Consider these data points on cancer disparities:
- The number of NCI-designated cancer centers: 71
- The number of African American directors of NCI-designated cancer centers: 1
Now meet Robert A. Winn, a pulmonologist who started his job as director of Virginia Commonwealth University Massey Cancer Center last month.
Winn is the second African American to run an NCI-designated cancer center. The first director to hold that distinction was Franklyn Prendergast, who ran Mayo Cancer Center until 2006.
“Interestingly, there are a number of different fields, e.g. business, law, education etc., and studies that have clearly demonstrated the benefits of diversity,” Winn, former director of the University of Illinois Cancer Center and a proponent of what he describes as “bench-to-community” research, said to The Cancer Letter. “The importance of diversity to a high-functioning organization is not questioned these days. I think that the lack of diversity that we see among center directors reflects a multitude of issues, including the need for enhanced pipeline and retention programs.”
Winn takes this job at a time when NCI requires that designated cancer centers reach out to their communities through “outreach and engagement” programs, which have become a crucial component of the Cancer Center Support Grant applications.
“I applaud the NIH and the NCI for really pushing this effort of community outreach engagement,” Winn said. “This is one of the areas that I wish were in place right from the beginning, in 1971, with the advent of NCI cancer center designation. I think that had we also emphasized the implementation sciences as much as the discovery sciences we would have had a greater impact on reducing disparities among all communities by now.
“Importantly, we would have also potentially gained more trust within communities for research.”
In Chicago, Winn set up community programs that compiled—and reported—cancer data on what amounts to the neighborhood level, engaging people where they live.
He has also expressed concern about the potential of artificial intelligence to deepen health disparities by focusing on minority populations and the potential of targeted therapies and immunotherapies to create divergent outcomes for rich and poor:
Kadija Ferryman and Robert A. Winn, “Artificial intelligence can entrench disparities—here’s what we must do,” The Cancer Letter, Nov. 16, 2018.
John H. Stewart and Robert A. Winn, “Getting beyond the immunotherapy divide: a call to action,” The Cancer Letter, May 3, 2019.
Winn spoke with Paul Goldberg, editor and publisher of The Cancer Letter.
Paul Goldberg: Welcome to the cradle of the Confederacy.
Robert Winn: It is certainly true that Richmond, Virginia, was the capital and the cradle of the Confederacy. The folks in Richmond are very aware of its past, however, I’ve been thinking about how lucky I am to be in Richmond at this period in time, as the city recreates itself and writes a new chapter of history for Richmond, Virginia, and the South. I am very happy and excited to be in a position where I can help contribute to that next chapter of history.
My grandmother and I were recently talking about my becoming the new cancer center director for VCU Massey, and I could tell that she was both filled with a tremendous sense of pride and a curious amazement that I was a director of a cancer center in Richmond of all places.
Your grandmother is living?
RW: Oh my God, yes! She’s very much alive at 93 years old and still is as sharp as a tack—and preparing to visit VCU Massey in the spring. My grandmother, and her entire family, were all born in Virginia. Her description of growing up as a young black girl in Virginia during the 1930-1940’s was characterized as she put it, by “segregation and then more segregation.”
She is very excited for me and so proud of the city of Richmond, the state of Virginia, and the VCU Massey Cancer Center.
She’s in Virginia?
RW: No, she currently lives in Buffalo, New York, along with my mother. Most of my grandmother’s family, however, still reside in Virginia.
Importantly, last year marked the 400th year anniversary of the start of slavery in the U.S., which started in 1619. The impact of slavery has affected the lives of many people in the U.S. (i.e. blacks, whites, and Native Americans).
Growing up, I frequently heard many stories from my family about how slavery directly and indirectly touched our family. In fact, a number of those stories continue to inspire me even to this day. I suspect that there are a number of other people that may have similar stories as me about the effects of slavery on their own family.
Today, you hold the distinction of being the only African American director of an NCI-designated cancer center.
RW: I believe that is true. It is both a cause for celebration and an equal amount of serious self-reflection of the cancer field. It means that while we’ve certainly made some progress, we still have a ways to go. I hope in the near future this will no longer be the case. Having diversity among the NCI-designated cancer center directors is an achievable aspiration, and one that we should all commit to.
