Emil (Tom) Frei III, physician in chief at Sidney Farber Cancer Institute and one of the early leaders in development of anticancer chemotherapy, referred to clinical cancer research as “an embattled species” in delivering the Karnofsky Lecture at ASCO.
Among the threats Frei mentioned are the decreasing number of academically oriented young men and women entering clinical investigation, and the falling proportion of MDs who are principal investigators on funded NIH grants. “The attractions of practice; the prestige associated with basic research; the incredible bureaucracy that has mushroomed around clinical research; the insecurities associated with a shrinking federal dollar; the information explosion—these are only some aspects of the battle.”
Frei noted that “under the leadership of B.J . Kennedy, medical oncology became recognized by the ABIM as a subspecialty of medicine in 1972. Since then the number of medical oncologists that have been certified has increased linearly to 1,788 in 1979. That is one of the major accomplishments of the 1970s. The vast majority were superbly qualified and trained and have done an excellent job of bringing the best in this rapidly moving field to the bedside. I am proud to number myself among you. Why is there a problem?”
The current number of certified medical oncologists plus the surgeons and others doing medical oncology roughly is equivalent to the need, each treating in a major way about 100 patients a year, Frei said. Although more medical oncologists will be needed, he estimated “there will be an excess within five years and a glut by 10 years. Obviously this is a threat to the practicing medical oncologist per se. How will it affect our clinical investigator in cancer centers? There is good evidence that the number of referrals to some cancer centers over the past few years have diminished, with a relative increase in the number of patients with advanced disease. It is inevitable that this trend will increase with the increasing number of practicing clinical and medical oncologists.”
Frei said negative feedback of an increasingly crowded field will help reduce the number of physicians going into medical oncology. “The marked reduction in NIH supported training and education grants, while it will have adverse effects in other areas, should help. A careful monitoring system for medical oncology requirements in various geographical areas, and as affected by predicted trends in health care delivery, should be developed.”
Another issue is the relationship of the practicing medical oncologist to the cancer center, Frei said. “Cancer centers should and most do concern themselves in a major way with their relationship to practicing oncologists and are proud of that relationship. Oncology practitioners in turn should have an important relationship to the cancer center, which is non-condescending in either direction, and may participate in the development of new knowledge such as participation in clinical trials.
“On the other hand, the referring medical oncologist should have a sense of participation in that research and the patient should be referred back as soon as those clinical investigative activities that require the patient’s presence at the cancer center are completed…
“The next threat to clinical research is basic science. Basic biomedical science is much higher in the pecking order than clinical science in most institutions, and particularly at major academic centers….The basic science community has persuaded itself and a good part of the academic community that clinical research generally, and clinical cancer research specifically, is largely descriptive, empirical, and derivative of basic science…. We have done a thoroughly inadequate job of persuading basic scientists-and to some extent science administrators, the public, and even ourselves–that clinical investigation is a science in its own right, full of dignity, challenge, and the opportunity for creativity–in short, an excellent career choice.
“Another major and current threat is the funding situation. The funding of NIH and NCI is set finally by the political process. It is essential that the public and the politicians understand what a bargain they are getting for their cancer research dollar….
“In subjects under the age of 45 there has been a greater than 20 percent decline in mortality from cancer over the past 15 years. The vectors started down 10-15 years ago and continue down. The incidence of cancer in these age groups has not changed during this time period. Therefore this decrease has resulted from improved treatment. This is supported by the fact that the turndown in these curves occurred following the introduction of curative treatment. More compelling are the mortality statistics for individual cancers where major progress in cancer treatment is known to have occurred. I would emphasize again that there has been no change in the incidence of these cancers and that the difference between 1967 and 1977 represents a trend, not an abberation. The 20-40 percent decline in Hodgkins, ALL, and non-Hodgkins lymphoma mortality is consistent with the development of curative treatment for these diseases 15-20 years ago. The decline in bone cancer, which is mainly OGS, is of interest in view of treatment controversies relating to that disease. Premenopausal breast cancer mortality has fallen, perhaps as a result of adjuvant chemotherapy, and curative treatment for advanced testis cancer has been introduced too recently to impact on national statistics up to 1977….
“What is not sufficiently realized is that such improvements in treatment result in substantial savings of the federal dollar. This saving is based primarily on the much reduced cost of curing the patient with initial treatment as compared to the much greater medical cost incurred if the patient fails or relapses from initial treatment and finally succumbs several months to several years later. Dr. DeVita has calculated that the savings from these and related examples are substantial and exceed 50 percent of the current NCI budget.
“Another threat to the clinical cancer investigator is the hematology/oncology issue. A major effort is under way to combine hematology and oncology in major academic and clinical centers . Medical oncology is in its adolescence, whereas hematology is a long established mature discipline. In most institutions hematologists are more powerful as of now in the academic structure and with no important exception that I am aware of, hematologists are selected to head up combined hematology/oncology divisions. We must beware. Many hematologists, certainly in the past, have not been sympathetic to medical oncology. Medical oncology represents a much larger clinical and scientific challenge than does hematology, and we must persuade department chairmen that this reality must be given prime consideration in the structuring and allocation of resources to the clinical and research activities that comprise medical oncology.”