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Strengthening the Role of Cancer Centers Many important discoveries are occurring in the basic biologic, clinical, and behavioral sciences that relate to cancer. The committee recommends that the National Cancer Institute seren~hen its core support of cancer centers in order to exploit fully the application of these advances in the prevention and treatment of cancer and its consequences. The committee believes that cancer centers provide an interdisciplinary environment that is valuable not only for research but also for the translation of research discoveries into better methods of prevention, early detection, diagnosis, treatment, and of meeting the long-term needs of survivors and family members. Recent advances in the new biology, cellular and molecular, have greatly increased our understanding of the etiology of cancer. For this reason, support of basic research should remain a high priority of the NCI, and the core grant program should continue to include basic science centers. Advances in basic science wall continue to increase the understanding of cancer processes and result in better treatment and prevention in the future. Recent examples include the discovery of oncogenes and their cellular counterparts, proto- oncogenes; increased understanding of processes of metastasis; and greater elucidation of the mechanisms of the viral transformation of cells to malignancy (and other diseases, such as AIDS). The rapid growth in understanding of the developmental stages in chemical and radiation carcinogenesis has the potential of greatly increasing the capacity to prevent the development of cancers. A number of basic biomedical discoveries, however, are ready now to be extended into clinical practice and better methods of prevention. Cancer centers encounter relatively large numbers of cases of many types of cancer, which makes it more efficient for centers to conduct clinical trials of new forms of therapy in meaningful numbers of tumors of specific kinds. The centers also provide economical shared research services and resources and leaders who attract substantial amounts of additional research funds. Lacking hard evidence of the effects of the existence of cancer centers on the nature or quality of research conducted in them, the committee relied on its judgment, based on its expertise in biomedical research and study of existing information on cancer centers and their achievements. The committee, including its members without cancer center affiliations, concluded that centers fulfill an important objective for the NCI. The interdisciplinary focus of 9
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centers and the opportunity they provide to bridge the basic, clinical, and behavioral sciences will enable them to be particularly effective in translating the new understanding of cancer processes into better methods of diagnosis, treatment, and prevention of cancer. Ultimately, the widespread application of these better methods should lead to better health of the public by reducing mortality and morbidity and increasing survival rates from cancer. For example, there are unprecedented opportunities to use immune mechanisms and naturally occurring and genetically engineered biological substances in immunotherapy, hormone therapy, and other new treatments that are being added to the oncologists' traditional armamentarium of surgery, radiation, and chemotherapy. Researchers have developed methods of removing the white blood cells from the blood or tumors of a cancer patient and activating them in vitro with natural substances, such as interIeukin-2, that stimulate the immune system. The activated cells can then be reinfected in the patient with more interieukin-2, where they increase the body's ability to destroy tumor cells. This promising type of immunotherapy is being tested experimentally at a number of cancer centers with patients who have cancers that are especially difficult to treat (e.g., melanoma, renal cell). Laboratory discoveries that promise to have important clinical uses include human growth factors, such as G-CSF and GM-CSF,6 which are substances that stimulate the production of new white blood cells to replace those that are destroyed by chemotherapy. These factors have been produced using genes that have been cloned, and early experimental trials indicate that their use should enhance the effectiveness of chemotherapy by allowing the administration of larger doses as well as resulting in diminished side effects. These factors have also shown improvement in the defenses of immunocompromised patients, and increased recovery from bone marrow transplantation in experimental settings, and are now being tested further in clinical settings. Other discoveries in immunology will enable clinicians to manipulate parts of the immune system in ways never before possible, with implications not only for cancer but for diseases such as arthritis, diabetes, and AIDS. 6 G-CSF is pluripotent granulocyte colony-stimulating factor; GM-CSF is granulocyte-macrophage colony-stimulating factor. 10
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Other examples of recent laboratory discoveries that have potential clinical applications include: substances that increase antitumor immunity and tumor-cell killing; nucleic acids that can enter tumor cells and "turn off' genes that cause the cells to be neoplastic; and tumor-reactive monoclonal antibodies that can target towns, radioactive isotopes, or chemotherapeutic agents specifically on cancer cells. It will be possible to use supercomputers and crystallographic techniques for the molecular modeling of drug interactions and to design new drugs and drugs that are effective against drug-resistant tumors. Advances in epidemiologic and prevention research, in the laboratory and in the field, are also very promising. For example, large-scale nutrition intervention and chemoprevention trials are under way that will reveal the role of diet and nutrition in cancer and the efficacy of venous vitamins, minerals, and other substances such as fiber in preventing cancer. Research on behavior is providing scientific knowledge that shows promise for the development of clinical interventions. The focus of such research includes increasing tolerance for side effects of treatments, preserving ability to perform usual activities, and enabling patients to overcome barriers to treatment, care, and rehabilitation, and improve their quality of life as survivors. These advances in cancer research in recent years have reinforced the initial wisdom that led to the development of the national cancer centers program. Advances in basic, clinical, prevention, epidemiologic, and behavioral research have brought breakthroughs closer that will reduce cancer incidence, morbidity, and mortality and improve the functioning and quality of life of survivors and their families.7 NCI-supported cancer centers, diverse in character and multidisciplinary in scope, have played an important role in furthering those important advances. In addition to supporting a network of cancer centers, NC! supports other mechanisms--e."., individual investigator and program project research 7 Survivorship research is conducted in the areas of rehabilitation, quality of life, and reentry for cancer patients, including, for example, biomedical research on long-term effects of radiation and chemotherapy, reproductive health of younger patients, or cognitive dysfunction resulting from secondary nervous system treatment; and psychosocial research on the role and effectiveness of peer and professional counseling, systems for dealing with altered self-image, or barriers to insurance coverage and employment. 11
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