publication date: Jul. 29, 2019
Conversation with The Cancer Letter
Sylvester becomes 71st NCI-designated cancer center
Sylvester Comprehensive Cancer Center
After six years of aggressively recruiting and spending more than $250 million to build up its programs, Sylvester Comprehensive Cancer Center has become the 71st NCI-designated cancer center in the US and the only such institution in South Florida.
The designation was announced July 29.
Sylvester, which is a part of the University of Miami Leonard M. Miller School of Medicine, is one of 64 cancer centers with the NCI Cancer Center designation in the nation. Fifty of these centers hold the Comprehensive Cancer Center designation. Seven more are designated as Basic Laboratory Cancer Centers.
“There are over 21 million people who live in the state of Florida. In 2014, Florida became the third largest state in the United States, surpassing New York—yet New York has seven NCI designated cancer centers and Florida had had only one,” Stephen D. Nimer, director of Sylvester, said to The Cancer Letter.
“There are over six million people in our catchment area, South Florida, and if they wanted to go to an NCI-designated cancer center they’d have to either get on a plane or drive nearly 300 miles—to Tampa.”
In addition to Moffitt Cancer Center, Florida has a Mayo Clinic Cancer Center in Jacksonville. Mayo, which holds an NCI Comprehensive Cancer Center designation, operates centers in Rochester, MN, Phoenix/Scottsdale, AZ, and Jacksonville.
Public health programs that helped Sylvester secure the NCI designation include the Game Changer vehicle, which brings evidence-based interventions to underserved communities in the cancer center’s catchment area (The Cancer Letter, April 27, 2018). The center’s cancer control program also includes the Firefighter Cancer Initiative, a long-term study of exposures to carcinogens and ways to reduce and prevent cancer risks for Florida firefighters.
PETER TUNNEY b. 1961
Game Changer Vehicle Canvas, 2018
57 x 46 inches
The cancer center is working on deploying another Game Changer vehicle. Recently, Peter Tunney, a New York and Miami-based artist and gallerist who donated a painting for the first Game Changer van, donated another painting that Sylvester can sell to raise money for its programs (The Cancer Letter, April 27, 2018).
The bright-yellow interpretation of antique wallpaper and an eye chart reads: “I am walking on sunshine.”
PETER TUNNEY b. 1961
I’M WALKING ON SUNSHINE, 2018
Acrylic paint and vintage wallpaper on canvas, signed lower right by the artist in acrylic
60 x 48 in.
“When they got that designation, they were walking on sunshine,” Tunney said to The Cancer Letter. “I think it’s a universal idea. I think that’s the goal for all of us—for all of mankind, for sick and healthy—to have that feeling that is so rare today: I am walking on sunshine. It’s almost like a thing of the past. Who can walk on sunshine today, in this crazy world filled with suffering and illness? And I just feel like we can, we can, it’s possible to be grateful for the things we have.
The intense yellow wallpaper motif reminds Tunney of the wallpaper in his grandmother’s house in the 1960s and 1970s, the time when American astronauts walked on the moon. “It’s somebody’s grandmother’s wallpaper from the sixties. We look back at that time, we look back at landing on the moon, and everyone is aflutter, ‘Oh, those were the good old days.’ No, these are the good old days.”
The word “comprehensive” in Sylvester’s name doesn’t refer to its level of NCI designation. When it was founded in 1973, the institution was known as the Comprehensive Cancer Center for the State of Florida. In 1992, after receiving a $27.5 million gift from the philanthropist Harcourt Sylvester Jr., it was renamed Sylvester Comprehensive Cancer Center.
Sylvester director Nimer spoke with Paul Goldberg, editor and publisher of The Cancer Letter.
First of all, congratulations.
Thank you; it’s a big deal.
How long did it take to get this done?
I’d say, six years. I arrived in 2012, seven years ago, and the first year started by assessing what’s going on at Sylvester. We then developed our first five-year strategic plan, which ran from 2014 to 2018, and we submitted our [Cancer Center Support Grant] application in September 2018. We’re now in the midst of our second five-year plan.
And how much money did it require?
