Last week, I had the pleasure of giving a talk on cancer at the University of Iowa Carver College of Medicine Mini-Medical School, a series of presentations provided to the lay public to introduce them to a topic in medicine. Every time I give a talk to a lay audience, I think back to a wonderful woman I had as a patient when I was doing my oncology training in the 1980s. She was a retired English teacher who took pleasure in gently ribbing me about the words I selected when I spoke with her (once a teacher, always a teacher). I recall one time when I suggested we consider putting her “on trial.” Her response – “Put me on trial? What a strange phrase. I certainly wish getting cancer was against the law! Why do you want to put me on trial?” That lead to an animated conversation about not only that phrase, but how doctors use expressions when talking to each other that are interpreted differently by patients. While I don’t recall which additional specific phrases we discussed back then, that conversation had a long lasting effect on me, and the phrases I use when I speak to patients, families and the public.
This blog is not an appropriate place for me to express my personal political opinions. On the other hand, recent political events could well influence the Holden mission of reducing the burden of cancer for those we serve. I therefore decided it would be appropriate for me to use this forum to discuss the potential impact of current national politics on cancer research.
We are all too aware of recent political happenings such as the government shutdown, the resulting short-term continuing resolution that reopened the government (at least for now) and the major issues of ongoing political contention. We know recent haggling has been accompanied by political name calling, finger pointing and what seems like an endless discussion of who got a “win” and who got a “loss.” It comes across as if we are keeping score in a game rather than trying to have a positive impact on people’s lives. Indeed, the discussion seems to be based on the assumption that political deliberations are a “zero sum game.” If one side is to win, the other side needs to lose. And, if decisions are viewed in this manner, no matter how bad a politician appears, that politician still gets a “win” if their opponent can be made to look worse.
There may be no better way to get the members of any organization to roll their eyes and groan than to say “we are going to develop a new strategic plan!” Most of us have been through this before. At its worst, strategic planning begins with the hiring of an expensive consultant, followed by endless hours of meetings dedicated in large part to educating the consultant about the organization. The result is often a “plan” that states the obvious. This is then formalized into a slick, glossy document that sits on the shelf until the next time someone says “we are going to develop a new strategic plan!”
Given this perspective, who would have thought it would be me who, a few months back, said “we are going to develop a new strategic plan” for the cancer center. Indeed, it took some self-reflection before I was able to suppress my own eye rolling and groaning . This decision was based on the timing and value of such a process.
Last month, I attended back-to-back meetings in Washington D.C. Both had a cancer focus, but otherwise it appeared there was little in common. The first was a meeting of the Society for the Immunotherapy of Cancer where the latest scientific and clinical advances in cancer immunotherapy were discussed. The second was a meeting of the National Cancer Policy Forum that included a workshop where we discussed approaches to helping cancer patients navigate the complexities of the health care system.
It is difficult for all of us to identify and address, on our own, those areas where we should and can do a better job. Sometimes dealing with day to day challenges limits our ability to step back and look at the big picture. Sometimes we might see an issue that needs to be addressed but hesitate to do so because of concerns about unintended consequences we know or suspect might result from implementing a solution. Sometimes we might not realize there is a better way. Sometimes we might see a better way, but are simply unable to implement the needed change on our own. This certainly is true for a complex organization such as a comprehensive cancer center where we are working to reduce the burden of cancer across the spectrum of clinical care, research and education – where opportunities and challenges are ever present and ever changing.
Achieving our potential requires we ask ourselves whether we are we doing our best to…
- Identify and support the most promising cancer research.
- Recruit and retain the best faculty, staff, students and volunteers.
- Bring advances from the research lab to where they help patients as quickly as possible.
- Provide state-of-the-art, personalized clinical care and service to every patient.
- Educate the next generation of cancer researchers and caregivers.
- Work within our community and across the state to disseminate advances so they help as many people as possible.
- Collaborate optimally with other units within our own institution (departments, colleges, the hospital, etc).
- Collaborate optimally with outside institutions (referring physicians and medical centers, other cancer centers, the National Cancer Institute, etc).
- Structure our own efforts to be as efficient and effective as possible to facilitate our ability to do all of these things well.
