At a time when federal immigration policies are becoming stricter, Kunle Odunsi, director of University of Chicago Medicine Comprehensive Cancer Center, reflected on the fact that cancer research is a highly international community.
“I was born in Nigeria, I grew up in Nigeria, I went to medical school in Nigeria, and then I did some of my training in England, in the United Kingdom,” Odunsi said. “My residency in obstetrics and gynecology was at Yale School of Medicine, so it was a very welcoming environment.
“In fact, many of us in my class, four out of six, were international graduates, because Yale had the philosophy at the time that we’re just going to take the best from wherever, and that was my experience. I felt just as good as anyone else. It was a great time.”
Ruben Mesa, president of Advocate Health Center Cancer Service Line, is the child of Cuban refugees and agreed with Odunsi that international collaboration is vital for a healthy research ecosystem.
“I trained at Mayo Clinic, and when I was a resident and fellow, I think about some of the extraordinary individuals, folks like Kunle, again, who came and had trained from other countries, but were just exceptional individuals and really moved forward the science and brought tremendous skills also from their medical training,” Mesa said.
As part of its crackdown on immigration under the Trump administration, the U.S. Citizen and Immigration Services announced that as of Sept. 21, H-1B visa petitions will require a $100,000 fee in an attempt to “curb abuses and protect American workers.”
“For someone like myself, I don’t think Yale would’ve paid $100,000 to get me an H-1B visa at the time, and I’m sure it’s going to be hard,” Odunsi, who is also the director of the Comprehensive Cancer Research Center, the AbbVie Foundation Distinguished Service Professor of Obstetrics and Gynecology, and dean for oncology at University of Chicago Medicine, said. “But as I said, and as you pointed out, we have to keep our eyes on the target, on our target, and that is cancer.”
Mesa and Odunsi appeared together on The Directors, a monthly series which focuses on the problems that keep directors of cancer centers up at night.
This episode is available exclusively on The Cancer Letter Podcast—on Spotify, Apple Podcasts, and YouTube.
Federal policy changes like the new H-1B fee have the potential to be “tremendously harmful” to the field of biomedical science, Mesa said.
“I think the potential is tremendously harmful, certainly in medicine, in biomedical science, as well as in other areas,” Mesa, who is also the president of the Atrium Health Levine Cancer and executive director of the Atrium Health Wake Forest Baptist Comprehensive Cancer Center, said. “I think one of the things that is really rewarding about our field is that it’s very diverse in every way that you can imagine, in terms of race, ethnicity, background, different world experiences, that really enriches your experience.”
Diversity is a boon to the oncology community, Mesa said.
“One, I think it makes us less competitive as a medical community, and two, our communities that really benefit from all of that energy and expertise will benefit less,” Mesa said. “I think, again, of all of the different visa programs where you have tremendous physicians coming from around the world, this has always made our environment stronger, not weaker.
For someone like myself, I don’t think Yale would’ve paid $100,000 to get me an H-1B visa at the time, and I’m sure it’s going to be hard. But as I said, and as you pointed out, we have to keep our eyes on the target, on our target, and that is cancer.
Kunle Odunsi
“There were pipelines that came from Singapore, from the UK, from Ireland, from Malta, there were many of these pipelines that were built-in, and they were just exceptionally well-trained individuals, and how much that enriched our environment, to really limit that, I think, is very self-defeating on many levels.”
For Odunsi, international and diverse collaboration has a direct impact on the quality of the research coming from the field of oncology.
“When I look at the composition of folks doing research, even in my lab, it’s an international community, and the environment is so enriched when you have these folks interacting, sharing experiences, coming from different perspectives, and this is so critical as we think about our patients, because ultimately, we want to impact the care of our patients,” Odunsi said. “How do we accelerate discovery? How do we move things very quickly, so that ultimately, it can have an impact?
“So, you have folks from different diverse backgrounds coming together, asking difficult questions in cancer research, and now it’s going to be difficult.”