You are not the first African American director of an NCI -designated cancer center, but you’re actually the second—ever.
RW: Correct. Dr. Frank Prendergast was the first African American director. He was the cancer center director at Mayo until 2006. By all accounts, Dr. Prendergast was universally recognized as an outstanding center director. He has served as an excellent role model for many aspiring cancer center directors, myself included.
This lack of representation is really a loss for the National Cancer Program; isn’t it?
RW: This is certainly an area that needs some improvement. Interestingly, there are a number of different fields, e.g. business, law, education etc., and studies that have clearly demonstrated the benefits of diversity.
The importance of diversity to a high-functioning organization is not questioned these days. I think that the lack of diversity that we see among center directors reflects a multitude of issues, including the need for enhanced pipeline and retention programs.
It is important to note that there have been, and continues to be, tremendous efforts around creating and sustaining the next generation of diverse researchers, led by Dr. Sanya Springfield at the Center to Reduce Cancer Health Disparities and Dr. Hannah Valantine at the National Institutes of Health, among others.
It must matter in very big ways, but I don’t think I have the standing to even suggest what those ways are. Let’s put this into words: Why is it important to have a more diverse group of people running cancer centers?
RW: I think that it does matter to have a diverse group of people leading cancer centers.
First of all, the U.S. population has significantly changed since the creation of NCI-designated cancer centers in the 1970s. We must also be mindful of how cancer center leadership should reflect this ever-changing diversity.
Second, I suspect that as we increase diversity among researchers, we will also have different and maybe more relevant questions that may translate into having big benefits to the cancer health of our different communities.
Having diverse cancer center directors with different life experiences and different scientific backgrounds helps us all in addressing the big issues of our society as they relate to cancer.
I can see how it matters in the clinic and in outreach and engagement. How does diversity impact the science?
RW: I do believe that diversity matters at the level of the cancer center director as it relates to the investigational research that gets prioritized. My being African American is certainly noteworthy, but it’s my lived experience that becomes most important to my science. Having a variety of cancer center leaders with different lived experiences can be a major strength in the framing and driving of scientific agendas.
One example that immediately comes to mind for me is my passion to develop newer and less expensive approaches to immunotherapy. In the new “miracle” era of immunotherapy there is, and rightfully so, a lot of excitement; yet, my lived experience reminds me that many of these therapies will barely, if ever, touch the community in which I was born and raised as a kid; or by the time it gets to my community, the cancer field will have gone on to the next “miracle” drug that somehow seems to bypass my community.
My lived experience is not so much separated from my scientific interest, but integrated into my scientific thinking, as such, it helps form the foundation of many of my scientific questions. In this way, I believe that my lived experience and the rich diversity that it brings is a potential contributing strength to the field of cancer research.
I think precision oncology, big data, various clinical trials, and the population sciences are telling us that gaining a better understanding of the science behind health equity is a great win for us all, and certainly better advances our understanding of cancer development.
The field of health equity has enjoyed a fantastic amount of progress and growth over the last decade, in no small part due to the efforts of a number of outstanding experts in the field, who have established an undeniable discipline, rigor, and excellence around the field of health equity science. The quality and impact from this field of science continues to get better and better each year. Diversity in science does matters, but so does the diversity of workforce carrying out the various research.
I probably say this too often, and I don’t seem to be able to stop: If you’ve seen one cancer center, you’ve seen one cancer center. How does VCU differ from the University of Illinois?
RW: Interestingly, there were a number of similarities between VCU and UIC. The patient populations, for example, are similar at both institutions. In fact, both institutions value and have had longstanding missions of serving the urban and rural underserved in their perspective states.
However, the main difference between VCU Massey and UIC is that VCU Massey has been a NCI-designated cancer center since 1975, and is currently pursuing NCI Comprehensive Cancer Center status. Another distinguishing factor of VCU is the remarkable total commitment that the senior leaders have in supporting efforts that truly impact the community it serves.
