Robert MannelDirector, Rainbolt Family Endowed Chair, Stephenson Cancer Center
The Stephenson Cancer Center at the University of Oklahoma May 2 announced that it has received Cancer Center designation from NCI.
This designation brings the total number of NCI designated cancer centers to 70. With Stephenson included, 14 of these centers now have the Cancer Center designation, 49 have the Comprehensive Cancer Center designation, and seven have the Basic Laboratory Cancer Center designation.
Oklahoma’s pursuit of the NCI designation started 17 years ago, and investment in the center has added up to $400 million.
“I’ve never viewed the NCI-designation as a goal or an endpoint, but rather an external validation of a journey toward excellence,” said Robert Mannel, center director and the Rainbolt Family Endowed Chair.
“I do think that one of the things that I’ve learned, and my senior leadership team for the Stephenson Cancer Center have learned over the past 10 years, is that it forces you to think differently,” said Mannel, the Rainbolt Family Endowed Chair at the University of Oklahoma Health Science Center. “It forces you to commit to a level of excellence that, to be honest, I’m not sure otherwise we would have. It also allows the movers and shakers in the political community–the philanthropic community, the university—to see an external validation that their dollars have been well spent.
“I think that that’s one of the reasons it’s been important for us. It gave us a framework to organize ourselves around, and then it gave us external validation that the clinicians, scientists, and the researchers that we were bringing into Oklahoma were having an impact.”
Mannel spoke with Paul Goldberg, editor and publisher of The Cancer Letter.
The designation comes with a five-year, $10.1 million core grant that will support research programs and infrastructure, recruitment and community outreach.
In the process of seeking designation, the cancer center has reached the following landmarks:
The center has enrolled more than 2,500 patients over the past five years—more than any other institution—in the National Clinical Trials Network clinical trials.
Received $16.1 million in annual research funding from NCI in 2017.
Received $43.8 million in annual cancer research funding from all sponsors in 2017.
Publishing 650 scientific articles in peer-reviewed journals over the past three years.
“It’s critically important that Oklahoma has an NCI-Designated Cancer Center as a resource to address the state’s high cancer incidence and mortality rates,” Rep. Tom Cole (R-OK), chairman of the House Labor, HHS and Education Subcommittee, said in a statement. “In addition, NCI designation will have a significant economic impact by opening the door to millions of dollars in grant funding, creating more research jobs, and enhancing opportunities for developing the biotechnology sector.
First, congratulations. It has been a long road—17 years? Please correct me If I am wrong.
It’s exactly right. In 2001, the state legislature voted to establish a statewide cancer center, leading the state forward in education, research, patient care, and—importantly—to seek a designation as an NCI-designated cancer center.
So, why 17 years? Well, we are the state’s only academic health system, and though before 2001 we had pockets of excellence—we had some good surgeons, and some good researchers—there was no coordinated effort for our research and patient care.
It was spread out amongst departments, and so it took a while to sit back, assess the situation, and then to start developing a five-year strategic plan. We had to accrue capital and build infrastructure initially. Then we had to recruit into that, and eventually that allowed us to pull together an application for the CCSG.
How much did you need to spend to get to where you are?
It was a pretty heavy lift, and it required a lot of people coming together. Over the past 12 years, we put in over $400 million into the Stephenson Cancer Center. It was the largest public-private, biomedical initiative ever in the history of the state of Oklahoma. And to give you an example, since 2011 we’ve recruited 30 new physician-scientists, and 45 new PhD researchers. In 2011, we opened our Stephenson Cancer Center building, which enabled us to move all the patient services, clinical research, and administrative activities into one building. That building now houses all of our multi-disciplinary disease-centered programs.
It houses our large clinical trials office, radiation therapy, medical oncology, and infusion therapy, patient supportive services, etc. I took over as cancer center director in 2006. The first five years, from 2006 to 2011, were spent basically getting the capital and developing the infrastructure. The next five years, from 2011 to 2016 or so, we spent recruiting the MDs and PhDs, and allowed us to start then developing a critical mass towards pulling this together.
