Journey to the Center of the Cancer Universe
As the UAB O’Neal Comprehensive Cancer Center celebrates the 50th anniversary of its first core grant from the National Cancer Institute, its comprehensive vision comes full circle in this retrospective on the history of the NCI designations that started it all.
Story by Anna Waters
Photos courtesy of the UAB Archives
Cancer Center Magazine | Spring 2022
For decades after President Franklin D. Roosevelt signed the first National Cancer Act in 1937, most academic medical centers were still deeply hesitant and even reluctant to pursue cancer research or invest resources in clinical care for cancer patients.
The National Cancer Act of 1937 established the National Cancer Institute of the National Institutes of Health, marking the first time that Congress had ever appropriated funds to support the research of a noncommunicable disease. However, after Congress approved the Public Health Service Act of 1944, which dialed back the authority of the U.S. Public Health Service, the NCI was restructured and reorganized as an operating division under the authority of the NIH.
Through the 1960s and 1970s, many clinicians, scientists and institutional leaders in medicine still believed that what little was known about cancer at the time was not enough to justify investing resources in cancer research, that the care of cancer patients was a futile exercise and that federal involvement in the research of a particular disease like cancer would lead to a disparate allocation of resources and would indirectly take time, money and laboratory space away from other important research areas.
In their 2021 book, “Centers of the Cancer Universe: A Half-Century of Progress Against Cancer,” authors Donald L. “Skip” Trump, M.D., and Eric T. Rosenthal explain that this resistance to cancer research and cancer care was inherent in a variety of scientific and medical institutions at the time.
“In the scientific community, there was – and would continue to be – reluctance to commit what some considered ‘disproportionate’ resources to any particular area of scientific research,” Trump and Rosenthal write. “In addition, there was great skepticism that the time was right for meaningful progress against cancer.”
However, interest in cancer research and federal funding was growing among the general public, driven by a wave of cancer advocates, grassroots organizations and powerful philanthropic supporters. In 1969, the Citizens Committee for the Conquest of Cancer paid for a full-page ad in the New York Times that called for then-President Richard M. Nixon to expand federal support for cancer research, comparing the mission of finding a cure for cancer to the mission of landing a man on the moon.
By 1970, cancer had become the second-leading cause of death in the United States, leading to the formation of a team of respected physicians and scientists, called the National Panel of Consultants on the Conquest of Cancer, who presented a report to the president and to Congress that laid out a new plan for progress on the cancer front. In the report, the panel wrote: “The long-term future may belong to the immunologist and the geneticist, the intermediate future to the chemotherapist, but the present and immediate future belong in the main to the surgeon and to some extent the radiologist.”
After a series of additional reports, panels, bills and recommendations from both advocates and critics of the expanded federal intervention in cancer research funding supported by the panel, Nixon signed the country’s second National Cancer Act on Dec. 23, 1971, declaring a “war” on cancer.
This National Cancer Act of 1971 restored and reorganized much of the authority of the NCI. In addition to creating the presidentially appointed National Cancer Advisory Board, which comprised a total of 18 members representing the scientific community, the general public and other government agencies, the NCA of 1971 gave the NCI more autonomy than other divisions of the NIH, including the agency to award funding and contracts for cancer research, to appoint advisory committees, to create a global cancer research data bank, to expand cancer research facilities across the country and, with the help of the National Cancer Advisory Board, to develop a new National Cancer Program that would establish 15 new cancer research centers throughout the United States.
These 15 new cancer research centers, then called National Research & Demonstration Centers, were each awarded an NCI support grant of up to $5 million to develop the infrastructure to support “clinical research, training and demonstration of advanced diagnostic and treatment methods relating to cancer,” according to the original language of the bill. Among those 15 was the University of Alabama at Birmingham – then called the University of Alabama in Birmingham, which also housed the University of Alabama School of Medicine, now named the UAB Heersink School of Medicine.
History in the making
Following the death of Alabama Gov. Lurleen B. Wallace to cancer in 1968, a grassroots fundraising campaign, called the Courage Crusade, was well on its way to its $5 million goal to help fund the build of the state’s first specialty cancer hospital. In its first issue, published in June 1971, the Courage Crusade’s newsletter, called Conquest, printed a letter from the president of the Lurleen B. Wallace Memorial Cancer Hospital Fund inviting the people of Alabama to contribute to the fund. A copy of the newsletter, including the letter, was sent to Nixon after his visit to Birmingham, Alabama, in May, just a few months before he signed the National Cancer Act of 1971.
