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A STRONGER CANCER CENTERS PROGRAM Introduction On October 18, 19~, the National Institutes of Health (NIH) asked the Institute of Medicine (IOM) to conduct a study of the cancer centers core grant program of the National Cancer Institute (NCI) and to make recommendations concerning the funding needs and organizational location and direction of the program. The NIH initiated the request in response to the Senate Appropriations Committee report that accompanied the NIH appropriations bid for fiscal year 1989 (U.S. Senate, 19~:94), which stat-cd: The Committee has heard an ever increasing series of complaints regarding the relatively small avocation of funds to cancer centers. The Committee intends to explore this issue thoroughly with NTH and NCT personnel in the upcoming months and focus on the question at hearings next year. Furthermore, the Committee requests the NIH to contract with the Institute of Medicine to undertake a study, to be completed for the Committee hearings next year, which win report on the present state of the Cancer Centers Program [and] on its funding and organizational needs required to fulfill the role established for cancer centers In the 1971 National Cancer Act. NCI's support of cancer research centers began in the early 1960s. The 1970 report of the Pane] of Consultants on the Conquest of Cancer argued that multidisciplinary cancer centers were "the best organizational structure" for an expanded effort to solve the cancer problem (U.S. Senate, 1970:89), and the resulting National Cancer Act of 1971 authorized an expanded program of basic operating support for existing and new centers as well as the 1

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establishment of a network of comprehensive "national cancer research and demonstration centers" (P.L 92-218~. By the late 1970s, the core grant program had reached its present size and shape--grants to support the central functions of approximately 60 centers that conduct large amounts of cancer research and training. (Figure I). Currently, NCI provides core grants totaling slightly more than $101 million to 59 centers selected through a process of competitive renew. NCI proposes to award approximately the same amounts ~ fiscal years 1989 and 1990 (Table 1~. The grants are administered by a staff of four (three professionals) In a branch of NCI's Division of Cancer Prevention and Control. The program of core grants has enabled NCI to develop and maintain a network of cancer centers where high-quality research takes place.2 Scientists and clinicians in institutions with NCI core grants receive nearly half the research project grants awarded by the NCI through a process of competitive peer review (Figure 2), and they receive substantial amounts of peer-rev~ewed support from other NIH institutes, the National Science Foundation, the Amencan Cancer Society, and other sponsors (Figure 3~. As a result, cancer center researchers have been involved in many of the important basic, clinical, and epidemiologic cancer research advances made in the last 20 years (see, for example, Narin, 1987~. The centers also are sites for more than half of the cancer research traineeships funded by NC! (Figure 2), and many centers are involved in cooperative oncology groups that conduct clinical trials supported by NCI, in NCI-supported working groups that foster research on cancer of specific organ systems (e.g., bladder, breast, pancreas), in cancer prevention and control research and other activities, and in other aspects of the national cancer program, such as operation of NCI's cancer information system and participation in the~Community Clinical Oncology Program (CCOP) that involves community physicians in clinical trials and cancer control research. As a group, the centers are a valuable resource for the NCT in the national effort to understand, prevent, and treat cancer and its consequences. They are also ~ The NCI's process for-awarding support grants for cancer centers is described in Appendix A. 2 See Appendix B for a list of cancer centers with NCI core grants. 2