$400 million seems to be the number that most of the new centers keep coming up with. $300 to $400 million; is that the right number?
Yeah, and I think also, it’s not $400 million from one source. There’s a true partnership, the state of Oklahoma contributed about 29 percent of that, predominantly through tobacco tax.
The citizens of Oklahoma in 2006 passed a tobacco tax, and that brings in about $5.5 million a year to the cancer center. University has about 12 percent of that total through dedicated faculty lines and start-up dollars. The hospital about 26 percent of the total, in particular they were supporting the physician recruitment and bringing in new specialists that had never been to Oklahoma before, and neuro-oncology, thoracic oncology, urologic oncology, and other specialties.
We had a very interesting situation, where we have our tobacco settlement and endowment trust-fund. And that was a fund that was set up for the tobacco settlement in the mid-1990s. But there was a constitutional amendment passed by the citizens of Oklahoma, such that half of those dollars went into an endowment trust, the other half went to the general revenue for the state of Oklahoma.
And that half that’s in the endowment trust fund, now is about $1 billion, and it’s distributed by an independent board and for tobacco cessation, and for cancer research, and for the general health of Oklahoma.
So far, we’ve been the recipient of more than $60 million from that fund, and that’s been a big part of our portfolio.
Oklahoma is probably the only state that didn’t spend all that money on roads.
Yeah, it’s one of the few states that I think the citizens and the politicians were far-sighted enough to provide a protection, knowing that all state budgets eventually come on hard times, and if you don’t protect resources like that, they disappear pretty quickly.
I hear many cancer center directors complain about what it takes to get and keep NCI-designations, and yet the club of cancer centers is growing. Why is it worth it to jump through all these hoops?
I’ve never viewed the NCI-designation as a goal or an endpoint, but rather an external validation of a journey toward excellence. I do think that one of the things that I’ve learned, and my senior leadership team for the Stephenson Cancer Center have learned over the past 10 years, is that it forces you to think differently.
It forces you to commit to a level of excellence that, to be honest, I’m not sure otherwise we would have.
It also allows the movers and shakers in the political community—the philanthropic community, the university—to see an external validation that their dollars have been well spent.
I think that that’s one of the reasons it’s been important for us. It gave us a framework to organize ourselves around, and then it gave us external validation that the clinicians, scientists, and the researchers that we were bringing into Oklahoma were having an impact.
So, it’s not about the core grant at all? It’s about other things?
I think the core grant is certainly nice, and it will certainly move us toward our next step, but you know, everything we’ve done up to this point, and all the investment we’ve had has been without a core grant.
And so, I view the core grant as allowing us to then push toward an even higher level of integration, team science, and a community outreach and engagement.
Oklahoma seems to have been a big void on the map of NCI-designated cancer centers, so Oklahomans had to drive to Texas or Kansas or Missouri. What is your actual catchment area? What will you be able to do now that you couldn’t do before?
I think that every cancer center will define catchment area differently. In Oklahoma—since the 2001 state bill—we have viewed the state of Oklahoma as being our catchment area.
That’s what the state legislature has mandated us, and it was what was signed by the governor.
We’re still a very rural state: 38 percent of our population lives in federally designated rural counties, and that opposed to only 14 percent of the nation as a whole. So, patients have to travel a long distance to get quality care in Oklahoma.
Indeed, 40 percent of our patients drive more than 50 miles to receive their care at our cancer center, and so, having a designated cancer center right in the heart of Oklahoma really brings that level of research commitment, clinical trials commitment, and expertise in patient care to a large void in the southern plains region of the United States.
Also, Oklahoma is not a small state. It’s has a four-million population; it’s bigger population-wise than New Mexico, Kansas, and Nebraska, which all have NCI-designated centers.
And it’s bigger than Arkansas, on our eastern border, which still doesn’t have an NCI-designation. So, this area of the country is large geographic distances, but actually a fairly robust population that was underserved.