“It is particularly heartening to learn about the University of Alabama’s deep concern and interest in cancer research and training,” Nixon wrote back in his response, adding “the time has now come for us to put our money where our hopes are, and I am hopeful that by working together, the government and the men and women in our great medical research centers will find a cure against cancer and eliminate this enemy of mankind from our world.”
As public interest in building this new cancer research and treatment facility in Alabama continued to grow, UAB recruited John Durant, M.D., from Philadelphia, Pennsylvania, to serve as the cancer planning coordinator in 1968 and, upon formalizing the cancer program in 1970, named Durant its first director. Alongside Durant was a young Joan Kemp, who had begun working as Durant’s assistant just 14 months after he joined the faculty at UAB.
Kemp remained in that role for 48 years. In 1970, she helped Durant submit UAB’s first NCI planning grant, the first of many she would submit in her 48 years as assistant to the director.
“He was such a visionary in how he pulled off our first designation,” Kemp said. “He used his creative talents and all the resources that he could pull together at UAB with very little support and very little manpower. He was the perfect person to be the founding director.”
As an example of Durant’s vision, Kemp fondly describes one conversation with him while the two were preparing application materials for that first NCI planning grant.
“As we were nearing the deadline,” Kemp said, “he impatiently asked, ‘How much longer?’”
Kemp was typing as quickly as she could on a first-generation IBM mag card typewriter. This kind of 1960s-era typewriter was connected to a box that held magnetic cards upon which lines of text could be saved and revised. Kemp told Durant that, once she finished her edits on the typewriter, she would have to take the edited pages to the copy machine in the next corridor to print the 25 copies that had to be mailed to the NCI.
“And he said, ‘Well, I don’t understand. If you can send that information from that typewriter to that box right there, why can’t you send it to the copy machine?’”
Kemp looked at him, laughed and asked, “Have you lost your mind?”
“After all, it was 1970, and that kind of networking had not even been thought of at that point in time,” she recalled. “We needed somebody like John Durant who was always 20 to 25 years ahead of everybody else.”
Their hard work, coupled with Durant’s vision, paid off a few months later when they received an award letter for a $254,334 planning grant from the NCI to help lay the foundation of what would become the state of Alabama’s first cancer center.
The public push for an in-state cancer center at that time was largely led by the Courage Crusade but more than half of the $5 million raised for the proposed cancer hospital and tumor institute came from small, individual contributions. State workers, local churches, community groups, civic clubs, small businesses and even schoolchildren donated their boxes of pennies and nickels to the fund.
With the $5 million from the Courage Crusade and another $10 million from federal and state funds, a total of $15 million was designated to build the Wallace Tumor Institute and Radiation Therapy building and the Wallace Patient Tower.
As a result of this statewide demonstration of dedication to the cause, the NCI seemed to trust that Durant, the medical school and the institutional leadership at UAB would follow through on their commitment to establishing and maintaining the kind of cancer center that the NCI and the people of Alabama hoped to build.
In February 1972, roughly two months after Nixon signed the National Cancer Act of 1971, Durant and Kemp received another letter in the mail from the NCI – a formal notice of award totaling $4.3 million in funding over the next three years. With their first NCI cancer center support grant in hand, it was official: The cancer center was a reality.
The designations in the details
Initially, before the term was formalized, the NCI referred to all its National Research & Demonstration Centers as “comprehensive cancer centers,” but the need to differentiate the rising quantity of these centers soon beget the need to define what it meant for a cancer center to be truly “comprehensive.”
“After that, as other institutions applied for status, it was obvious that there were different levels of capabilities for each center,” Kemp said.
Although many of the chronological details have been lost to time, from 1972 to 1973, the NCI began making a distinction between cancer centers that met its criteria for basic science research, centers that met its criteria for clinical research, and centers that met the criteria for both basic science and clinical research.
Fifty years later, these centers are categorized as “NCI-Designated Cancer Centers,” “NCI-Designated Comprehensive Cancer Centers” or “Basic Laboratory Cancer Centers,” the latter of which primarily focus on lab-based scientific research and preclinical translational research and generally collaborate with other institutions to apply their basic science findings.
“I think there were maybe 40 institutions or so that qualified for either a clinical research center or a basic science center, but not very many that qualified for the comprehensive status,” Kemp said. “And then, as the years went on, they added additional criteria for a center to meet to either become comprehensive or to remain comprehensive.”
The NCI designated centers that met both sets of criteria as “comprehensive” and identified the centers worthy of that designation over the course of a few years, announcing them in batches, beginning with the first eight in June 1973. These initial eight comprehensive cancer centers included UAB, where researchers, clinicians, staff and leadership had already been working diligently to address the burden of cancer for the people of Alabama.