I’d have to add it all up. One of the most important things for us was that the state, in 2014, started giving us a bit over $16 million a year so that we could become NCI-designated. The health system, over a five-to-six-year period, probably gave us somewhere between $90 and $100 million. And then we’ve raised philanthropy. The philanthropy over five to six years, is maybe close to $100 million. So, it’s probably $250 -$270 million.
How many people did you have to recruit?
We went in [to NCI] with 124 members on our CCSG application, but over the last seven years we’ve recruited nearly 150 people. In addition to recruiting researchers I’ve been given the opportunity to build the clinical programs also.
Many of the clinical people are not included on the grant, because the grant has very specific requirements to be a member. For example, we’ve hired a couple of breast cancer surgeons, and they are not listed on the grant, because they are not yet doing significant research.
The NCI doesn’t want to know about people who don’t have grants or aren’t running clinical trials. So, out of the 124, which is what we went in with, I believe nearly 50 of our members were new.
How is your cancer center different from all others?
One of the things that we got the highest marks on is our community outreach and engagement efforts and how relevant the research we’re doing is to our catchment area.
A couple of examples:
We have a West Indies population, so we have an endemic HTLV-1-infected population, and thus a significant number of HTLV-1-related adult T-cell leukemia patients. So, one of our physician scientists has an R01 studying ATL. And we have a number of clinical trials for people with adult T-cell leukemia.
We also have a large burden of advanced cervical cancer patients in our region, especially in Little Haiti. And so, we have a lot of efforts on early detection of high-risk HPV, prevention and clinical treatment trials for women with cervical cancer.
Another thing that distinguishes us from many centers is the diversity of our faculty, our students, and the patients we put on clinical trials. In our CCSG application, roughly 30% of the patients on interventional trials were black and 40% were Hispanic—so both racial and ethnic diversity. We also have incredible socio-economic diversity.
What’s unique among the black population in our catchment area is that it is Afro-Caribbean more than African American—different genetics, different cultures.
The Hispanic population is unique as well. MD Anderson is probably largely Mexican Americans. New York is probably mostly Dominican and Puerto Rican. We have significant populations of Cuban Americans, Venezuelans, Brazilians, Argentinians, Colombians—an incredibly diverse group.
One example of how this plays out is in our prostate cancer research. The watch-and-wait approach is an appropriate strategy for many people. We found that our black population has more anterior prostate cancer lesions, so when you do blind biopsies, you’re more likely to miss lesions.
And then we’ve looked among the Hispanic populations as to who has a better or worse prognosis and we’ve identified subgroups within the Hispanic population that have different genetics and a different biology. So, we are tailoring our approach. Based on genetic ancestry as well as other factors.
The other thing is, we have a very strong cancer epigenetics programs, a very strong program on infections and cancer, including H. Pylori, HPV, and hepatitis viruses B and C.
We are very focused on developing programs that meet the needs of the people in this six-million-plus community.
Our catchment area is four counties, somewhat famous, because of the election news nearly every cycle: Broward, Palm Beach County, Miami Dade and Monroe County.
New York, where you come from, has an NCI-designated cancer center on every street corner. And Miami—make that South Florida—has just one now. How is Florida different? You would have thought that there would be multiple NCI-designated cancer centers in South Florida.
Your point is very well taken. There are over 21 million people who live in the state of Florida. In 2014, Florida became the third largest state in the United States, surpassing New York—yet New York has seven NCI designated cancer centers and Florida had had only one.
Moffitt had gotten a huge investment from the state in the past, and that enabled them to become NCI-designated. And upon designation, they could recruit more researchers, attract more patients, and get more philanthropy, and get all the positives from that. And for the longest time, Florida has only had one.
There are over six million people in our catchment area, South Florida, and if they wanted to go to an NCI-designated cancer center they’d have to either get on a plane or drive nearly 300 miles—to Tampa.
Now, one problem that we face in our region, which is very splintered in terms of market share, etc. is that there’s a lot of community hospitals here that have cancer centers, but they are not necessarily conducting cancer research in any way.
I’ve been reading Joe Simone’s Journal of Clinical Oncology paper from 2002, where he talks about the fact that there are no criteria to call yourself a cancer center. And because people may feel like you can get great care anywhere, they may not seek out the experts.
Probably, in many markets throughout the US, there’s still an ongoing process of trying to educate people as to what’s the difference between an NCI-designated cancer center and one that’s not. And, obviously, the designation is given, because of the research that’s going on. And so, people wonder: “What is the connection between the research and me being a patient there?”
