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year 1989, the committee suggests that the director allocate the additional funding needed to fund at 85 percent of recommended levels the core grants of the competing centers that have fundable priority scores, up to a limit of $6 million.~3 For fiscal year 1990, the administration should work with Congress to develop a budget that wait avoid the current situation and continue to provide support grants to those competing centers that have excellent programs, as measured by peer-review priority scores. Planning for the Future The committee recommends that the National Cancer Institute develop a systematic program plan during the coming year to ensure adequate fiscal. managerial. and organizational resources, coordination with related programs, and effective scientific oversight for the core grant program. The plan should take account of the changing fiscal and organizational arrangements involved in the delivery of health services. The committee believes that support of cancer centers has been an elective way to support advances in cancer research for nearly 30 years. However, translating recent basic research advances into better patient care and prevention programs and, ultimately, reduced cancer incidence and mortality rates, wait not be easy. Many of the advances have been made with cells in vitro or in animals, and have yet to be tested extensively in human patients or populations. Developing their potential applications wall require close and sustained interactions between scientists and clinicians, and among clinicians with different specialties. The interdisciplinary, cancer centers are especially well suited for developing new applications in cancer prevention, treatment, control, and rehabilitation that recent research advances wall offer. They are structured and equipped to foster regular interactions across disciplines and health professional schools and hospital departments, thereby bridging the gap between laboratories and the bedside. Thus, it is an ]3 If funding all the competing centers with fundable scores at 85 percent of recommended levels totals more than $6 million, the funding should be prorated at less than 85 percent of recommended levels. If one or more of the competing centers does not receive a fundable priority score, less additional funds would be needed. 17
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especially appropriate time to reassess the mission of the cancer centers core grant program and its place in fulfilling the future goals of the national cancer program. NCI's overall program involves basic laboratory, clinical, epidemiologic, and behavioral research, research training, and applied research on the application of basic advances to better methods of prevention, early detection, diagnosis, treatment, and rehabilitation. Although respecting the diversity and independence of the individual centers, the cancer centers program should address all aspects of a balanced national research effort to prevent and treat cancer. Each center has one or more areas of special research competence, but, taken as a whole, the centers are involved in even aspect of the national cancer research program. The program should, however, provide more incentives for individual clinical centers to broaden the scope of their research agendas, although centers focusing only on basic science research also have a place in the program. The peer-rev~ew process that has ensured the quality of the cancer centers program in the past should continue. On average, however, basic laboratory centers have tended to receive better peer-review scores. The criteria for review might be changed to recognize efforts to engage in interdisciplinary preclinical, clinical, prevention, rehabilitation and survivorship, epidemiologic, and cancer control research, even when they are funded by other mechanisms. NCI's dual mandate goes beyond research and research training to include demonstrations of better models of care delivery, education of health care providers, public information, and community outreach efforts. The comprehensive research and demonstration centers mentioned in the National Cancer Act of 1971 were intended to have this broader role in the national cancer program. The cancer centers core grant, however, supports only research. As community organizations, clinical cancer centers could, and most do, engage in providing state-of-the-art patient care, continuing education of community clinicians who treat most cancer patients, screening and prevention programs, public information, and other services, but they must fund these activities through other mechanisms. The review criteria and procedures in the current core grant guidelines do not consider a center's involvement in patient care, public information, or community education and outreach services, and they do not allow the use of core grant funds for those purposes. They only consider a center's capacity to conduct high-quality research. Thus a disparity 18
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exists between NCI's support of cancer centers as research institutions and the broader role of centers intended by Congress and expected by the public. This disparity between the broad role expected of cancer centers and the range of activities actually supported by the core grants is one of the issues that should be addressed in developing the program plan recommended by the committee. The committee is aware that the subcommittee on cancer centers of the NCAB is currently considering revised guidelines and procedures for designating cancer centers as comprehensive. These would have more detailed criteria regarding center involvement in activities of the national cancer program beyond those required for the core grant alone (e.g., participation in high-priority national clinical trials; involvement in cancer prevention and control research and community outreach activities, not only laboratory and clinical research; dissemination of state-of-the-art clinical techniques). Since the NCAB last reviewed the comprehensiveness of centers in 197S, some clinical centers are said to have developed a range of activities at least as comprehensive as those of some officially designated comprehensive centers. Centers should be encouraged to broaden their activities in support of the full range of national cancer research program goals; therefore, the committee endorses a concept, such as the proposal under consideration by the NCAB subcommittee, that recognition as at comprehensive center be time-limited and recommended through the same process of peer review that is used to review applications for core support. In addition to addressing the relationship between the core grant program and the overall mission of the cancer centers, the new plan should be integrated with the-national cancer plan (especially if that plan is updated), the NCI's Goals for the Year 2000, and other program plans being developed by the NCI. Also, the plan should be coordinated with the programs of related agencies that might affect or even be carried out by cancer centers (e.g., the Food and Drug Administration, the Centers for Disease Control, and the Environmental Protection Agency), although it is not necessary that the core grant support these other activities directly. In its planning, NCT should take into account the appropriate relationship between the center core grants and the NCI-funded research and training grants they are intended to support at each center. More than half the core grant funds go to support shared resources and services for peer- 19