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reviewed cancer research projects. If the plan proposes additional or expanded activities for the centers, the core grant guidelines might be revised to allow support of those activities. The new plan should also consider program structure (e.g., number, type, and geographic distribution of centers) and application and review procedures (e.g., revision of criteria, separate criteria and review committees for different types of centers, varying limits on the allowable increase in renewal applications depending on size or degree of development of the center). The plan should be developed by the NCI program staff, equipped with adequate resources (recommended in the following section), after consultation with relevant experts and officials in and out of NCT, NTH, and the federal government. It is important that representatives of the cancer centers have the opportunity to consult on development of the plan. External advice should also be incorporated in the development and review of the plan. Finally, the plan should contain milestones, so that progress can be measured. There should be a provision for modifying and updating the plan as needed. Adequate support for monitoring implementation of the plan also wall be necessary, and is discussed under the recommendations for strengthening program management and organization below. Strengthening Program Management and Organization Strengthening the capacity of cancer centers to exploit the unprecedented opportunities to incorporate emerging scientific advances into better cancer prevention and treatment, including consideration of needs and impacts in human terms, wall require organizational changes and increased management capacity for the core grant program. The- specific decisions, however, should be left to the director of NCT, who is in the best position to determine effective ways to improve the program's location, representation, and oversight and to strengthen the program's capacity for data gathering, planning, evaluation, and implementation. The committee recommends that the director of the National Cancer Institute consider how best to increase representation of the cancer 20

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centers program NCI planning and decision-making Processes, _ _~ including regular representation at the NC! executive committee meetings and creation of an external advisory committee to renew their multidisciplinary programs. The cancer centers core grant program has gone through a number of organizational changes that have isolated the program from high-level decision making and from related programs within NCI. The program's expanded role in translating basic biological and behavioral research advances into better prevention and treatment programs and practices wall require increased representation of the program in decision making about the national cancer program. It wait also require increased coordination with other NCT activities in which centers are likely to be more involved in the future (e.g., preclinical and clinical research programs, research training, clinical trials with cooperative oncology groups and community oncology programs, and cancer prevention and control efforts). Until 1980 the program was located in a division with the other extramural grant programs of the NCI. In that year the cancer centers program, along with other resource functions (training, construction, organ systems), was combined with parts of the former division for cancer control and rehabilitation to form a new Division of Resources, Centers, and Community Activities. In 1983 a prevention program was added to the division, which was renamed the Division of Cancer Prevention and Control to emphasize its new primary mission of research on cancer prevention and control. During that reorganization the research resources program was abolished, and the centers branch was placed in a newly created Centers and Community Oncology Program (with the construction Dronram but not with the training program).14 r D These two major organizational changes were only incidentally concerned with the management of the centers program per se. The main purposes of the 1980 reorganization were to separate peer-rev~ew activities from responsibilities for program administration and to provide each of NCI's research divisions with a full set of mechanisms for accomplishing its mission-- e.g., grants, contracts, intramural staff ~ _ The 1983 changes were designed to 14 Historically, NCI has invested a large share of its construction program' which totaled $227 million between 1972 and 1987, in cancer centers. The program has not been funded since 1987, however. 21

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strengthen NCI's prevention and control capacities. The reorganizations, however, had the effect of reducing the program to an organizational level that is not commensurate with its size or key relationships with the other research grants the program is designed to support and enhance by providing an interdisciplinary environment and shared resources. The cancer centers supported by the program are the sites for many NCI-funded research activities, but NCI's oversight of the program became increasingly fragmented. This decreased attention is a particular problem for the centers program because of the involvement of the centers in all aspects of cancer research (e.g., basic, clinical, and cancer control) and other activities (e.g., trainings public informationN. The contributions of the program to NCT ~ _ _, . as a whole, therefore, are not taken account of in one place. In addition to having an appropriate location and representation in planning and decision-making processes within NCI, the program would benefit from oversight by an external group with a broadly based membership that is knowledgeable about the full range of cancer center responsibilities.~S The program would also benefit from increased management resources, which are discussed next. The committee recommends that the National Cancer Institute substantially strengthen the management capabilities of the cancer centers program unit. That unit must be able adequately to plan, monitor, evaluate, and implement the cancer centers program. Research program management and support have been reduced at NC] overall, and the cancer centers program management has not been exempt. The staff of the cancer centers branch has been reduced from eight to four (from six to three professionals). Funds for data collection, analysis, evaluation, and other support services have been cut appreciably. The capacity of the branch to carry out the basic monitoring, analysis, evaluation, and planning functions critical to the success of any program needs to be strengthened. The current level of staffing and other resources wall not be adequate to plan, evaluate, and implement a strengthened cancer centers Is The reactivation of the centers subcommittee of the NCAB and the plan to elect a committee of center directors to meet regularly with the director of the NCT are important first steps in creating better communication between the cancer centers and the NCT. 22

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program. The staffing of the cancer centers branch ~11 have to be substantially increased to carry out expanded program management functions. Stronger program management also depends on an increased capacity to collect and analyze, systematically and on an ongoing basis, data on the activities and accomplishments of the cancer centers both locally and nationally. Additional funds will be needed for the systematic and ongoing data collection and analysis that is required. Expanded data collection and analysis that included activities supported with all funds, not only federal, would have a number of benefits. This information would encourage more realistic utilization of the centers by all parts of the NCT, it would help the Congress better understand the centers program, and it would provide a basis for monitoring and evaluating the success of the previously recommended program plan. Development of a new program plan and of the data necessary to monitor its implementation would lessen the disparity of expectations caused by the difference in the range of activities supported by the core grant program and the broader scope of activities envisaged in the national cancer program. The difference has to do with the lack of agreement about and knowledge of the role and accomplishments of the centers. Exhortations to centers to become active in areas such as cancer control or high-priority national clinical teals without additional core grant funding appear to be unreasonable to the centers. At the same time, the lack of reliable information on the extent of center accomplishments and activities in such areas as outreach and local or regional clinical trials causes the centers to appear to be unresponsive to NCT priorities. Besides the development and implementation of data collection and analysis activities, which would provide a basis for long-term assessment of the centers program, it is important that the staff begin to develop the systematic program plan and the procedures for its implementation and monitoring. In the longer run, there is also a need for increased monitoring of the activities of the cancer centers and the evaluation of the the level of success of the overall program. The staff of the program should also coordinate regularly with other programs in NCT to ensure that the cancer centers are appropriately involved in all aspects of the implementation of the overall national cancer program. Finally, as conditions change, as new scientific developments occur, and as national priorities evolve, it will be necessary for 23

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the staff to develop new issues and options to update the long-range plan and ensure that it remains a viable document. 24