Over the next three years, the NCI announced additional designated comprehensive cancer centers, bringing the total number of designated centers and designated comprehensive centers to 19 in 1976. By then, the Cancer Center at UAB had moved into the 38,000-square-foot Lurleen B. Wallace Tumor Institute and Radiation Therapy Building, which represented the culmination of the years of public and philanthropic advocacy that the Courage Crusade and other individuals and organizations across the state had kicked off in 1968.
That same year, the NCI launched its Cancer Information Service, a toll-free telephone service for health professionals and the general public, in 1976. To use the service, anyone could call 1 (800) 4-CANCER and speak to a team typically staffed by each cancer center. The service came to UAB a few years after its initial launch, and in 1980, Cancer Center staff members received their first call.
Jordan DeMoss, MSHA, serves as the vice president of the UAB Cancer Service Line and has helped expand and refine many of the early mechanisms of NCI-Designated Comprehensive Cancer Centers.
“A diagnosis of cancer has always been one of the scariest realities one can face, and it deserves a team of professionals who understand each patient’s needs,” DeMoss said. “Today, we still use dedicated phone lines for our cancer patients that link each of our new cancer patients to a nurse navigator who remains by the patient’s side through the treatment journey.”
How to be “comprehensive”
But what does it mean to the NCI, to UAB and to the O’Neal Cancer Center, as well as to the Cancer Center’s many researchers, doctors, staff and patients, for a cancer center to be considered “comprehensive”?
Today, the distinction between a cancer center designated by the NCI and a cancer center designated as “comprehensive” by the NCI is similar to what it was back in the early 1970s, but with the addition of criteria for cancer epidemiology, prevention and control. While an NCI-Designated Cancer Center must meet the NCI’s standards for one of three areas – cancer prevention, basic science research, or clinical research and services – an NCI-Designated Comprehensive Cancer Center must meet the standards for all three of those areas.
In their book, Trump and Rosenthal describe six essential characteristics of an effective NCI-Designated Cancer Center that leaders of the NCI Office of Cancer Centers, senior advisors to the NCI and individual cancer center leaders have identified as necessary for cancer centers to address in their NCI cancer center support grant – commonly called a “core grant” – application materials. These designated cancer centers are expected to address characteristics related to the center’s physical space, the center’s organizational capabilities, transdisciplinary collaboration and coordination at the center, the center’s scientific focus on cancer, institutional commitment to the center and the center director’s expertise and vision.
Barry Sleckman, M.D., Ph.D., joined the UAB O’Neal Comprehensive Cancer Center in January 2020 to serve as the O’Neal Cancer Center’s new director.
“Continued growth and improvement in these six essential characteristics enable the O’Neal to meet its mission of advancing our understanding of cancer to improve prevention, detection, treatment and survivorship for all people and to make our vision of life without cancer a reality for everyone,” Sleckman said.
To be eligible for a comprehensive designation from the NCI, cancer centers must have at least three research programs, at least one shared resource – specifically, a shared biostatistics resource – and a robust clinical trials program that effectively accrues participants to studies and that provides substantial education to assure and inform the public on how trials work
An NCI-Designated Comprehensive Cancer Center must also effectively identify the geographic area that it serves or intends to serve, referred to as its catchment area; define the problems and impact of cancer that are most relevant to its catchment area; and serve its catchment area, as well as a broader population, via the research it conducts, the cancer control activities it has undertaken, the communities it engages and the outreach it performs.
“We are forging new partnerships across the state in alignment with our UAB Health System affiliations to play a role in filling the gaps in care across our state to ensure no patient leaves Alabama for cancer care,” DeMoss said. “It is exciting to see how telemedicine and digital health are beginning to transform how we are able to connect with patients and clinicians across our state.”
In 2017, the NCI began requiring each of its NCI-Designated Comprehensive Cancer Centers to incorporate into the center’s institutional structure an office dedicated to community outreach and engagement. This move has contributed to much of the success of the UAB O’Neal Comprehensive Cancer Center, its Office of Community Outreach & Engagement and its programs in cancer control and population sciences, which are also required for the NCI’s Comprehensive Cancer Center designation. Similarly, the center is expected to educate and train biomedical scientists and health care professionals to achieve its scientific mission, as is the case in the O’Neal Cancer Center’s Cancer Training & Career Development Office.
“Under the leadership of Dr. Monica Baskin, the Office of Community Outreach & Engagement focuses on cancer education, prevention, control and treatment in Alabama counties with the greatest cancer burdens and disparities,” Sleckman said. “Likewise, under the leadership of Dr. Lalita Shevde-Samant, the O’Neal Cancer Center’s education and training efforts focus on inspiring young minds toward careers in cancer research and care with a specific focus on our minority students.”
