NEWS

Collaboration to Play Key Role in NCI’s Future, Director Says

Interview by Katherine Arnold

Andrew von Eschenbach, M.D., took the helm as the director of the National Cancer Institute earlier this year. He was previously at the University of Texas M. D. Anderson Cancer Center in Houston, where he headed the Genitourinary Cancer Center and the Prostate Cancer Research Program. Von Eschenbach is also a member of the National Dialogue on Cancer, an independent forum of cancer experts from several key national organizations.



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Dr. von Eschenbach

 
Von Eschenbach discussed with the Journal his first few months as director and his plans for the future.

How have your first few months as NCI director been?

Exhilarating. I came with the expectation that I would spend the first quarter listening, learning, and hopefully understanding the organization and the people within it. The fact that I had not been in the institution—I spent 25 years at a cancer center—is a two-sided coin. I bring different perspectives, but at the same time there’s much that I needed to appreciate, learn, and value with regard to the organization. It is a culture that is very much like the culture I came from at M. D. Anderson, made up of people who have a tremendous sense of commitment, purpose, and mission.

I have a sense of collaboration, cooperation, and integration, and a multidisciplinary, integrated approach to cancer is sort of my mantra that I learned and grew up with. I think this is an opportunity for me to help promote that within the organization as well. I think it’s an opportunity even for the promotion and integration of the NCI with the larger cancer community in a more intimate, more effective kind of way, whether it’s with the cancer centers, cancer organizations, or advocacy groups. One of my particular initiatives will be to have the NCI play a much more visible and much more central role in the National Dialogue on Cancer, for example.

So the [first few months] have been a great immersion. Now what I’ve been working toward is the next phase, which is to put in place an organizational structure that will help me both effectively lead and manage the organization.

What types of things are you looking at changing?

A very important lesson that I’ve learned in the past is that large, complex organizations like this can never be led and managed by one person. That there is no such thing as the CEO—it is the office of the CEO. And within the office of the CEO one creates a shared decision-making model where other people who are an integral part of the team have leadership and management responsibilities. Collectively we can provide what is necessary for the rest of the organization, which is rapid access to rapid decision making.

So what I’m in the process of creating is the office of the CEO. People get a little distressed with me throwing around words like CEO because it sounds corporate. But I use the word CEO because I do think a corporate model has some value in terms of understanding concepts. I think it’s a way of functioning that is really important.

What is the role of NCI in collaborations like the National Dialogue on Cancer and in partnering with other cancer organizations?

It’s central. The Dialogue was conceived around the notion that cancer was a complex, societal problem and that there were multiple elements, like it being a scientific problem, a medical problem, a cultural problem, a political problem, a social problem, an economic problem. For us to really address the problem of cancer comprehensively, all those elements had to come together into a forum where we could discuss and deliberate and define what that comprehensive solution would be. When one thinks about that in that context, it’s apparent that key and central to that entire deliberation is the National Cancer Institute. You can’t conceive of a discussion in this country to the solution of the problem of cancer that doesn’t have at its center the National Cancer Institute and the National Cancer Program.

So my vision is that the NCI has to be a core, central contributor to that dialogue. That is also matched by the realization that when one looks at the complexity and the size and the magnitude of the problem of cancer, it doesn’t matter how big and powerful the National Cancer Institute is, it doesn’t matter how much money President Bush gives us in Congress—it will never be enough. We can’t do it all. But it is absolutely our responsibility as the National Cancer Institute to make sure it all gets done. And we have to partner, we have to collaborate, and we have to respect and recognize what other people, other organizations, and other components are bringing to the table and bringing to the process.

Do you see opportunities to partner with industry?

All over. I come from 25 years outside the institute rather than inside the institute. I do bring the realization that these partnerships and these collaborations are very important, and I want to see us forge and nurture these relationships. Our mission is to see that cancer is eliminated, that people’s lives are saved, and that their suffering is prevented and alleviated. I believe what [former U.S. Rep.] Paul Rogers said—I believe that without research there is no hope. Once we have the research and we understand cancer, it’s got to get translated into something else. Without research there is no hope, but without translation there is no value. So that piece, that translational piece, is important to what I think my contribution should be here.

That translational piece requires partnering. Partnering with the pharmaceutical and biotechnology industry, partnering with cancer institutes and centers around the country that are platforms for the development and delivery of the translational agenda, so I see as part of my role and responsibility the creation of those relationships.

Our understanding of cancer has shifted in the last 25 years. So, too, must the research. Is NCI set up to change focus to accommodate the changing understanding of cancer?

I think that we’re on track, but I think that we have to define and develop that track a lot more. I think we began with a very intensive focus on identifying and dissecting out the specific components. We have a lot more to learn about the genetic, molecular, and cellular mechanisms of malignant transformation and malignant progression.

What’s become progressively more and more apparent is that, although causation rests with changes that occur in the cancer cell, behavior or malignant expression is highly dependent on the interaction of that cancer cell with the micro- and macroenvironment. So I think what we begin to start to see is that now we’re dissecting the individual pieces, but we now need to see how those pieces fit together and interact with each other and the interrelationships that occur, whether it’s the cancer cell and the microenvironment or the tumor in the person. The person is becoming as important in the equation as the tumor cell.

