NEWS

Despite Challenges, Cancer Prevention and Control Programs on the Rise

Steven Benowitz

David Alberts, M.D., likes to tell the story about how he was "asked" 15 years ago to take over a nascent cancer prevention and control program at the University of Arizona Cancer Center in Tucson, with little administrative vision and few resources, save a tiny piece of the cancer center core grant pie. Today, Arizona’s prevention program is one of the most well respected in the country.



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Dr. David Alberts

 
Although not all programs have such humble beginnings, cancer prevention and control research programs have been, in many cases, considered second-class citizens. Prevention research has "historically played a second-tier role in cancer centers," said Robert Young, M.D., president of Fox Chase Cancer Center in Philadelphia.

Why? Until recently, said Young, federal funding for research had been lacking. But in the last decade, a change in thinking took hold, fueled by the dramatic increase in knowledge and understanding about the genetic underpinnings of the development of cancer, along with the realization that preventing—not necessarily curing—cancer was a smart and needed approach. The National Cancer Institute committed to creating funding mechanisms and increasing support. Now, said Young, more and more, cancer centers are recognizing the importance of prevention and control research.

One such center—the Institute for Cancer Prevention in New York—is devoted solely to cancer prevention and control, the only NCI-designated cancer center to do so. The institute, which began as the American Health Foundation in 1969, focuses many of its basic and clinical research efforts on better understanding cancer susceptibility, mechanisms of cancer development, nutrition and chemoprevention, and the role of tobacco and environmental influences on cancer, among other areas. At the same time, it participates in national clinical trials, such as the Women’s Intervention Nutrition Study, which is examining the idea that a low-fat diet will lower the incidence of breast cancer recurrence while increasing survival of those treated for early-stage disease.

In Young’s case, Fox Chase Cancer Center built on its solid population science program and opened a 125,000-square foot center in 2000 focusing solely on prevention efforts and research, particularly in epidemiology, chemoprevention, and tobacco control, Young said.

Building a Program

But as institutions and cancer centers increasingly step up their cancer prevention and control efforts—from both basic and clinical research to actual outreach for patients and the public—they are finding in many cases that the reality of putting together a program may not be so easy. Prevention projects are the poster children for interdisciplinary research, and may not always be an easy sell to academic medical school departments.

"You recruit investigators into departments," not interdisciplinary programs, said Alberts, who is now director of cancer prevention and control at the Arizona Cancer Center. "Basic scientists don’t know anything about prevention and control, and clinicians focus on treating patients. Prevention is often a secondary thought.

"One of the difficulties used to be to make the faculty and administration understand that cancer prevention and control is much more than the epidemiologists at the end of the hall," he continued. "You need to get all of the disciplines involved [in creating and running a successful cancer prevention and control program]."

Increased awareness or not, a prevention research program cannot be successful without support from the top, said Frank Meyskens Jr., M.D., director of the University of California at Irvine Cancer Center, who worked for years with Alberts in Arizona. "The key is to get an interested director or associate director," he contended, "someone who takes a long view."



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Dr. Frank Meyskens

 
Alberts agreed. A successful program needs a cancer center director that has "a broader view, that cancer prevention and control is truly an everyday part of what we do [at a cancer center], and be willing to put some resources into that."

New Funding Mechanisms

One of the key changes that has helped broaden the breadth and scope of prevention research has been an increase in funding support from the National Cancer Institute. In 2002, NCI devoted more than 11% of its annual budget to prevention and control efforts.

Alberts has built a program through a variety of funding methods. "In the early years—the 1980s—we didn’t have many [funding] mechanisms," Alberts said. An NIH program project grant helped, and his program subsequently landed a training grant and a 5-year career development award in preventive oncology. "With 11 years of solid support, you can become a substantial investigator in the cancer prevention field," Alberts said. "You need that kind of support with a long view because prevention studies take years, and it takes years to develop a program."

Despite increasing research opportunities, one problem in building a prevention and control research program may lie in the structure of academe. "The clinical component of cancer centers include senior people who are tenure track in molecular and cell biology, basic science areas, [and] in the college of medicine, but when it comes to prevention and control, there are no obvious home departments," Alberts said.

"Unless you have a school of public health, the epidemiologists don’t have a home," Alberts said. "Those in epidemiology, behavioral science, and nutritional science are research assistant professors in medicine—they won’t have the tenure track positions. There aren’t natural departments for those people and tenure track positions are hard to come by."

Getting young investigators interested in pursuing prevention and control research may run into institutional roadblocks. "Many young assistant professors can’t get involved in long-term prevention projects," Meyskens said. The criteria for academic advancement—publishing in high-powered, peer-reviewed journals—may not allow them to participate." In many ways, he said, "Prevention [research] has still not been embraced."

Long-term prevention trials are costly, too. "Even medium-sized trials are expensive," said John Potter, M.D., senior vice president and director of the Division of Public Health Sciences at the Fred Hutchinson Cancer Research Center in Seattle. "Such trials require large teams, lots of time and expertise. People trained in prevention must be able to devote a lot of time to long trials."

Shared Resources

Academic roadblocks aside, there is also the issue of shared resources. At many cancer centers, shared resources from the center core budget are targeted to the basic scientists, contended Susan Mayne, Ph.D., associate director for cancer prevention and control research at the Yale Cancer Center in New Haven, Conn. "They lack shared resources targeted to cancer prevention and control. That’s been a sticky issue: Are the resources used by different research programs?" she said. "That’s easier in the basic sciences—it can go to cell biology research or molecular virology research, for example. But it’s harder to implement in prevention and control; most cancer centers don’t have multiple [prevention and control] research programs. They might have one or two."

Although there is no magic formula for creating a program, Alberts and Meyskens recommend building on an institution’s strengths. "You try to emphasize those programs that are strong already," Alberts said. "If you inherit a strong program in nutritional science, you don’t necessarily try to establish an epidemiology or a basic science program."

At the same time, because many prevention and control programs have a decidedly urban flavor, he noted, community programs must develop direct lines of contact to minority physicians and health care providers. "You need minority faculty to be role models and help train and convince minority physicians to become researchers," Alberts said.

For minority and nonminority researchers alike, the right combination of training can be hard to come by. "The biggest problems people face in the beginning [of establishing a program] is that there are very few people trained in the essential disciplines—epidemiology, biometry, behavioral science—that are necessary to put a program together," he said. "It will take another 10 to 15 years of training people so there is an enriched pool of talent available." And they should be trained in more than one discipline.

Potter agreed. "It’s difficult—and relatively rare—to bring all of these different disciplines together from prevention and conducting prevention trials to biomedical skills to conduct mechanistic studies," he said.

But for those who are interested in pursuing prevention research, opportunities abound. "We’re generating hypotheses about the nature of cancer causes and prevention and combining them with information from the genome project and new tools such as microarrays and proteomics," Potter said. "It’s a time of enormous opportunity."



             
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