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FIGURE 1 Number of Cancer Centere and Total Core Grant Obligations, Fiscal Years 1972-1990 (dollars in millions) C 100 r' too m e SO F ^~ So e a ~ ~ ~40 e O' 'I ' 1 ' 1:' i 1 ' 1 '' 1 ' ~ ' 1 ' 1 ' O 72 74 76 78 80 82 84 86 88 go Fiscal Year Number of Centers I Current Dollars ~ 1988 Dollars SOURCE: Appendix Table E1 TABLE 1 Cancer Center Core Grant Awards (in thousands of dollars), Fiscal Years 1988-1990 Obligations 1988 1989 - 1990 - (Actual) (Estimated) (President's Budget Source by NCI Budget Request) Regular NCI Appropriation 96,872 97,790a 96,605_ Appropriated for AIDS Research 3,555 3455 4,740b Total 100,427 . 101,345 ' 101,345 a . . . . Includes $1 million administered separately by NCI's Division of Extramural Activities for a program.of supplemental core grants to existing cancer centers that are making special efforts to address high rates of cancer prevalence and mortality in minority populations. . : b NCI plans to allocate this amount from its share of the appropriation for AIDS activities requested by the Assistant' Secretaly for Health, Department of Health and Human Services, in the consolidated AIDS budget for fiscal year 1990. SOURCE: National Institutes. of Health, 1989:36, and Financial Management Branch, NCI. 3

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FIGURE 2 Share of Selected and Total NCI Grants (number and amounts) Awarded to Institutions with Cancer Center Core Grants, Fiscal Year 1987 1OI 80 60 20 ROT/PO' Other (grants Tralneeships Cancer Control Total Grants Grant Mechanisms _ Number of Grants a\\\\\ Amount of Awards SOURCE: Calculated from data provided by NCI's Financial Management Branch (see Appendix Table E5). . ~ FIGURE 3 Research Support, by Source of Cancer Centers with Core | Grants (dollars in millions), Fiscal Year 1988 or 1989 500 . 200 _ _ NCI Other NIH ACS NSF Private Sector NOTE: NCI column does not include core grant awards. SOURCE: Administrative Protile Database, Cancer Cantors Branch, NCI (sso Appendix Table E4). 4

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valuable community resources for cancer treatment, prevention and control, and education serv~ces.3 NCT's Cancer Centers Program The NCI's cancer centers program supports the core functions (see below) of centers that are conducting high-quality interdisciplinary laboratory, coccal, epidemiologic, and other research on the causes, prevention, detection, diagnosis, treatment, and consequences of cancer. On average, the core grant amounts to about 20 percent of NCT's total grant support of cancer center institutions, although that percentage is declining (Figure 4~. The main purpose of the core grant program is to support functions that make a center a center rather than an assemblage of researchers pursuing unrelated projects (a breakdown of expenditures among allowable program categories is displayed in Figure 5~. The typical grant provides partial salary support for the center director and senior staff, other administrative personnel, and directors. The core grant also enables a center to provide shared services and equipment that would be more expensive or imnn~.~ibif~ for inrlivirl,,~1 rP~P~rrh projects to provide for themselves. On average, more than half of the grant funds are used to support services and resources that are shared by NCI- funded research projects, ranging from electron microscopes and other sophisticated research equipment to biostatistics- staff units to laboratory animal and glass-washing facilities. These services and resources involve economies of scale that cancer researchers could not achieve on their own with individual research grants.4 ~~ hi_ _~_~^v^~_ ~~ ^~van eve ~~l I~1~11 The core grant also allows centers flembili~ to explore new research leads and to recruit and retain promising staff. A small portion of the funds may support developmental projects, such as the research of newly recruited investigators until they receive regular research grants, or it may cover the salary of an investigator with an approved but unfunded research grant. In 3 See Appendix C for a map of cancer centers with NCT core grants. 4 Appendix D gives examples of shared resources supported in cancer centers by core grant funds. s

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- ~ ~ l : FIGURE 4 Core Grant Support as ~ Percentage of Total NCI Support to Institutions with Cancer Centers, Fiscal Years 1981-1988 30 O , , , , , , 1981 1982 1983 1984 1985 1986 1987 1988 Years FOURCE: Calculated from data provided by NCl~s Financial Management Branch. (see Appendix Table E7). 1 - 11 FIGURE 5 Use of Cancer Center Core Grants (in percentages), Fiscal Year 1987 (Including Program Directors) Senior Leadership _~,, 14 (Including Planning ~ Evaluation) Administration 12 Developmental Funds A............. 8 Al terations ~ Renov. , 1 (. 06, Staff Investigators Shared Resources 51 NOTE: The analy~le is based on authorized direct costs, excluding supplements and administrative adjustments. SOURCE: Data from Administrative Profile Database, Cancer Centers Branch, NCI (see Appendix Table E8). 6

