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.
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).
I spent an evening last week doing two things that, at first, I thought were unrelated.
First, I viewed a preview of “Cancer: The Emperor of All Maladies,” a PBS documentary based on the book by Siddhartha Mukherjee. His preview was sponsored by the Iowa Cancer Consortium, The American Cancer Society, The Iowa Department of Public Health and Iowa Public Television. It included excerpts from the 3 part PBS documentary by producer Ken Burns that starts tonight, March 30 and runs through Wednesday, April 1. The preview was followed by a panel discussion. My fellow panelists and I made brief statements, and then entertained a range of outstanding questions from the audience.
Last week, I had the honor of moderating a panel discussion on Capitol Hill on behalf of the Association of American Cancer Institutes and the American Association for Cancer Research. This panel was sponsored by the congressional cancer caucus and focused on the importance of the nation’s premier cancer research centers. In such settings, it can be challenging to talk about the vital importance of the work done at our cancer centers in a way that highlights the hope without appearing to be resorting to hype.
Environmental biologists have studied it for years – cancer biologists are just starting to think about it – and it has the potential to result in a fundamental change in our understanding of cancer. I am talking about ecosystems.
We all learned in elementary school that diversity helps an ecosystem thrive. Bees need flowers so they can make honey from the nectar. Flowers need bees for pollination. Neither would be able to exist without each other.
How does this concept apply to cancer? Our traditional view of cancer is that cancer cells within a tumor are the same. One cell starts growing out of control, pushes out the normal cells, and the result is cancer. Indeed, we talk about cancer as being “monoclonal,” i.e. all cells being the same. A major goal of cancer research over the past decade has been to understand the changes in genes that drive the monoclonal growth of cancer cells. In some cases, such as chronic myelogenous leukemia and some cases of melanoma, we have identified the gene that causes the cancer to behave badly, and have been able to treat the cancer successfully by targeting the product of the rogue gene.
I am writing this on a weekend morning. It is really cold outside, and there is nothing on my calendar for a few hours. Instead of doing something productive, I find myself curled up on the couch in front of the fireplace surfing the web on my laptop. I am having no trouble finding totally useless but entertaining sites – a few thoughtful, some silly, and all too many outrageous. I know this is keeping me from more important projects (such as getting our family photos in order or writing a cancer research grant) but I am having a hard time focusing. My wife, who has experienced my channel flicking when I have the TV remote, knows this side of me all too well.
People of different faiths have varied perspectives on the value and meaning of the December holidays. Getting past the commercialization can also be a challenge. Nevertheless, with the possible exception of individuals who are humbug down to the core, we are all affected positively by the spirit of giving, receiving, and togetherness this time of year. I am not speaking here about giving and receiving “stuff,” but giving, receiving, and being together in a much more profound sense.
I spent time during my education and training at The Ohio State and the University of Michigan before arriving in Iowa City 25 years ago. I have close family members with ties to essentially all the other Big 10 schools. This time of year, we discuss the past season and bowl games, and argue about whose football team is overrated or underrated. When you are connected with a Big 10 school, you hear a lot about football. Collaborative cancer research is generally not part of the Big 10 discussion. However, we are working to change that.