A big part of educating our community is to tell people that oftentimes the doctors who are doing research on a specific cancer have a deeper knowledge about its management. Also, experts more often make the correct diagnosis and come up with more exact multidisciplinary treatment approaches for many cancers.
NCI-designated cancer centers have more clinical trials and more investigator-initiated clinical trials. Now, with NCI designation, we’ll have access to the [NCI Cancer Therapy Evaluation Program] drugs and treatments. Already, we have a very robust phase I clinical trials program, having put 161 patients on phase I trials last year.
This means that we are doing more innovative things, not accepting the status quo, which is what you often get in community hospitals.
I get asked all the time: “Don’t only complicated cancers need to get seen in Sylvester?” and I usually say, “Any cancer that you have is complicated.”
There are other things we need to stress: Sometimes patients spend more time figuring out which flat screen TV they’re going to buy than they do figuring out who should be taking care of them. And so, we tell patients to ask: “How sure are you that you have made the correct diagnosis?”
So many people are misdiagnosed in the US each year, and sometimes people are treated who don’t need to be treated and vice-versa.
For instance, we are working with Moffitt and the University of Florida on pancreas cancer. We’re hoping to look at how many patients in our state are told that with radiation, chemotherapy, and surgery there’s a potential for cure, as opposed to being told that pancreatic cancer is terrible, and you better get your affairs in order.
While the NCI designation, of course, relates to multidisciplinary and collaborative research efforts, we have—given the diversity of our catchment area and community—an important task to educate people in culturally appropriate ways.
Well, there’s a lot happening that actually very good. Having the University of Florida on the path to designation is also wonderful for the state. There’s so much room in there for growth.
Since we are talking about Joe Simone’s paper, the word “comprehensive” is in the name of your cancer center. Yet, you don’t—yet—have the NCI-koshered comprehensive designation. Can you change the name? Do you need to?
The University of Miami’s cancer center started in 1973 shortly after Nixon signed the National Cancer Act. Later, with a naming gift from the Sylvester family, we opened our doors as the Sylvester Comprehensive Cancer Center in 1992. The comprehensive in our name does not refer to an NCI designation. It’s been our name because we have always delivered comprehensive cancer care.
Let’s talk about the Game Changer. That’s such a cool thing. That was one of your center’s great ideas.
The Game Changer vehicle has been really incredible, already in its impact on our cancer education and early detection programs (The Cancer Letter, April 27, 2018). We’re accruing people for research, and we’re already following some of their health habits.
We’re in the process of delivering HPV vaccines. We have been working with our AIDS group, so you can get PrEP. And we go into communities, like Little Havana, Liberty City, Little Haiti. We are also going into areas to provide education on HIV. As you know, the incidence of HIV in the Miami Dade area is the highest in the nation. So, the vehicle is already having an impact in so many ways.
We’ve just gotten the second Game Changer!
Peter Tunney, the artist, is going to wrap this one also. And this one’s going to focus primarily on Monroe County, which has been hit hard by hurricanes, and also has very poor medical infrastructure.
If you travel to Miami, for business or pleasure, you don’t realize that it’s not that far to get to an extraordinarily rural area. The density of population in Monroe county is very low and access to health care is limited.
The areas that we’re trying to reach have so much socioeconomic gap and disparities. And the Game Changer vehicles are going to help us reach people who otherwise do not access traditional medical systems.
You asked me about the Game Changer vehicle as an idea, and I wanted to shout out the leadership team that we’ve been able to put together at Sylvester. They have been incredible. Our people have worked together in amazing ways. And so, when you say, “That’s a great idea of yours,” yours is the whole team, of course.
It’s remarkable how much work it takes to build the research programs that allow us to even have a competitive application. There were so, so many people who spent so much time for the benefit of the cancer center, and not for their own research.
Can we talk about hurricanes? They have an impact on your mission.
It’s interesting, because the Sylvester Comprehensive Cancer Center opened its doors in 1992, which is just when Hurricane Andrew hit. I’ve looked through our archives: There are some great articles in the Miami newspaper, because we remained open and provided care right after Hurricane Andrew, which has been the most devastating hurricane here in, I don’t know exactly how many years, maybe 30 or 50 or whatever.