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some centers, the core grant also helps to support a group of staff investigators. The centers are diverse in focus, structure, and size. Currently, there are 15 laboratory science centers that do only basic research, 41 clinical research centers that do clinical, basic laboratory, and, In some cases, cancer control research, and 3 consortium centers that focus on cancer control.s In the 1970s, 20 of the clinical research centers also were designated as broadly based "comprehensive" centers under the terms of the National Cancer Act of 1971. They are not only expected to do research and trading, but also to demonstrate state-of-the-art patient care and to conduct cancer control activities (e.g., community education, outreach, and intervention) (National Cancer Advisory Board, 1985~. The designations have not been reviewed since 1978. The National Cancer Advisory Board (NCAB) is considering revised cAtena and processes for recogm~ng centers as-comprehensive; which are discussed later In this report. Some cancer centers, such as Memorial SIoan-Kette~g, M.D. Anderson, and Roswell Park, are free-stand~ng independent or state institutions, but most centers are university-based. The consortium centers include state and local public health agencies as weD as universities and other cancer research organizations. The support grants range in size, from $318,000 for the laboratory science center at Purdue to $7.4 minion for the Memonal SIoan-Kettering comprehensive cancer center (Appendix Table Elk. The centers also vary In overall size. Laboratory science centers tend to be the smallest. The La Jolla Cancer Research Foundation, for example, has -an annual budget of approximately $9 minion (about half Tom NCT and most of the rest from other NTH institutes) (La JoDa Cancer Research Foundation, 1987:3~. The comprehensive cancer center at Duke University, on the other hand, has a peer-reviewed research budgee of more than $52 minion (including $16 million from NCI and $32 million from other NIH institutes) (Appen~ Table Em. Institutions with clinical centers may provide substantial amounts of patient care that cannot be paid for through NCI support or research grants, but which must be reimbursed by patients, insurance, and charitable contributions. 5 Appendix B lists the centers by type: comprehensive, clinical, basic laboratory, and consortium. 7

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Over the past 5 years, the Memorial Sloan-Ketter~ng Cancer Center has raised $368 million in charitable contributions to cover patient care, research, and construction costs not covered by any form of third-party or government payment, reimbursement, or grants (Memorial SIoan-Kettenng Cancer Center, 1987:33~. Individually and as a group, it is apparent that the cancer centers are able to leverage substantial amounts of support from sources ~ addition to NCT and NIH. Other sources include the National Science Foundation, other federal agencies, state governments, foundations, private individuals and businesses, and charitable organizations (Appendix Table Elk. Conduct of the Study The timetable for the study was very short, less than 6 months from the request to delivery of the report, because the Senate Appropriations Committee requested that the study results be available for hearings on appropriations for fiscal year 1990. The IOM agreed to undertake the study on short notice because the cancer centers supported by the NCI represent a valuable resource in the nation's efforts to understand, prevent, treat, and address the consequences of cancer. The TOM was asked specifically to address funding and organization issues concerning the core grant program, but the TOM committee found it necessary to proceed first by reviewing the purpose of the grants and the role of cancer centers in the national cancer program relative to other NCI- supported programs. Committee staff, with the- cooperation of the program planning and evaluation staffs in the offices of the NTH and NCT directors, the staff of the cancer centers branch at NCT, and the leadership of the Association of American Cancer Institutes and the National Coalition for Cancer Research, which represent cancer centers, gathered and analyzed a great deal of information about the organization and management, historical development, financing, and impact of the program. After meeting three times in three months to review the history and current status of the cancer centers core grant program in detail, the stringent fiscal context facing NIH and NCI in the foreseeable future, and the likely future directions of scientific advances in cancer research, the committee developed the recommendations that follow. 8