The president of VCU, Dr. Michael Rao, The Executive Vice President/Chief Executive Officer Dr. Marsha Rappley, and Dr. Peter Buckley, dean of the College of Medicine, were all very clear during the interviewing process that they were as interested in a cancer center director who was concerned with generating new knowledge, as they were in having a director who could also favorably connect with and have impact on the communities throughout Richmond and the state of Virginia.
In the new “miracle” era of immunotherapy there is, and rightfully so, a lot of excitement; yet, my lived experience reminds me that many of these therapies will barely, if ever, touch the community in which I was born and raised as a kid.
I would say that VCU’s unapologetic stance on pursuing academic excellence along with serving the needs of the underserved was a driving factor in my decision to move to the VCU Massey Cancer Center.
Lastly, Dr. Gordon Ginder, the previous cancer center director at the VCU Massey Cancer Center, has made my transition to Massey incredible easy. Over his tenure of more than twenty years at Massey, he has built an outstanding program with an incredibly solid foundation. Dr. Ginder has left big shoes to fill.
What have you learned at the University of Illinois and what’s your advice to your former institution?
RW: I think what I’ve learned most is that for a cancer center to have the greatest impact, it needs institutional resources, and this can often be a struggle at public institutions, not because of the institutional senior leaders, but because the stark realities of state budgets. I have the utmost respect for the senior leaders at the University of Illinois.
In which areas would you be recruiting the most at VCU Massey? Will it be population sciences? Will it be clinical? Will it be basic sciences?
RW: I am now convinced that we need a balanced approach to setting the research agenda at a modern-day cancer center.
VCU Massey has always had great basic science, but I will also focus on growing the health equity, population health, big data, and implementation sciences. In addition, I will also aggressively recruit physician-scientists engaged with clinical trials.
We will certainly continue to expand our phase I trials, but we will also pursue increasing the number of prevention trials and non-treatment, but interventional trials, that more directly engage the various urban and rural underserved communities throughout Richmond.
I will also be aggressively recruiting researchers focused on survivorship research. Creating a team of innovative catchment area researchers and those focused on community outreach and engagement will be key to making sure that our research effort impact the communities we serve.
With the recruitment of Dr. Saïd Sebti, we are also making great strides in developing new drugs and that will be used in our very own investigator-initiated trials.
What is VCU Massey now, and could you describe the catchment area?
RW: Our catchment area currently is the Central and Southeast portions of Virginia.
There is a great amount of diversity within our catchment area. There is a high burden of cancers of the lung, breast, prostate. Also, colorectal and multiple myeloma. We serve some of the poorest folk in the state. We have a large number of underserved people who could potentially benefits from our efforts at the VCU Massey Cancer Center.
I should ask you how you’re going to do this.
RW: The interesting thing I learned from Chicago about catchments is that if we really want to motivate people to participate in their care, we ought to provide data that’s meaningful to them.
Here’s what I mean. Whether a person has a PhD or a second-grade education, if I show them their CAT scan and I explain that the spot on their lung belongs to them and then go on to explain the meaning and implication of the spot on their lung, in general, there is an immediate sense of ownership and understanding.
This is an example of disseminating data in a way that is both easy to understand and relevant. We are creating a team that believes likewise that catchment area data should not just be “useful,” but “usable,” that the data be as relevant to the community served, as much as it is to researchers using the data, and that the dissemination of the data back to the community be guided by approaches that include robust “community in-reaching” efforts.
For example, if someone lives in Chicago, New Orleans, or Washington, D.C., they likely live in a ward. Interestingly, the people living in that ward probably don’t know what’s going on with their cancer health, although they might know the county cancer rates.
In my mind, this is a potential shortcoming of not giving our communities the data they are seeking, i.e. “precise data” about their communities.
In 2017, we attempted to address this issue by developing an approach by which data is shared with the community in a way that they can understand and was relevant.
This approach allowed us to have a bigger reach into our communities and help them understand what the issues are and what we’re trying to address as a cancer center.
We hope in the future that we’re not only able to give our communities individual precision medicine based approaches, but also provide our communities with data that could somehow be precise and usable for the neighborhoods in which they live. We have learned a great deal from the Chicago experience, and are more than poised to roll out these efforts in Virginia.