Do you see yourself developing a sub-specialty strength that may not be there for some areas of the nearby states?
In the area of clinical subspecialties, we have real opportunities in neurologic oncology. We’ve recruited an outstanding team there, and we get referrals from throughout the state.
Because of the nature of where we are, we’re a place where a lot of subspecialists come that aren’t available anywhere else. So, as an example, we have five fellowship trained urology surgeons, and we’re the only ones in the state of Oklahoma.
It’s not just that we have one person that’s doing something, we create teams. And those teams then can offer proton therapy in the area of urologic oncology. We have proton therapy, great radiation therapy, expertise, the urologic surgeons and the specialists in urologic oncology.
But what I think in each of the specialty areas what we offer that’s not available anywhere else in Oklahoma, is all of our clinics are disease-based, they’re multi-disciplinary, team-based care that is patient-centered, and brings in clinical research into that environment.
It’s an experience which isn’t available otherwise in Oklahoma.
Can we talk about community outreach and engagement?
Yes, well, that’s good timing for that question. I’m actually at the annual NCI center directors meeting. And we’ve had the opportunity to hear from both [NCI Director] Ned Sharpless and [Director of the NCI Office of Cancer Centers] Henry Ciolino, and it’s quite clear that Dr. Ciolino feels that this is a very important new component. It was actually a new component for the new funding opportunity announcement. I think NCI really wants cancer centers to show how they’re impacting the catchment area.
I think it plays into the strength of a center like Oklahoma, because if you look at how we’ve been able to maintain the momentum and enthusiasm, it’s because we can go back to our community, whether it’s the legislative leaders or the university leadership or the philanthropic community and say, “This is how we’re helping the citizens of Oklahoma. And not just within the walls of our cancer center, this is how we’re going out into the community and making a difference.”
It is clearly being emphasized more now than it has been in the past. I think both Dr. Sharpless and Dr. Ciolino have stated that it should be considered a very important part of the CCSG applications, and I think centers are really focusing their energies and efforts to make sure that’s a big part of their portfolios.
Could we talk about the underserved groups, maybe focusing on the Native American population? How do you bridge the disparities and what are the lessons that can be learned from studying Native American tribes? I may be just asking too many questions at once.
Health disparities is a very important issue for the state of Oklahoma. We are a relatively poor state.
We are 37th in the country as far as household income, but that disparity goes way up when you go to the rural and American Indian populations.
Our poverty rates are quite high for rural populations—about 20 percent live below the poverty level. For American Indians, it’s 25 percent. It’s a quarter of that population, so that’s a big disparity for us.
Those disparities then spill over into some lifestyle issues, with obesity and tobacco abuse being higher in both the rural and American Indian populations. Lack of access to health care is a problem, and screening rates are down as well.
When you do an analysis, Paul, it’s interesting, because there are some cancers in American Indian population, which you can’t ascribe all of their increased incidents in mortality just due to lifestyle and lack of access.
As an example, colorectal cancer has almost 100 percent increase in mortality in the American Indian population. Renal cancer is over 200 percent increase in mortality. So, we think there are probably factors beyond what we know are risk factors, such as diet, exercise, screening, tobacco use, and probably we have to look at other things, such as microbiome, the proteome, or genomics.
And so, we’re doing research and partnership with the American Indian tribes to address that.
Now, I think that’s probably the critical thing. If you’re in a state like Oklahoma, and you’re gonna make a difference, it’s about creating partnership with the tribal entities. We actually have 11 NIH sponsored grants that are partner grants with the American Indian community.
They’re addressing issues all the way from food resource and sustainability to tobacco cessation programs to a better understanding of ethical ways to do genomic and proteomic research.
Are there any special obstacles that you might be encountering in going to the reservations? Are you welcome there, for the most part?
