Abstract
With the increasing need for high-quality, state-of-the-art cancer care reaching more people than can be accommodated by National Cancer Institute (NCI)-designated and other academic cancer centers, a new breed of hybrid center has been emerging over the last several years. Although there does not appear to be an official consensus on what proportion of cancer patients are treated in community settings, some sources indicate that it may exceed 70% [1], making it an important goal to provide the same standards of care for all patients regardless of treatment setting. This paper describes four institutions that have been identified as “hybrid academic-community cancer centers,” and explains what differentiates them from traditional academic or community settings.
1.0 Hybrid Center Identified and Defined
The hybrid academic-community cancer center concept was first identified, named, and described in a series of articles [2][3][4][5] initially appearing in MedPage Today in August 2015 following an observation made during that year’s American Society of Clinical Oncology (ASCO) annual meeting in Chicago.These hybrid centers shared several common features:
- Most recruited respected academic-clinician leaders from NCI-designated comprehensive cancer centers.
- They were established at large, well-respected, financially secure not-for-profit regional community hospital systems interested in increasing quality of care and standards of practice.
- They sought to infuse greater academic rigor into their programs, develop translational research programs, enroll more patients from their respective communities into clinical trials, and provide the best cancer care to populations not served by traditional academic centers.
- They often adapted existing resources through collaborative efforts rather than reinventing the wheel.
Originally, four such centers were identified: Carolinas HealthCare System’s Levine Cancer Institute, Charlotte, NC; Christiana Care Health System’s Helen F. Graham Cancer Center and Research Institute, Newark, Del. [6]; Inova Schar Cancer Institute, Falls Church, Va.; Gibbs Cancer Center and Research Institute, Spartanburg Regional Healthcare System, Spartanburg, SC.
Baptist Health South Florida’s Miami Cancer Institute, Miami, Fla., and West Cancer Center, Memphis, Tenn., were identified in later articles.
During the course of the interviews for the articles and subsequent discussions between the author of the MedPage articles (ETR) and the hybrid center directors it was determined that the hybrid concept could benefit from a full-day interactive session among the hybrid leaders sharing best practices, as well as respective aspirations and challenges facing them.
2.0 Hybrid Symposium
In late February 2017, Miami Cancer Institute hosted a “Hybrid Symposium: the Nature and Nurturing of Hybrid Academic-Community Cancer Centers” featuring presentations and discussions by four hybrid directors: West’s Lee S. Schwartzberg, MD, ISCI’s Donald L. “Skip” Trump, MD, Gibbs’s Timothy Yeatman, MD, and MCI’s Michael Zinner, MD. Session moderators were Dr. Zinner, and symposium organizer Eric T. Rosenthal, the journalist who wrote the original articles.
Invitations to participate were extended to each of the hybrid center directors identified in the series, and four were able to attend. Other attendees included medical, executive and professional staff from the four centers; CME/CE credit was offered.
3.0 The Conference Objectives included
- Recognizing and discussing the emerging presence of hybrid academic-community cancer centers.
- Reviewing similarities and differences between existing models that vary according to individual centers’ strengths and needs.
- Identifying and recommending new concepts inspired by models and practices of other centers.
- Formulating a plan for future and ongoing collaboration in support of further development of hybrid academic-community cancer centers.
After the hybrid center directors provided respective overviews of their centers, a series of roundtable discussions commenced dealing with issues of common concern regarding: funding research at hybrid centers; relating to academic partners; dealing with culture clash; balancing the medical and scientific mission with fiscal realities; recruiting and retaining staff; branding and marketing centers within hospital systems and in communities; conclusions and next steps.
The participants agreed about the core common features defining their centers as hybrids, but one remarked that, “if you’ve seen one hybrid center, then you’ve seen one hybrid center,” noting that there is not and should not be only one model.