Explore previous episodes of The Directors.
Some highlights:
On losing a generation of scientists
Oncology—and biomedical science more broadly—is at risk of losing an entire generation due to the uncertainty facing the field, Mesa said.
“I’m very concerned that if I am a really smart undergraduate or PhD student that’s considering a career in biomedical science, that there’s a lot of headwinds there and that we’re going to lose people to possibly other careers on the basis of challenges that they’re facing, whether that’s individuals that are training in the U.S. or individuals that are in other countries that had contemplated coming to the U.S. for training and have decided to really forego that altogether, I think both of which are at tremendous threat,” Mesa said. “I think we all realize that we’re only as impactful as our people, the people we can recruit, the energy, the talent, the passion they bring to what they’re doing.”
The continuity of mentor-mentee relationships is important for the field, Mesa said.
“There’s a pipeline,” Mesa said. “Who trains that new person in the lab? Probably the person that was the new person in the lab the year before. There’s a momentum to these things that is important. There’s a lot of steps between the entry person into the lab and being yourself as the cancer center director, and they need to see people at every level of that to know what sort of trajectory really is possible.”
Nearly everyone in the U.S. has been affected by cancer, one way or another, Mesa said. Mesa hopes that the importance of the mission will carry the field forward.
“I think one of the things that is tremendously rewarding about focusing on cancer, as we all have, is just the importance of the mission,” Mesa said. “None of us have to close our eyes and think very hard to think of someone that we directly love that lost their lives to cancer, or went through that journey and it was a tough journey and we’re glad that they’re cancer survivors. But we’re all touched by it, it’s a very, very personal piece.
“So, that, I think, is foremost amongst them, how do we, again, try to get people through this period, to keep folks who have that as a spark in their mission, to keep them excited, to help them realize that… What the future looks like, none of us know for certain, but if we continue to focus on the mission, continue to work together, continue to engage new partners, continue to advocate for the impact that the cancer research that we have done, the impact that that really has made, I think the more impactful we’ll be.”
On funding
The field of cancer research has made “tremendous progress” over the last three decades or so, Odunsi said. Cancer mortality has been reduced by more than 30%.
“Because there has been so much progress with new technologies, new knowledge, understanding of cancer biology, that has provided us now with avenues to even go to the next step, to the next level,” Odunsi said. “So, the pace of cancer science, cancer biology, understanding of mechanisms of cancer development, provides, more than ever before, unique opportunities to intercept cancer before it starts, prevention, and new therapies, and potentially cures for those with disease.”
Federal funding cuts threaten to hinder progress at this critical moment.
“We’re just at this important threshold in the fight against cancer, and what do we have now?” Odunsi said. “We have declining resources, funding rates have been cut, as you know, where I think the funding level now is fourth percentile.”
I think one of the things that is really rewarding about our field is that it’s very diverse in every way that you can imagine, in terms of race, ethnicity, background, different world experiences, that really enriches your experience.
Ruben Mesa
In an update posted on the NCI website July 23, the institute said that it “will not establish a specific R01 payline for the remaining competing [Experienced Investigator/New Investigator] applications that have not yet been awarded for FY 2025,” but that they “expect to fund through the fourth percentile for those EI/NI applications” (The Cancer Letter, July 25, 2025).
Odunsi said that he now has “investigators in [his] institution who scored fifth percentile, seventh percentile, and guess what? They’re not going to be funded. How good can a grant get when you get fifth percentile in your score?”
NCI’s tightening of the belt has a cascade of negative effects for the field.
“That leads to all the other components regarding our mission,” Odunsi said. “How do we continue to innovate? How do we continue to make an impact? How do we continue to train the next generation? Because when you’re funded, you hire postdocs, you hire graduate students, everything fits into each other.”
Cancer centers are sturdy, but with a flood of changes coming from Washington, the “for-all” mission of many cancer centers becomes more challenging to uphold.
