Opinion: Are 71 NCI-Designated Cancer Centers Too Many?

As a senior administrator at two centers and a frequent attendee at national meetings, I witnessed little researcher interest in designation. The program contains minimal research funding. The annual budget of $313 million, divided 71 ways, averages $4.4 million per center, a trivial sum for an institution-wide cancer grant and a pittance compared to that needed to gain and maintain designation. Funding varies for individual centers, but even those on the short end continually seek renewal. Others are organizing and investing resources, hoping for eventual designation. 

I knew of one center that spent $17,000 for design of a slide presentation template and another that printed its strategic plan on placemats for site visitors.

So why the intense interest? Designation is perceived as some sort of gold standard by important constituencies not directly involved in research. University hospital executives see it as effective, even if somewhat deceptive, advertising for clinical operations. Almost every center uses the designation to boost fundraising. Some politicians see it as a symbol for their region and a way to “attract thousands of jobs and billions of dollars.” All a bit surprising just for making the top 71!

With so much symbolism, biological science takes a back seat to hyped-up grant writing for insuring (re)designation. The five-year designation-determining Cancer Center Support Grant (CCSG) is perhaps the most ritualized and massive proposal in science. Preparation can begin more than a year in advance. Scientists are pulled out of laboratories to write and rewrite sections. Graphic artists, presentation coaches, formatters, and proofreaders are hired. I knew of one center that spent $17,000 for design of a slide presentation template and another that printed its strategic plan on placemats for site visitors. A governor or senator occasionally appears at a site visit.

Absurdities go beyond grant writing. I witnessed contrivances such as hiring specific researchers from other institutions who might have served as grant reviewers as consultants to conflict them out of reviews, or arranging meetings only for the purpose of documenting collaboration. The overlay of centers onto traditional academic department-based organizations (for example, oncology, radiation oncology, surgery, pathology, etc.) pushes leaders into endless meetings to resolve administrative confusion and turf conflicts.

A bigger problem is that CCSG metrics don’t encourage the best science. For example, cross-disciplinary publication counts make it advantageous to force a strained collaboration between epidemiologists and basic lab scientists rather than support a well-conceived project by either.  Total center-wide patient accruals to clinical trials skews the balance between basic and clinical/translational research. Overall, the metrics strongly favor clinical/translational research over basic research; a preference held by fundraisers and politicians, but one that causes debate among scientists.

NCI’s supplemental “comprehensive” label (51 of the 71 centers are “comprehensive”) works against exceptional programs needed to combat an exceptionally complex disease. Comprehensive centers must achieve metrics in basic science, translational science, clinical research, population science, and research on community engagement. Institutes neglect strengths and invest where they have little tradition and capability. Comprehensiveness beats excellence in a 51-way race to the middle.

Efforts to increase efficiency and improve metrics would be welcome, but such efforts should first deal with fundamental questions such as:

• Should we have a defacto national strategy for organizing cancer research by designating 70+ centers with a common organizational template? Or should we concentrate limited program funding on fewer centers?
• Should the template allow greater flexibility in organizational design? 
• Should the program continue to prioritize clinical/translational research over basic research? Comprehensiveness over specialized excellence?
• Can the NCI avoid misuse of the designation by regulating its use in clinical advertising and fundraising?

Given the vested interests, reform processes will need to include the voices of scientists, physicians, and administrators not currently involved with designated centers and not unduly influenced by concerns about hospital finance or fundraising.

David Rubenson is the director of the scientific communications firm nobadslides.com. He spent 15 years in senior administrative positions at NCI-designated cancer centers. Prior to that he served as a public policy analyst at the RAND Corporation.