Hybrids must be adaptable, and build upon their individual strengths, community needs, and collaborations with academic partners. The one-size-fits-all model does not apply here. Their major goals should be enhancing access to quality cancer care and clinical trials, and providing oncologists and other health care practitioners with the opportunity to practice medicine without some of the restraints of academia while still participating in clinical trials and other research activities. The day’s discussion highlighted many similarities as well as differences.
4.0 Self-Descriptions
All centers involved in the conference met the basic criteria established for hybrid academic-community cancer centers, but this is how each center self-described its respective hybrid model:
Gibbs referred to itself as a “next-gen” cancer center. Its focuses on clinical research and trial activities, as well as a basic research wet-lab effort with DNA sequencing expertise related to colorectal cancer. With community partners Gibbs developed the Guardian Research Network (GRN), dedicated to precision medicine and democratizing clinical trials. GRN has 85 hospitals sharing millions of documents and EMRs to enhance drug development to search discrete data and non-structured text for specific inclusion and exclusion criteria for clinical trials to rapidly enroll patients using centralized architecture. Gibbs has relatively few therapeutic trials, but is involved in diagnostic, screening, and prevention trials, and has enrolled more than 700 patients on a single diagnostic trial.
ISCI is developing a patient-centered, clinical-translational research program to bring high-quality, interdisciplinary, ambulatory and inpatient cancer to the Inova Health System, a successful traditional, “hospital-centric” community model.
MCI has married the best community oncology practices in South Florida with Memorial Sloan Kettering Cancer Center’s standards of care, resources, capabilities, and clinical trials.
West Cancer Center is a hybrid center with its board of directors equally represented by former West Clinic clinicians and its CEO, Methodist hospital executives, and University of Tennessee officials. Some financial aspects are still monitored by the hospital system, but West anticipates evolving more fully into all aspects of its overall program.
5.0 Dedicated Facilities and Programs
All the centers have dedicated cancer center facilities on their main campuses built within the last several years.
West Clinic, a private 30-year-old multi-specialty oncology group, is currently affiliated with Methodist LeBonheur Health and University of Tennessee Health Science Center. Its 125,000-square-foot facility was completed in 2015 and houses comprehensive cancer services. Administrative offices are located off-site, and the hospital system is building another 75,000 square-foot cancer facility near the medical school. West has 12 locations in a 90-mile radius staffed by more than 100 providers.
Gibbs Cancer Center and Research Institute, with four locations, is a division of the 600-plus-bed Spartanburg (SC) Regional Health System. Gibbs has 250,000 square-feet dedicated to its cancer center and Beardon-Josey Breast Health Center, With Edward Via College of Osteopathic Medicine, Gibbs constructed a 7,500 square-foot basic research laboratory for personalized cancer treatment, colorectal cancer biology, cancer stem cells, and regenerative medicine.
Inova Health System has five hospitals, four with hospital-based radiation facilities and a fifth radiation facility in partnership with another community hospital partner and five ambulatory hematology-oncology practice sites in Northern Virginia. Inova is currently refurbishing Exxon Mobil’s former world headquarters to house a 240,000 square-foot ambulatory interdisciplinary cancer center. New construction has also begun for a 120,000 square-foot building for radiology, radiation oncology, and a two-vault proton beam facility, and another 240,000 square-foot building is being retrofitted to serve as research laboratories, with one-third dedicated to cancer. The Schar Family provided a $50 million gift to name the cancer institute and support program development and recruitment.
Miami Cancer Institute is part of the eight-hospital Baptist Health South Florida system, serving South Florida. MCI opened a $430-million four-story, 440,000-square-foot ambulatory cancer center in late-2016, connected by a pedestrian bridge to the Baptist Hospital of Miami, a 770-bed secondary/tertiary hospital. It has 113 examination rooms, 60 infusion rooms, eight infusion beds, a pediatric infusion suite, and a comprehensive radiation oncology program that includes proton therapy, MR-LinAcs, infusion, gamma knife, cyber knife, tomo- and true beam radiation therapy machines.