“So, all these things are so interrelated, and that’s part of my concern, that if you come at all angles, Medicaid, the Affordable Care Act, people really can’t afford it, because the premiums go up dramatically, 340B, site neutrality, all of these really end up tackling a segment of the population in multiple ways that makes it very, very challenging to have very much of a for-all mission, which has been one that we very strongly try to maintain,” Mesa said.
Odunsi remains steadfastly optimistic.
“I hope that this is just a temporary lull in the evolution of how we fund cancer science in our country,” Odunsi said.
On site visits
Odunsi lamented the loss of site visits as part of the Cancer Center Support Grant application review. CCSG review has been centralized to a review board at NIH as part of the Trump administration’s efforts to improve efficiency at NIH (The Cancer Letter, Oct. 31, 2025).
“One thing that I am sad about during this era, that I do hope changes, is the loss of the site visits for the cancer centers,” Odunsi said. “Yes, there’s some expense with that, although I don’t think it’s really enormous, but that in terms of community building and leadership development for the people at our centers was such a powerful tool.”
In addition to bringing the “cancer team” together, site visits help keep “cancer toward the top of the institutional priorities,” Odunsi said.
“The institutional leaders, they really have to be there and speak to their center in front of external reviewers in a way that is very unique,” Odunsi said. “I think participating in those reviews really enriches our faculty, it creates collaborations between cancer centers. If you’re a site visit reviewer, you learn what’s going on at other centers, and that creates opportunities and cross-pollination.
“So, it strikes me, it’s such an own goal to cut this piece, because that’s such an enriching piece of our cancer community for really a relatively modest expense that was held in the past.”
On access
Mesa recently celebrated his mother’s 15th anniversary of being a cancer survivor.
“It was this week, my mother, she reached out to me and she said, ‘Ruben,’ she was like, ‘This week, I am a 15-year breast cancer survivor,’ and she’s this feisty 79-year-old Latina, and she’s fabulous,” Mesa said. “And I reflected, I’m like, why do I get to celebrate that with her as opposed to now just remembering her memory?”
Mesa’s father died from lung cancer in 2006, before the advent of the checkpoint inhibitors.
“Who knows if he would’ve done better if he had had it later?” Mesa said.
Mesa asked himself: “Why was my mother a survivor?”
Said Mesa:
And there were really two things. One, clearly research. I share with the people, I chat with them, she is a survivor because of everything that went into them understanding how to do the surgery, how to leverage adjuvant radiation therapy.
She was hormone receptor-positive, someone found the hormone receptor and then blockade and then which therapy to use. So all of that benefit of research really translated into directly saving her.
But two, that she had her cancer found early, and that was the crucial difference, that she had the access to be able to be screened for her breast cancer, that the screening recommendations for her at her age, post-menopausal, were still appropriate, so it was found in time and that she had access to care and received that care.
But if that had been delayed, because she was afraid to go in for care, or she was afraid to incur a medical expense, or she was afraid that someone would question her immigration status, then she comes in with advanced breast cancer, and then she’s not a breast cancer survivor.
So, it’s very much like when the ER docs speak about the golden window, the golden hour, that if someone has a trauma, they’ve got an hour to stabilize them. In cancer, we have that window. And one of my things that really keeps me up at night when we’re in periods like this, is how many people, like we had during COVID, do we lose the window, because they screen late, they come in late, they’re afraid to come in, and when they come in, it’s too late?
On reducing dependence on federal support
The oncology community has to start thinking about how cancer centers can reduce their dependence on federal funding, Odunsi said.
“One of the areas that I think we need to be thinking about as a community, cancer centers, is how do you reduce the dependence on federal funding to power the enterprise? Again, I love the federal funding, I think we should restore it to where it is,” Odunsi said. “But even beyond that, how are we thinking about reducing the dependence? What are the alternative revenue sources that we can begin to explore in order to power our mission and our vision regarding the fight against cancer?”