Well, you were also working with a group, if I’m remembering this correctly, within the University of Illinois that was also working on gang violence, and you were using the same approach to “interrupt” cancer.
RW: We were absolutely working with CURE Violence and others, and adopting many of their approaches, because the reality was that we simply couldn’t be effective reaching the community by sitting in our ivory tower and simply collecting more data. Being physically present in the communities mattered.
The population of people living in our communities expected more from our cancer center. So, we were delighted and challenged to develop approaches that demanded that we have more presence in our various neighborhoods in a consistent manner.
While getting data about communities from GIS satellite is good, there is no substitute for gaining the trust of a community, and that trust is earned by consistently showing up, being respectful, and demonstrating impact.
As Dr. Steven Woolf, who is at VCU, and others, have shown, the ZIP code you are in matters greatly to your health. He has been very famous for collecting life expectancy data all over the country. As the cancer center director I am excited about getting the opportunity to work with him on developing “usable” community data.
I would say that place and space in which a person lives really does matter in cancer—the influences that various access to healthy foods, the stresses that you may have daily, can really have a big outcome on the effectiveness of the drugs used to treat cancer.
So, you are basically taking that approach to Richmond? What you were doing there in Illinois was unique.
RW: That’s right. We believe that the partners we now have throughout Virginia will afford us an even better opportunity to effectively use our community data approach to impact the health of our catchment.
Maybe we should just actually stay on this subject for a few moments and you could explain how things worked in Chicago and how you are planning to use this experience in Richmond. So, basically, you break up the place into ZIP codes. That’s already done. Then what?
RW: We stopped using ZIP codes. We found that ZIP codes were simply too confusing for us and most of the people in our communities. What we found to be effective in Chicago was the approach of presenting data by where people voted. In general, our communities were much more responsive when we showed them data in this manner.
What do you want them to do with data once you’ve shown it?
RW: Motivate people to get into gear and have different conversations about how to better align all of our efforts in having the greatest impact on our communities.
We also hope to promote more solid partnership between universities, community hospitals, community groups, and our civic leaders based not on just good will alone, but data.
When we presented data in which people understood, it was amazing the response we got from the politicians, the community, and the community hospitals. We were able to enrich the conversations between these groups, which resulted in—and not surprisingly—better approaches and coordination between the groups wanting to impact change.
So, you’re talking about screening, early detection awareness, treatment?
RW: As a result of using this community data approach to guide our efforts, we were able to increase our screening rates significantly. We were also better able to target where cancer educational efforts were needed as well.
So, you have the light-up map, basically; right?
RW: Yes, more or less. We call it a living map.
Okay, and you’re building one for Richmond now, for your catchment area?
RW: We are building such a map/cancer portal for Richmond. We’re really excited that in the not-too-distant future that we will be able to share our work with the folks living in Richmond.
We hope that it will be easy to use and relevant to the various communities within our catchment.
Fascinating. So, outreach and engagement is very local.
RW: Yes, community outreach and engagement is a very local effort and the traditional approaches to engaging communities are the bedrock of our work. But, we also believe that democratization of data is also becoming a necessary part of truly effectively engaging our communities.
I hope you don’t mind, but maybe in a year or so, either I or someone else from here would follow you around and figure out how it’s working.
RW: Oh, that would be great.
That would be very interesting, to see the facts on the ground. Now, maybe we should just go to the macro level. Could we reflect on the past 49 years of the National Cancer Program—what went right, what went wrong?
RW: So, if you look back to 1971, when the War on Cancer actually started, it’s clear that if you look at our numbers, there have been some things that have gone right, like the treatment of childhood blood malignancy, the treatment of breast, prostate, and more recently, lung cancer.
These improved outcomes have stemmed directly from research that came from the support of the NIH. We have more people living with than dying from cancer as a direct result of research, but we must also continue to have a laser focus on health equity to reduce the current health disparities between various groups.
It’s abundantly clear that basic research alone will not reduce health disparities. I have been very encouraged by the NIH’s recent emphasis on health delivery research, and on pushing for more robust Community Outreach and Engagement efforts to reduce health disparities.
So, there are a lot of people in oncology right now who believe that this field is at its apex, and the only way forward is down. I’m hearing this from people both of us respect. I actually don’t believe this. What do you think?