6.0 Recruitment of Leadership
Three of the four centers participating in the symposium had specifically recruited leaders from NCI-designated comprehensive cancer centers.
Dr. Yeatman was recruited in 2012 from Moffitt Cancer Center, where he was Professor of Surgery and EVP for Translational Research. He managed a $100 million Merck-Moffitt partnership, and cofounded M2Gen to manage the partnership. He is Center Director, President of GCC&RI, and President and CSO of GRN.
Prior to joining ISCI in 2015, Dr. Trump had been president and CEO of Roswell Park Cancer Institute.
MCI began recruiting Dr. Zinner a number of years before it began construction of its new facility. He joined MCI in 2016 after serving as clinical director of the Dana Farber-Brigham and Women’s Cancer Center, Surgeon-in-Chief at Brigham and Women’s Hospital, and Moseley Professor of Surgery at Harvard Medical School.
Dr. Schwartzberg has spent most of his professional career at the West Clinic.
(Derek Raghavan, MD, PhD, of Carolinas HealthCare System’s Levine Cancer Institute, was recruited from the Cleveland Clinic; and Christiana Care Health System’s Helen F. Graham Cancer Center recruited Nicholas Petrelli, MD, from Roswell Park Cancer Institute. (2))
7.0 Changes in Academic Partnerships
MCI formally joined the Memorial Sloan Kettering Cancer Alliance in January 2017 as its third member. It has a direct relationship with Florida International University Medical School with joint appointments including basic laboratory work done at FIU by MCI faculty and staff.
Inova has had a long-standing relationship with Virginia Commonwealth University for medical student education, and faculty have VCU appointments. In 2016, Inova and the University of Virginia announced development of an education and research affiliation to pursue novel programs in broad scientific research areas, education and eventually business and entrepreneurship. A critical component of the Inova-UVa relationship is the synergistic partnership between ISCI and the UVa NCI-designated cancer center with the potential to seek joint NCI comprehensive center designation. Inova also collaborates with George Mason University (GMU), Shenandoah University, and NCI, and is opening a joint proteomics facility with GMU.
Gibbs has had formal relationships with multiple academic institutions in both South Carolina and North Carolina, including the Medical University of South Carolina, Duke University, Wake Forest University, University of North Carolina, and Edward Via College of Osteopathic Medicine. Gibbs recently expanded its partnerships with five more health systems in the GRN, and is considering exposing surgical residents to a research year. There are no current plans for medical, surgical, or radiation oncology fellowships.
In 2012 West entered into a professional service agreement and co-management agreement with Methodist LeBonheur Health, which was serving as the major clinical affiliate of University of Tennessee Health Science Center and its College of Medicine. West assumed all responsibilities for the hematology-oncology division, formally operated by a different private practice group. The three partners evolved into the West Cancer Center, responsible for all clinical, research, and educational cancer services, including the subspecialty fellowship program. A proposed structure is being developed to integrate all clinical and academic staff as members of the cancer center, with the goal of creating a standalone center within the matrix organization.
8.0 Volume- vs. Value-Based Systems
All the centers noted that hematology-oncology is one of the most financially successful medical service areas. These centers also manage a substantial number of patients with benign hematologic problems, posing organizational and staffing challenges. Research funding has come through philanthropy, federal and foundation grants, and pharmaceutical company grants and clinical trials.
The centers are all extremely interested in changing from volume-based to value-based reimbursement. ISCI has value-driven aspirations and opportunities, and hopes to develop a health system based on value-based care. MCI plans to expand the existing Accountable Care Organization throughout its system. Gibbs is volume-based and dealing with the challenge of allowing physicians’ “protected time” for clinical research when clinical duties require most of their effort. West is transitioning to a value-based system through participation in the CMMI Oncology Care Model and other alternative payment models.