In Oklahoma, by and large, the tribal system is not based upon reservations, like some of the other states. There are 38 federally recognized tribes within the state of Oklahoma, and over 13 percent of the population claims American Indian ethnicity, either complete or as a mixture.
That is a large population. It’s actually the second largest absolute number of American Indians in any state in the United States, second only to California, and it’s the second greatest percentage of population registering as American Indians.
The issues with the American Indians in Oklahoma stem from historical challenges. Most of the tribes in Oklahoma, those 38 tribes, are not from Oklahoma. They were forcibly relocated.
So, that’s always led to some tension between the American Indian community and the government. We’ve tried to overcome that.
I think, importantly, the key here is to create partnerships to go to the tribal entities and not say, “This is what you need to do,” or “This is what we want to do,” but rather, “What is it that you want to do in order to try to address some of these disparities?”
And listen to their concerns, and then partner with them at designing and developing the programs that can be successful.
So, that’s the way to overcome mistrust?
I think so, and it doesn’t happen overnight. It happens because you commit to it, and you show respect, and cultural awareness, and you go in as a partner, rather than as the entity that’s gonna say this is what we need to do.
I’ve just run across a cool statistical factoid that Stephenson Cancer Center has placed more patients on the NCTN clinical trials than any other cancer center in the US. First of all, is this correct and if yes, how’d you do it?
So, for intervention treatment trials last year we placed 268 patients on clinical trials. There’s a network system and I think second place had 186, somewhere around there.
How did we do it?
I think that you asked are there areas of strengths? I think one of the areas of strength that we’ve committed to is we think that we can make a difference in people’s lives and our catchment area by offering them access to clinical trials.
And we’ve used the philanthropic community to support us because as you know, putting a patient on an NCTN trial is, unfortunately, a money-losing proposition. But we decided that we would use philanthropic funds to offset any loss. And that would be one of the key areas of our outreach to our catchment area.
And we also want to translate that into good science that will impact not just our catchment area. As you know, these clinical trials are national, so if they impact, ultimately, the way patients are managed nationwide, that’s the way that our cancer center can be a value added to the NCI network.
I think it came from probably a long-standing passion of the investigators here, but when we decided that we were going for NCI-designation and we wanted to make an impact in our catchment area in the nation, we felt that this was one way we could do that, just build upon our existing strength, and to capitalize that through philanthropic funds, where went to our donor pool and explained to them the situation and they liked it.
They saw that as a good way to spend money.
How are you doing on industry trials?
We do quite well. We are very large phase I center. We have a partnership with Sarah Cannon, and we are one of the largest phase I centers in the country.
And we have a very robust investigator-initiated trial portfolio. And we also participate in some larger phase III registry trials for pharma, as we think those are important as well.
So, our clinical trials network is robust, even beyond NCTN. It’s because, as you know, that portfolio is not going to cover all situations, so we want to have a diversified portfolio for our patients. Essentially, a broad spectrum of clinical trials including early phase trials so that they never feel the need to travel to get access to great care.
What’s next for Stephenson Cancer Center?
Well, I feel confident that the next five years we’ll continue the trajectory that we’ve had.
And we’ve made a bold statement that we are going to double our clinical volume and we’re going to double our research funding over the next five years.
So, to put that into perspective, in 2012, we saw one out of every 20 cancer patients in Oklahoma. This year, we’re seeing one out of every six, and at the end of the next five years, we want that to be one out of every three.
So, that’s number one, and then number two, from the standpoint of research, we are going to continue to recruit.
We’ve recruited a great group of researchers here, we’re going to do more targeted research recruitment. But we’re still going to have as our goal to double our NCI, NIH, and other national funding over the next five years.
And if we can accomplish those two things, then I think we may be in a position to potentially go for comprehensive status with our next renewal.
Is there anything we’ve missed?
I don’t think so. Hopefully you’ve seen kind of the dynamic changes that have occurred here in Oklahoma, and I think we have a relatively small, but very passionate group of both basic and clinical researchers. And I think you’re going to hear more good things from us over the next few years.