, because of some absolute concern about numbers, there should be a barrier put up.

ER: And we have comprehensive cancer centers and cancer centers, which don’t have a comprehensive status, which can still serve that community, but do not have the full measure of capabilities to be designated as comprehensive. So, that’s a step toward at least meeting that need.

But every cancer center director we spoke with, after they get the designation, they all have their plans, when do we need to go for of the comprehensive designation? And the question is why? Is that as important as doing a good job just serving your public?

Well, what about hybrid cancer centers? I’m asking this because of course, you guys are all into hybrid cancer centers. Is that happening still? Is that…

ER: Well, that came out of a series that I had done for MedPage Today. And when I started observing that there seemed to be a number of academic leaders who left NCI designated comprehensive cancer centers, and were going to large community cancer centers or large community hospitals.

Skip was one of the people that I had thought of, because he had made the move from Roswell Park to Inova. And so, at that point several years ago, we put actually a conference together bringing together a number of the hybrid cancer center leaders.

And the hybrid academic cancer center basically is a cancer center that’s within a large community hospital system, but is striving to reach more academic excellence, and go beyond.

It came out of Derek Raghavan’s brain. That’s the way I think of it, but he did come up with this idea, and he was the first person to really start truly engineering it, although there are of course…

ER: And Nick Petrelli also.

ST: It’s a complicated story though, because John Yarbro went to Missouri and Ellis Fischel, presumably to build a cancer center. And for whatever reason, probably politics and limited community support and university support, he was not able to do that. In a similar vein, several folks, including me, have gone to very successful community-based centers, hoping to develop what has been called a hybrid center, and some have been extremely successful, others not so much.

And I think a common feature is the extent to which community institutional, philanthropic, sometimes even government support can be brought to bear. And the history of other centers, Oklahoma had a run at center development with a very successful senior cancer person moving there to get them NCI designation, Howard Ozer.

ST: And that could just not be brought together in talking with the folks at Oklahoma for the book. I think it’s clear that new support and new enthusiasm emerged outside the cancer center that allowed things to happen. And there are other examples of successful folks going to programs, hoping to build a center, and then the resources just don’t come together in that region.

ER: Well, we revisited a number of the centers that we had labeled as hybrid several years ago. And I’d say about half of them were no longer pursuing that goal because they had lost… Basically, unless you have the CEO of the hospital system fully behind you. It’s not going to work.

And it was the clash of cultures between academic and community cancer centers. And to some degree one wonders how much that played a part in not allowing the fruition of the academic part. The other example was you’ve never seen Miami. Who came down from NCI, Skip?

ST: Gordon Zubrod.

ER: Gordon Zubrod left NCI, went to Miami, and almost automatically they became designated as an NCI center. So, one wonders how much was the old boy’s network? How much was politics?

Though, it’s interesting in talking to a number of the cancer center directors whose centers were newly designated, they all pointed out that there was no preference given to them by political leaders, congressmen, senators in their state, that they had to earn their accreditation the old-fashioned way by basically having everything in place, not the favor of politician.

ST: And that loops us back to Yarbro, because there are two centers that appear in Yarbro’s notes, where in John expressed the biggest problem that he had with those centers. I think this was the Hutchinson Cancer Center and Hahnemann was that the director was closely connected to a powerful political personality in the region who made life very difficult for the personnel and the cancer center’s office that John oversaw.

In the case of the Hutch, the politician who was of importance was [Sen. Warren] Magnuson, in Washington. And John concludes that he decided that it’s easier just to go along with the political pressure than to waste energy trying to, you could infer, do the right thing.

So, it stands in contrast to what at least we were able to get at from the current center directors who maintained that… And I’m sure this is true, that there’s not no political influence in center’s designation, but centers are pretty well insulated, I think from overt day-to-day influence.

If you look at National Cancer Act, it’s a fool’s errand to separate politics from oncology.

ST: Right.

Because that’s Mary Lasker and going back to all of that, the whole thing is very political. And did it not work? Of course, it worked!

ST: Yep.

Speaking of which, maybe we should just reexamine the credit for this. One of the oncology zingers that every cancer center has two senators and a variable number of House members—that’s a Vincent DeVita line, at least that’s where I heard that. But have you heard it from anywhere else?

ST: No, that didn’t come up, at least that I recall in our delving into history.

ER: But we did hear NCI directors talk about getting frequent calls from senators and others about put his cancer center on their state. But Mary Lasker, her role was critical also. And here you had not only a public-private effort that was to create a successful National Cancer Act, but a bipartisan effort.

Just within the Lasker home, Mary was a Democrat, and her husband Albert was staunch Republican, and they were the major backers of the American Cancer Society in those days. And then the creation of the National Cancer Act.

Sure, sure, sure. They had that divide running through there, but it was also a different time.

ER: Absolutely.

It wasn’t the divide as it appears till today, but it’s… Yeah.

ST: And I know you all know this, but the other point to mention about Mary Lasker and the Laskers was that their influence was well past just cancer. They were advocates for national health insurance, advocates for mental health legislation.

Mary was the first layperson appointed to NIH advisory panel when she was appointed to the panel for the newly created Heart Institute. So, it’s really remarkable impact that they had on biomedical research and care.

ER: And she was very involved in city beautification. The other interesting thing is Albert Lasker’s advertising career, which made his fortunes. He was one who promoted Lucky Strike. And yet, the Laskers took lots of money later in anti-tobacco efforts.

Yeah. It’s all true. Yes. Is there anything we forgot? Anything we’d like to mention? I know we could talk for two or three days and never lose steam, but is there anything about John, anything about that era that we forgot to mention that you’d like to bring up now?

ER: No, but there was just one other little thing, and that is, we had a chapter where we asked many of the luminaries in cancer research in oncology world, what they thought were the three to five most significant advances in cancer research over the last 50 years.

And that was very insightful also, because you had basic scientists who were talking about population science advances, and it was just good to see that people weren’t staying strictly within their track, but basically looking at the cancer problem universally.

ST: And I think looking back to John, we can often forget that John had a very successful career in clinical pharmacology, early studies and cancer drugs. So, John was in fact, an administrator who committed some very interesting comments to paper, but also a clinician and a clinician-investigator.

Well, thank you very much, and good luck with the book.