9.0 Fundraising
Historically Inova has not had a robust fundraising arm, and although ISCI is without debt, the development of centers of excellence in cancer, heart, neurosciences, and genomics has presented the need and opportunity to feature notable accomplishments to expand their respective fundraising profiles. In response, ISCI is developing a $100 million campaign. MCI does not currently have a well-developed fundraising program, but it is also without any debt from its new $430-million facility. West is close to raising $15 million in pledges in support of its research and goal of seeking NCI designation.
10.0 Marketing
Marketing has been a challenge for all centers. ISCI is engaged with the Inova Health System to market the cancer center’s unique capabilities. It considers Georgetown’s Lombardi Cancer Center, George Washington University Cancer Center, and Johns Hopkins its biggest competitors.
MCI is challenged by making itself a known entity in South Florida, Latin America, and the Caribbean, and has the most competition from University of Miami’s Sylvester Cancer Center.
Gibbs is involved in helping patients understand the high quality of care offered at its center with 10 disease-focused programs, bench laboratory research, and clinical trial activity. It competes primarily with a larger local hospital system that is less focused on cancer.
West’s greatest marketing challenge is explaining to patients three-entity partnership when each institution had its own reputation in the community. It cited a minority of patient “leakage” to academic medical centers.
11.0 Cultural Clashes
The various hybrid models have fostered their share of cultural clashes at all the institutions. At Gibbs, it was manifested when community medical oncologists became more involved in clinical trials. ISCI cited differences among administrative staff from community hospitals, its flagship tertiary-care facility, and faculty and staff with a patient-centered ambulatory and translational research mission. MCI has seen cultural clashes between the academic and community cultures, between both salaried professional and private practitioners, and between its center and regional system, which nonetheless provides excellent support. West has had a fairly smooth integration of its three-partnership consolidation, but still faces a conceptual cultural clash between private practitioners and fulltime salaried professionals, although it has not affected clinical care.
12.0 NCI-Designation Goals
The institutions have all begun aggressive research and educational efforts with different aspirations toward achieving future NCI designation.
Inova Health System began developing a “hybrid pathway” in 2010 former NCI director John Niederhuber, MD, was recruited to establish the Inova Translational Medicine Institute, a genomics program focusing on bioinformatics infrastructure. ISCI is developing clinical and translational research that emphasizes target and biomarker delineation, drug discovery, and development and rational therapeutics with a genomic base, and has recruited a drug development team to focus on new and more efficient approaches to developing and devaluating new therapies. Strengths currently include a clinical trials operation lead by. Joan Schiller, MD, recruited from UT Southwestern Simmons Cancer Center, accruing almost 200 patients per year, and a DoD-funded gynecologic oncology translational center led by Larry Maxwel, MD and Thomas Conrads, PhD. IHS has ACGME-certified postgraduate medical training programs in internal medicine, surgery, pediatrics, and ob-gyn. ISCI will be eligible to apply for a hematology-oncology fellowship program in 2018 and surgical oncology and radiation oncology programs shortly thereafter. NCI designation was not an original goal of the ISCI leadership, but the partnership of the Inova Health System and UVa offers the opportunity to develop a formal relationship in cancer that would entail pursuit of NCI comprehensive center designation.
MCI established its Center of Genomic Medicine after recruiting Jeffrey Boyd, PhD, from Fox Chase Cancer Center. The clinical molecular diagnostic facility offers next-generation sequencing, bioinformatics, curation, and clinical reports, and houses a bio-repository, providing high-quality, well-characterized cancer-related human biological materials for research. MCI is building a clinical trials program for translational research, including a phase 1 program. There are no plans for basic research on its campus, but such activities are available through affiliations with MSKCC and Florida International University. MCI plans to add population sciences and cancer control.
The center currently has 32 open trials with the number increasing, and has submitted a grant for investigator-initiated trials.
MCI currently has a small GME program with FIU and has hired a GME consultant to help expand its program to include both ACGME-approved and non-ACGME sub-specialty fellowships.
The institute does not intend to seek NCI-designation for at least five years.