But even following the more recent hurricanes, we’ve been able to provide care for our patients. After Hurricane Irma, in one of our satellites we were open the next day, and we treated 30 patients with chemotherapy who needed it, even though many folks were without electricity.
It’s a unique challenge. We have hurricane preparedness for our laboratories. We have drills for the hospital. And we have a command center.
During Irma, because I live on Miami Beach, in a mandatory evacuation zone, I had to leave my home for a few days. And so, my wife and I slept in the hospital for three nights. There’s food, water, and air conditioning in the hospital. It’s not a bad place to be!
You’re driving now to one of the clinics, even as we speak; right? One of the satellite clinics?
Can you tell me about that?
We have seven sites where we deliver clinical care. The main site in downtown Miami, and then we have three quite large facilities, one in Coral Gables, one in Plantation, one in Deerfield Beach. And we have three other satellites that are smaller, in Coral Springs, Hollywood, and Kendall.
And this allows us to deliver regional care. We’re all on the same EPIC electronic medical record. And we have patients enrolled on clinical trials in the satellites. Not all the satellites at the moment can have a research pharmacy. But the plan is we’re going to continue our expansion of facilities and services and increase the number of accruals and the sophistication of the trials that are available here. Everybody working in these satellites is a University of Miami employee.
The doctors are all part of our site disease groups, and they teleconference in to meetings and lectures. And many of them spend a day in Miami at the main satellite for education and clinical and other purposes.
Many of the doctors in the satellites are principal investigators on the clinical trials. And it’s important because people don’t want to travel necessarily on the freeways here to get to downtown Miami. And so, we can deliver academic care out in the community, which is always important and a challenging thing to do.
Is there anything we’ve forgotten, anything we need to address?
Maybe I can talk briefly about the state money for a minute. When Sen. [Rick] Scott [(R-FL)] was the governor, he got us together in his office, the University of Florida, Moffitt, and the University of Miami, and asked us what we needed to become major cancer centers and attain NCI designation so we could have three such facilities in the state.
The next year, the state gave us $10. 5 million to split three ways. So, we each got $3.5 million to bring in somebody from outside the state of Florida, a world-class scientist, and provide them with $500,000 a year for seven years.
We brought Ramin Shiekhattar from the Wistar Institute. He’s one of the leaders of our Cancer Epigenetics Program and a year and a half ago, Ramin won one of the highly prestigious NIH Director’s Pioneer Awards. I believe they give 10 out a year.
Next, the state set up a pool of $60 million to be shared between the three institutions each year for five and now six years. These funds are being used so that all three institutions can attain NCI designation. The directors of these cancer centers get along extremely well, and, in a pretty unique model, we created something called the Florida Academic Cancer Center Alliance.
It exists to promote collaborations across our institutions to conduct important cancer research and bring more federal research dollars to the state.
There are one or two other points I’d like to make: Another person we brought in, Gilberto Lopes, is the head of our Global Oncology Program and the editor of the Journal of Global Oncology for ASCO.
He just gave a plenary talk at 2018 ASCO, showing that immunotherapy is better than chemotherapy for the upfront treatment of certain subsets of lung cancer. His talk was one of four plenary talks we’ve recently given at important national cancer meetings.
I think the other message is just the level at which we’re operating on now. We are demonstrating to our community that we have people who are national leaders, and programs that are among the very best in the country. For this, I must thank the incredible team of researchers who work at Sylvester.
I think that, as we recruit more and more people, this designation is going to help us. I’m very pleased that when we submit NIH grants, the reviewers comment upon the environment in Miami, we now get the high scores for the research environment.
This brings up a problem that held back Sylvester for years, which was the lack of independence of the cancer center, or at least it was perceived to be that. Do you have the independence you need now?
First of all, I would never have left Sloan Kettering without the authority I needed from the leadership of the University of Miami, the health system and the Miller School of Medicine…
Yeah, that’s a good point.
I should point out, that I am the head of the cancer center, but I’m also the head of the oncology service line for UHealth health system. This arrangement allows me to align the clinical and the research missions in a way that many cancer center directors cannot.
It’s a real privilege, and I have great leadership and great people working on the service line to make our patient care and patient-related activities superb.
Well, that’s hugely important.