In Reporter Michael McKay’s account of the UofL Board meeting earlier this month when progress towards the University’s 2020 Plan was summarized, and when the post-fraud “Audit” was formally presented; President James Ramsey commented on the University’s failure to earn a National Cancer Institute (NCI) designation for its James Graham Brown Cancer Center. Dr. Ramsey stated that it was unlikely that UofL would receive an NCI designation because the UK program is so close. (The Markey Cancer Center at the University of Kentucky was designated as an NCI Comprehensive Cancer Center in 2013.) Dr. Ramsey is said to have implied that UofL had been in talks for some sort of “partnership” with UK before that institution went on its way alone. These comments sound more to me like excuses than explanations. I found nothing in the NCI application documents that would indicate that distance from another center would be a factor. Indeed, depth of collaborations with other research and clinical centers is highly desirable if not essential.
Did UofL really have serious discussions with UK?
I am unaware of what sort of talks might have been underway with UK– indeed I was turned down when I asked to see the booklet of claimed collaborations with UK that President Ramsey brandished during a recent joint interview with UK President Capilouto. The track record of intra-state cooperation between the two institutions is not very good. The current dust-up over pediatrics suggests an underlying constitutional and structural inability to collaborate. Is it possible that only if the two schools are merged under one leadership structure will we ever see the meaningful cooperation that is so badly needed statewide? The UK-UofL divide mirrors and perpetuates the urban/rural friction that continues to drag our state down.
Does distance matter?
There are more than one kind of NCI Cancer Centers and geographic proximity is clearly not the main factor in their location. I do not find proximity to other centers even mentioned as a criteria in NCI application materials. The Brown Cancer Center and the Markey Cancer Center are 78 miles apart. A cursory look at a distribution map on the NCI website shows several clusters of NCI Centers even closer together. As one might expect, in large cities several centers of the same or different type can be found. There are 2 in Boston, 4 in New York City, 4 in Philadelphia, and 2 in Baltimore. California has 10 Centers of which at least 4 are in Los Angeles. There are three within 80 miles of each other in North Carolina. The Center at Rutgers is 42 miles from Slone-Kettering in NY and 49 miles from Fox Chase in Philadelphia. Yale is 137 miles form Dana Farber in Boston and 75 miles from Slone Kettering. Two centers in Virginia are only 72 miles apart, 2 in Indiana are 66 miles apart, and 2 in Michigan only 45 miles apart.
Population density is not the only factor that can support a successful Cancer Center. Even more important is a strong academic tradition and research programs. In Kentucky, the population center is in Louisville. I suggest that is in the latter categories that the the University of Louisville was found to be wanting. Evidence of other academic problems at UofL in our headlines enables such a conclusion.
What the the NCI thinks its Cancer Centers should be:
“NCI-designated cancer centers are institutions dedicated to research in the development of more effective approaches to prevention, diagnosis, and treatment of cancer. There are three types: Cancer Centers, Comprehensive Cancer Centers, and Basic Laboratory Centers. Cancer Centers must demonstrate scientific leadership, resources, and capabilities in some combination of laboratory, clinical, or population science. Comprehensive Cancer Centers must demonstrate reasonable depth and breadth of research in each of three major areas: laboratory, clinical, and population-based research, as well as substantial transdisciplinary research that bridges these scientific areas. Basic Laboratory Cancer Centers conduct only laboratory research and do not provide patient treatment. There is a total of 68 NCI-designated Cancer centers; 20 Cancer Centers, 41 Comprehensive Cancer Centers, and 7 Basic Laboratory Cancer Centers.” [Add to this list 21 NCI Community Cancer Centers.]
Not the first time a cancer partnership has failed.
UofL has had other opportunities to form meaningful local partnerships that well might have allowed it to capture its prize. It was reported publicly some years ago that UofL and Norton Healthcare came close to forming a shared Cancer Center. Such a relationship could have been a win-win for both institutions and for Louisville. Norton’s Cancer Center was and still is by far the community leader in providing clinical oncology services and in providing access to clinical trials. Norton was also generous in providing research and academic support to the University. Nonetheless, it was reported that those discussions ended unsuccessfully. I was a member of the cabinet of the Dean of the Medical School around that time and can speculate why. In my opinion, and as evidenced by the current open legal warfare between the University and Norton, UofL does not always play well with its partners.
Its not all your fault.