Comprehensive autonomy
Upon officially receiving its first NCI core grant in 1972, the UAB O’Neal Comprehensive Cancer Center was established as an NCI-Designated Cancer Center, and upon the NCI’s decision to further designate cancer centers as “comprehensive” in 1973, the O’Neal Cancer Center became one of the NCI’s first eight new NCI-Designated Comprehensive Cancer Centers. Since then, the Cancer Center has successfully been awarded 10 renewals of its NCI core grant funding and its NCI designation as a comprehensive cancer center. NCI-Designated Cancer Centers and NCI-Designated Comprehensive Cancer Centers must apply for a renewal of their core grant and their designation every five years, with a few exceptions for extenuating circumstances, such as recruiting a new director, that may require an extension on the five-year deadline for core grant submissions.
In the decades that have passed since the O’Neal Cancer Center’s original comprehensive designation from the NCI, the Cancer Center and the UAB Health System have worked together to bring the concept of comprehensive care and research to patients, families of patients, scientists, physicians, nurses and other staff, as well as the various communities within the O’Neal Cancer Center’s catchment area, which includes the entire state of Alabama.
In 2008, the O’Neal Cancer Center created the Integrated Multidisciplinary Cancer Care Program to unite the various specialists, modalities and treatment approaches in cancer care to streamline the process of receiving cancer treatment at UAB for patients and their families.
Then, in June 2011, the O’Neal Cancer Center launched the Cancer Care Network, an affiliation between the Cancer Center and other community cancer centers and hospitals in Alabama and Georgia, that allowed the Cancer Center to support the growth of its affiliates’ cancer programs at a local level by providing each affiliated community cancer center with access to the O’Neal Cancer Center’s best practices in cancer care, to its novel clinical trials and support services, to educational resources and opportunities for providers and to the expertise of its researchers.
“Being comprehensive is dynamic and in continuous evolution,” DeMoss said. “From ensuring our patients have access to the latest in precision oncology to finding novel ways of supporting cancer patients and their families through our virtual Arts in Medicine program, we will never stop refining what comprehensive means in terms of cutting-edge cancer care.”
One of the goals of the National Cancer Act of 1971 and of the NCI’s National Cancer Centers Program was to ensure the autonomy of the NCI director, as well as the autonomy of cancer center directors, who are required by the NCI to have more institutional authority than individual department chairs and to have some influence or control over the provision of clinical cancer care. At many matrixed academic medical centers like the O’Neal Comprehensive Cancer Center, that provision of clinical cancer care is managed by the Cancer Service Line, the operational arm of all clinical cancer care at an institution.
In 2019, UAB Medicine revamped the O’Neal Cancer Service Line, which had traditionally fallen under the sole purview of the UAB Health System. The relaunch of the service line as a “signature service line” formalized the priority and authority of cancer care and research at UAB and UAB Medicine while reworking the existing organizational structure to ensure that the service line was ostensibly housed within the O’Neal Comprehensive Cancer Center, which had previously been conceptualized as a purely academic, university enterprise separate from the UAB Health System.
This move to consolidate the goals and efforts of the academic, research-focused O’Neal Cancer Center and the clinical, patient-facing O’Neal Cancer Service Line demonstrated an institutional commitment from both the university and UAB Medicine to support and invest resources in the “comprehensive” mission of the Cancer Center and, indirectly, of the NCI.
While the NCI does not assess clinical outcomes in its evaluation of designated cancer centers, the designation itself has become important to other measures of a center’s reputation and effectiveness, such as U.S. News & World Report’s annual Best Hospitals list, which ranks hospitals across the country based on specialty and on criteria that include consideration for whether a cancer center is designated by the NCI. Last year, UAB was ranked No. 25 in the 2020-2021 list of Best Hospitals for Cancer, which represented the highest rank that the O’Neal Cancer Center has ever achieved on the list.
“What distinguishes cancer care at NCI-Designated Cancer Centers from care at other facilities are the NCI requirements that designated comprehensive cancer centers must carry out cutting-edge research in cancer prevention and care and that they must make what is learned from this research available to cancer patients through clinical trials,” Sleckman said. “It is really what makes cancer care at NCI-Designated Cancer Centers the best of cancer care.”
This story originally ran in the Spring 2022 issue of the O’Neal Comprehensive Cancer Center magazine. Learn more about the history of the O’Neal Cancer Center in this special, commemorative issue to celebrate the 50th anniversary of the Cancer Center.