Gibbs became one of the original NCI Community Cancer Center Program members in 2007. In 2005 Gibbs became an exclusive affiliate of MD Anderson Cancer Center, and established the Bearden-Josey Center for Breast Health in 2008. In 2014 the center received a five-year grant as part of the NCI Clinical Oncology Research Program. Rather than seeking NCI designation Gibbs intends to pursue disease-focused clinical and research programs) without the substantial associated costs and development time required for designation.
West has been involved in research activities for several decades through industry trials and as a previous National Cancer Institute – Community Clinical Oncology Program (NCI-CCOP), and is a full member of Southwest Oncology Group (SWOG). After affiliating with Methodist and UT, the center had nearly 40 open therapeutic research trials, mostly focused on phase 2 and 3 studies with a few phase 1 trials. It has since upgraded its research activities to include more than 50 staff and a full-time research director. Trials have expanded beyond medical oncology to include surgical and radiation oncology, translational work, and observational studies. Plans are under development for a more comprehensive bio-repository program. A scientific review committee evaluates all protocols and has launched the infrastructure to support investigator-initiated trials. The center is integrating university laboratories and scientists to focus on translational research and has recruited Neil Hayes, MD, from the University of North Carolina to head its Institute for Cancer Research.
West assumed management of the UT hematology/oncology fellowship program in 2012 and subsequently received full GME accreditation. Heme/onc fellowships have expanded to 15, with additional research fellowship positions planned for next year. West has also initiated a radiation oncology residency, and a gynecology oncology fellowship, and plans to begin surgical oncology and breast surgical oncology fellowships in 2018.
The center is highly focused on achieving NCI designation, anticipating between five to seven years to develop its assets to apply for designation, with comprehensive status planned within 10 years.
13.0 Future Goals
There was consensus that ongoing discussions among hybrid leaders had value, and that symposia should be continued on a rotating basis among the centers, with additional centers invited as they embrace the hybrid model. Interest was expressed for more cooperation among the centers, including clinical trials, population health, and sharing pathways.
Abbreviations:
ASCO, American Society of Clinical Oncology; GMU, George Mason University; GRN, Guardian Research Network; NCI, National Cancer Institute; NCI-CCOP, National Cancer Institute – Community Clinical Oncology Program; SWOG, Southwest Oncology Group.
Keywords:
Hybrid academic-community cancer centers; NCI-designated cancer center; Academic cancer center, Community Cancer Center.
November 27, 2017 | Authors: Eric T. Rosenthal * [1], Lee Schwartzberg, MD [2], Donald L. Trump, MD [3], Timothy J. Yeatman, MD [4], and Michael Zinner, MD [5]
[1] EvocaTalk® Research & Reports | [2] West Cancer Center | [3] Inova Schar Cancer Institute | [4] Gibbs Cancer Center and Research Institute | [5] Miami Cancer Institute
Corresponding Author:
* Eric T. Rosenthal, EvocaTalk® Research & Reports, 1404 Remington Road, Wynnewood, PA 19096, etr@evocatalk.com
Author Contributions:
The manuscript was written through contributions of all authors. / All authors have given approval to the final version of the manuscript.
Acknowledgements:
The ideas and opinions expressed herein are those of the authors.
Authors’ Disclosures of Potential Conflicts of Interest: None
Author Contributions: All authors.
Conception and design: All authors
Collection and assembly of data: Eric T. Rosenthal
Manuscript writing: All authors
Final approval of manuscript: All authors
How to cite:
Rosenthal ET, Schwartzberg L, Trump DL, Yeatman TJ, Zinner M.
The Nature and Nurturing of Hybrid Academic-Community Cancer Centers (2017)
DOI: 10.14229/jadc.2017.11.27.001.
Original manuscript received: October 15, 2017 | Manuscript accepted for Publication: November 1, 2017 | Published online November 27, 2017 | DOI: 10.14229/jadc.2017.11.27.001.
Independent Review:
This article was submitted for peer reviewed and approved for publication by an independent editorial review board.
Last Editorial Review: November 24, 2017