In addition to self-reflection and internal discussion, it helps to ask outsiders to take a fresh look and advise us on how to improve. One of the most forward-thinking aspects of the National Cancer Institute (NCI) Cancer Centers Program is the requirement that every cancer center have a yearly visit from an External Advisory Board (EAB) composed of experts from other cancer centers. Making optimal use of an EAB requires the hosting cancer center be totally open. We do not try to hide or paper over our major challenges when our EAB visits. Instead, we put them front and center. For the EAB to do its job and help us improve, it needs to be highly critical. As Oscar Wilde said “true friends stab you in the front.” Having an EAB say “keep it up, you are doing an excellent job,” just doesn’t cut it. We need the EAB to tell us how we can do better. Our EAB will be visiting next month and our presentations to them will include a discussion of what we are doing with a particular focus on where we feel we can improve. We will put down our armor, show them our soft underbelly, and say “hit me with your best shot.”
I have the privilege of serving on the EABs of nine other NCI-designated cancer centers and chairing five of them. I have no doubt participating on these boards helps me do my job at Holden more effectively. I get to see how other cancer centers handle particularly difficult issues. Sometimes I return home with a new idea of how we can address a gnarly challenge. Just as commonly, I return home after seeing a cancer center’s approach to dealing with a problem, grateful for the team we have at Iowa and the solution we have found to a problem that another center is struggling to address.
Sometimes it feels a bit awkward being on an EAB when I beat up on my colleagues and friends, and am rewarded for doing so by a nice meal and a sincere “thank you.” When our EAB visits next month, I am sure they will return the favor. I will say “hit me with your best shot,” and when they happily (and hopefully ruthlessly) comply, I will feed them and express my deepest appreciation.
Cancer, as in many complex problems, can best be approached by looking at it from every angle, i.e. in three dimensions. We do this literally through reconstructing images such as CT scans, confocal microscope pictures or computerized molecular modeling. We also do this figuratively through the 3Ds of discovery, development and dissemination.
Earlier this week, I was catching up on my computer at home when I received an e-mail notifying us that we had received a couple of important accreditations (more on these below). That got me thinking about writing a blog about the process of obtaining such accreditations. By chance, my eyes landed on an old book on my bookshelf – The Agony and the Ecstasy – a novel by Irving Stone about the life of Michelangelo. The title reflects how the artist’s life was divided into the agony of dealing with the politics and society of the day, and the ecstasy of completing his incredible masterpieces. Once it got into my brain, I just couldn’t shake the silly metaphor of linking the process of obtaining accreditations with painting the Sistine Chapel. So, despite the totally understandable puzzled expressions on the faces of my colleagues when they first heard of my plans for this blog, here we go…
Late last week we received formal notification from the National Cancer Institute (NCI) that our long-standing collaboration with the Mayo Clinic known as the “Iowa-Mayo Lymphoma Specialized Program of Research Excellence” or “SPORE” for short, has been refunded for another 5 years. This program has been funded continuously by the NCI for the past 15 years. We now know we will be funded for years 16 through 20. Like most cancer research grants, funding decisions on SPORE grants are based on a robust peer review process and are highly competitive. Needless to say, we were thrilled to hear that our SPORE was viewed positively by our peers.
Incredible advances in cancer genetics have revolutionized how we think about cancer. These advances are now being applied to patient care. A brief response to the question “how is our growing knowledge of cancer genetics impacting on cancer research and cancer medicine?” is to say “it’s complicated – and exciting!” That is not a very helpful answer. Here, I will summarize the big picture with the understanding that this brief summary will not even touch on some of the rapidly evolving, nuanced, yet very exciting concepts in cancer genetics.
Let’s start out with a review and discussion of why the genetics revolution in cancer is so important.
Once each year, I take a week off at the end of July and, with 10,000 other crazies, ride my bike across Iowa as part of RAGBRAI. For those of you who are not familiar with this Iowa tradition, RAGBRAI is the “Register’s Annual Great Bicycle Ride Across Iowa”. RAGBRAI follows a different route across the state each year. It starts on the western edge of the state and finishes on the east with the ceremonial dipping of the front bicycle tire in the Mississippi. RAGBRAI is a rolling folk festival with riders in costumes, bands in many towns, church ladies selling pie, and everything that makes Iowa a great place to live (including a growing number of beer gardens selling Iowa craft beer).