RW: Yeah, I’m sure you had a group of people who said that in the 1960s, 1970s, 1980s, and 1990s who said the same thing then.
We’ve made good progress, and given the current available tools, i.e. big data, machine learning, and the increasing body of knowledge, I am optimistic that we have not yet reached our apex.
The truth of the matter is, that these things tend to ebb and flow. When the next breakthrough is going to come, I don’t know. But I will tell you that I think that we will have another period of time, I’m not quite certain when, where we’ll be hopefully talking about pancreatic cancer in the same manner that we are now talking about lung cancer. I’m much more optimistic than I am pessimistic about our future.
I’m not seeing a lull, frankly, as I look out the window.
RW: Neither am I. I am convinced that—on both the discovery science side and the emerging field of implementation and health disparities sciences—we are really just scratching the surface of what it can do to have impact on reducing the country’s cancer burden.
So, I actually am of the camp that says, “We are not finished with our progress yet.”
The outreach and engagement component is now a critical part of the CCSG application. What are your thoughts about that program?
When you help the community, you help yourself, because you have the opportunity to better refine the questions being asked in partnership with the community.
RW: I applaud the NIH and the NCI for really pushing this effort of community outreach engagement.
This is one of the areas that I wish were in place right from the beginning with the advent of NCI cancer center designation in 1971. I think that had we also emphasized the implementation sciences as much as the discovery sciences we would have had a greater impact on reducing disparities among all communities by now.
Importantly, we would have also potentially gained more trust within communities for research.
I believe that Dr. Bob Croyle and Dr. Henry Ciolino, and the efforts from Dr. Doug Lowy and Dr. Ned Sharpless, in encouraging researchers to increase efforts in community outreach and engagement will not only benefit the people in the communities that we serve, but will also make us better and more responsible, and responsive researchers to the needs of our communities.
I am certain that there will be a great benefit for those researchers who consider our communities more as partners than subjects that provides tissue for our studies.
This basically says to me: Go out and help somebody. That’s how I read this part of the CCSG application.
RW: When you help the community, you help yourself, because you have the opportunity to better refine the questions being asked in partnership with the community.
Moreover, helping and having impact on our communities, and reducing the cancer burden was, after all, the original intent of creating NCI-designated cancer centers.
I think cancer centers are finally realizing that we’re more likely to have a bigger impact when we get out from behind our desks and into the communities we serve.
Ultimately, the more we know about our communities, and the more trust we gain from our communities, the more we will all benefit.
I always thought the leap between no designation and the cancer center designation would be much greater than the leap from the cancer center designation to the comprehensive cancer designation. Is that wrong?
RW: I would say that the leap from being an emerging cancer center to a designated cancer center is definitely steep.
However, it’s not easy going from a designated to a comprehensive center. The institutional support these days is substantial for both, however, more institutional resources are needed to obtain the comprehensive status.
I think you’re right, going from emerging to NCI designation is really tough. But going from a designated cancer center to comprehensive is not easy either.
But you don’t need to change the culture. The culture is there.
RW: I feel confident that the VCU Massey Cancer Center is positioned well to obtain NCI Comprehensive Cancer Center designation in the near future.
Dr. Ginder, our previous director, has put a number of things in place to make the Massey Cancer Center a great place to work, to do research, and to carry out clinical trials. I am fortunate to be following in his footsteps. Also, I am really fortunate to be surrounded by a great group of senior cancer center leaders, researchers, clinicians, and staff at Massey that makes it an ideal center to lead.
The state leaders, the community of Richmond, the “Massey Nation,” the institutional leaders, the faculty, and cancer center members are all committed and engaged. We’re excited by the journey of becoming a Comprehensive Cancer Center.
Is there anything we’ve missed?
RW: I don’t think so. I’m really excited about being part of the new chapter of Richmond and the VCU Massey Cancer Center. I am also excited about bridging the gap between the discovery and implementation sciences.
I thank you for the opportunity for this interview. I feel very lucky and fortunate to have the opportunity to be the cancer center director at the VCU Massey Cancer Center.
Thank you so much.