We’re on the right track, but we see the track beginning to take us to new places or different places. These new or different places are going to start to call us to different kinds of strategies or approaches. There’s a whole body of knowledge that needs to start now being transferred and applied to our understanding of cancer that is not only looking at dissecting the individual components but is really finding ways to look at how they fit. Things that seemed peripheral before may become much more central.

Other kinds of technologies and disciplines now start to become more important to fold into this. We already appreciate how incredibly dependent we will be on bioinformatics. But other disciplines like chemistry and disciplines like physics and systems engineering are going to start to play into this kind of process. I think we are on track, but I think that we can see that we are coming up over the crest of the hill and there’s another vista out there.

Shortly after taking over as director, you were called upon to testify before Congress on mammography. How do we continue to evaluate new screening tests?

I’ll use the case example of the emerging initiative around spiral CT scanning for lung cancer as kind of a case and point. First of all, the NCI, because of our size and because of our resources and because of our mission, has to take the leadership and the responsibility for initiating that effort. But we also have to be providing leadership to frame that initiative so that it is being applied with appropriate standards and rigor and so that we are making sure that we maximize the opportunity to gain as much knowledge and information.

One of the strategies with spiral CT that I look forward to is [our ability] to wed together with the screening trial studies that are going to help us understand basic mechanisms of the disease. That ranges from everything from the improvement in the imaging techniques to the ability to gain tissue and specimens from cases that are diagnosed with very early-stage lung cancer so we can begin to understand the differences in lung cancer in its earliest stages compared with what we’ve been dealing with, which is specimens that come from very advanced disease.

At the end of it, I hope that we can go back to the American public and to the world and not only give insights into what is the most effective and appropriate way of detecting lung cancer early so as to change its mortality and its outcome, but also that what we have learned has enabled us to also go forward in an even more effective way. What we’ve learned is also helping us to be able to cope with the disease itself at a fundamental, biologic level in addition to just being able to accurately and effectively detect it.

So I see our role as being again broad and comprehensive. And then that certainly becomes a source of guidelines for practice for what we should be doing, but it also becomes a blueprint for how we ought to be designing future research and how we ought to be taking the next step. These studies should not just simply have an end point and a closure and then it’s done. These studies should be building blocks and they should be foundations for the next step.

The Bush administration has taken some firm stands on medical research. How does that affect NCI?

I think that the NCI’s position is that we are here to conduct research in an ethically appropriate fashion. As guidelines and directives are provided to us, it is our responsibility to be responsive to them. At this point, I don’t see a problem.

Now that you have been here for a few months and now that you’re immersed, do you have a different understanding and respect for what it’s going to take to win the war on cancer?

First of all, we’re not going to win any war. There is no magic bullet or magic solution. There are lectures that I give now with regard to the changing paradigm. The paradigm of the 20th century was seek and destroy. Find it, find it as early as you can, kill it, kill it as dead as you can. And the weapons that we have are weapons of destruction. That’s part of the paradigm of winning the war on cancer.

What our investment in biomedical research, what the contributions of the NCI have made possible, is a completely different paradigm that I talk about as target and control. Going into the 21st century, unlike the story of the 20th century, we now are dealing with a disease that we’re beginning to understand at the fundamental biological level, and that’s opened up a whole new set of opportunities and horizons for us.

Just as we’re shifting the paradigm from seek and destroy to target and control, we’re shifting our goals and expectations. Cancer in many ways will no longer be treated like infectious disease, as an acute disease, where you find an antibiotic and you eliminate it—you’re cured. Cancer will in many ways for many patients be much more like diabetes or hypertension—a chronic disease. If you can control the hypertension and live your entire life and never have a stroke or a heart attack, it’s success. With cancer, if we can control and modulate the behavior of the cancer such that patients die with their cancer but healthy and not suffering any of the consequences, that’s a success. That is to have controlled cancer, not to have cured it. That is not to have won the war in the old paradigm, but to have achieved the goal of control.

And I think that there’s a lot to that in terms of helping patients and communicating to them. When we talk about new hope, we’re not talking about the fact that there’s a solution around the corner tomorrow. We’re talking about the fact that there are opportunities for them to live longer with their cancer. We’re talking about the opportunities for treating this disease in different ways than we ever did before. And things like Gleevec are not success stories in the context of magic bullets, they are success stories in proof of principle. If you can do it for that tumor, then why not for others? But then that changes the whole paradigm. We think about cancer as breast cancer, lung cancer, prostate cancer. Why? Well, because that’s the way you see it, and that’s the way you treat it. In the new paradigm, we may be thinking of a whole different taxonomy of cancer based on biologic mechanisms and molecular mechanisms. And subsets of prostate and subsets of breast and subsets of lung and subsets of leukemia may wind up getting treated in the exact same way.

How will we get the next Gleevec?

We get the next Gleevec by the process of target identification, target validation, development of an intervention that is target-specific, and testing it. It is a large agenda in terms of redefining how pharmaceutical and biotechnology views the market share and opportunity. It’s a new paradigm in terms of how regulatory approval processes have to view drugs. There’s a lot of work here to bring this to fruition, but it’s within our grasp. And that’s the vision that I want to communicate to the NCI and to the cancer community. There’s a lot of work that has to be done, and the only way it’s going to happen is teamwork. The only way it’s going to happen is cooperation and collaboration. And we’re going to have to work effectively together, and if we do that, if we can bring all of these pieces together and NCI provides the leadership to make it happen, I believe we can do it. I wouldn’t have come here if I didn’t. And I believe that this is the place that can get it done.



             
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