For decades, other Lousiville Hospitals have done their best to capture the most profitable service lines from University Hospital– sometimes with the eager cooperation of the University itself. When I was once the medical director of an insurance company in Louisville that was co-owned by all the not-for profit hospitals in the city, I was not allowed to approve patients to use the Brown Cancer Center because it was “out of network.” I had to send bone-marrow transplant patients out of the city even though UofL had the only certificate-of-need for bone marrow in the region. [I referred bone-marrow patients to Cincinnati where it was easy (even for one as inexperienced as I) to negotiate reasonable charges, and ironically where the same doctors were involved in the treatments. In my experienced opinion, beware of insurance companies owned by hospitals or providers!]
UofL has been trying a long time!
For the entire 30 years I have been associated with UofL, it has aspired to grow an oncology presence at its medical center. It had expectations that the upgrading of laboratory, imaging, pathology, and other clinical services required to adequately treat cancer would lift the whole hospital out of its poor-cousin status among other local hospitals. It was not a bad plan. Not lost on planners was that there is much money to be made in cancer care. [There is a reason that Cancer Centers are so heavily advertised in airplane magazines and other national media.] Having an NCI Cancer Center designation would have provided a jewel in the reputational crown of UofL. It has not yet happened yet. The hospital is still struggling to find its way.
Achieving NCI designation is not an easy task.
There are only 68 and very few are added. To add insult to disappointment, in July of 2013, the University of Kentucky’s Markey Cancer Center was designated as a Comprehensive Cancer Center– the highest category. Much to UofL’s distress, a few of its prominent cancer researchers subsequently voted with their feet and left to join the Markey Center. What must be embarrassing for UofL is that their current arch-competitor, Norton, was awarded one of 21 highly competitive NCI Community Cancer Center designations! It’s difficult to claim being “the best” in the face of such external evaluations. UofL could have shared in these prizes: they had opportunities to do so.
What did UK do differently?
How could UK achieve comprehensive status and UofL be denied? A deeper analysis would be instructive and perhaps suggest a way for UofL to be more successful, but I do not have access to the necessary information or the insight to do so. It is true that UK got more of the “Bucks for Brains” money from the state to renew its research efforts: two-thirds to one-third was the ratio. How then was it used? Additional tobacco-settlement money given to the two Universities for research was earmarked primarily to benefit lung cancer screening in Louisville. My UK lobbyist friends used to chide me that they were using their money to build infrastructure while we were using ours for “flash” and to hire scientists with existing NIH grants. In fact, that is why in the early 2000s we were able to improve our ranking so quickly in obtaining NIH funding compared other medical schools. That strategy may have run its course. UofL Medical School’s ability to obtain NIH grants has stalled, indeed diminished. I suggest we should try to understand why. Lack of federal or state government support may not be the best answer, even if it is easiest.
So what should UofL Do?
The University should by no means give up. I do not know when UofL last submitted its last NCI application. The rules say one must wait three years before trying again. Keep Cancer Center designation in your long term plans even though you might get an “incomplete” on your report card for longer. Consider lowering your sights a bit and apply for a research-only or an otherwise more limited Cancer Center until your clinical operation gets further off the ground and you can develop the collaborative relationships that the NCI favors. Make peace with Norton Healthcare, your immediate neighbor and former best buddy. This is harder now since you have promised KentuckyOne you would have little more to do with Norton without its permission. It will become harder too as UK begins to work more closely with Norton’s Cancer Center.
UofL, you have spent much energy burning bridges. You must start to rebuild them. You must abandon your stated plans to go it alone and to refer only among your own doctors in a single network. That strategy doesn’t seem to be working anyway. Alas, in the hyper-competitive Louisville market, I fear that wasteful duplication will continue to be an issue, just as we are seeing happening in pediatric medicine. Is there no alternative? Should you reopen discussions with UK about offering a joint program? Are you allowed to do so? Should state leadership require you to do so? Is it now impossible for you to provide leadership and to work with and for the community as a whole? I believe the role of a state university is to draw its community together, not to divide it. To do otherwise would be a tragedy and a waste of a community resource.
Perhaps our readers can offer additional suggestions, but I will proffer one more gratuitous one. It concerns appearances. I am personally put off by the prominence of commercialization in so many of your programs. I saw it up close and personal for some years. Indeed your zeal to commercialize your research frightens me. Such a focus can confound or distort the scientific and academic enterprise. Business ethics are not the same as scientific or academic ethics. Surely there must be some on NCI review panels who feel the same way I do. On the other hand, perhaps I am too much of an academic dinosaur and your path is the new norm. I hope not. Regardless, make it clear why you want to be designated as a Cancer Center and then act that way. It’s more than just a trophy. If you seek your goal for the right reasons, I believe you can succeed.
As always, if I have made an error of fact, please help me correct it. I invite discussion in the public comments section below.
Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
July 29, 2014