One of the areas that I think we need to be thinking about as a community, cancer centers, is how do you reduce the dependence on federal funding to power the enterprise?
Kunle Odunsi
The University of Chicago is focusing on those types of questions. The untapped profit of “intellectual firepower” at cancer centers is one potential area of new revenue, Odunsi said.
“Of course, we can all go to philanthropy, but there’s so much you can get from philanthropy,” Odunsi said. “What has become clear is that many academic institutions, including ourselves, have not taken full advantage of the intellectual power that we are generating. We get IPs, investigators make these discoveries, they publish a paper, they get a grant and then they get promoted, and many places, that’s what happens.
“So, perhaps to begin to think of a model where we are actually converting those intellectual firepower, for lack of a better word, into revenue streams… I know we tend to have our tech transfer offices, we do a little IP licensing and so on and so forth. But I was just looking around UChicago and I thought, if this place was industry, think about how they would have leveraged all of the discoveries to be self-sustaining, to the extent that maybe you need very little federal funding.”
Mesa agrees that new funding models may be necessary, since federal funding isn’t likely to increase anytime soon.
Said Mesa:
Federal funding is key, but I think it doesn’t take a rocket scientist for any of us to see the complexities of the federal budget and realize that dramatic increases in cancer funding are unlikely. There’s just so many pieces between defense, Social Security, on and on, there’s just not enough money in that bucket to do that. So, how does one really diversify that?
You’re right, I think we generate a lot of ideas that really have an impact. I see, again, the entirety of the pharmaceutical industry and then academic biomedical medicine, our share of the IP on that has been really too small. I’ve often wondered as well, again, even things like the NIH, if you think about all the IP that’s been generated from NIH-supported work, the fact that none of that IP really goes back to really support that. Again, are there are other models even within there that really could help to generate some support within there?
I do wonder as well whether there’s further opportunities to really cross-pollinate between centers as well. Again, there’s been a bit of a history of, well, we’re going to do this, but we’re going to do this on our own, because it makes us more competitive for this particular grant mechanism.
But if you took that away and said, “Boy, what is the most cost-effective way for us to be able to do this research?” We might do it in a very different way, to say, “Okay, we’re going to have a shared resource, Kunle, we both have a presence in the south side of Chicago, let’s do some stuff, we’ll just split it.” It might look very different if we’re not necessarily chasing a federal grant as part of that. But again, just trying to make that impact in the most cost-effective way that we can.
Listen to the full episode on Spotify, Apple Podcasts, and YouTube.
A transcript of the podcast is available below:
Jacquelyn Cobb: Welcome back to the Directors, a special segment of The Cancer Letter Podcast, sponsored by the American Society of Clinical Oncology.
This time, Ruben A. Mesa and Kunle Odunsi speak about what is keeping them up at night.
Mesa is the president of the Advocate Health Cancer National Service Line, president of the Atrium Health Levine Cancer, and executive director of the Atrium Health Wake Forest Baptist Comprehensive Cancer Center.
Odunsi is the director University of Chicago Medicine Comprehensive Cancer Center and director of the Comprehensive Cancer Research Center, as well as the AbbVie Foundation Distinguished Service Professor of Obstetrics and Gynecology and Dean for Oncology, University of Chicago Medicine
With that, let’s get started!
Paul Goldberg: With us today, we have Kunle Odunsi from the University of Chicago, and Ruben Mesa of Wake Forest and Atrium. And welcome to The Directors podcast, gentlemen. And on The Directors podcast, the first question is always the same, in October 2025, what’s keeping you up at night as directors of cancer centers? Why don’t we start with Dr. Mesa?
Ruben Mesa: Sure. Well, first, thank you so much, Paul, for the invitation to be here. I’ve been watching these with great interest, seeing thoughts of fellow directors as this year has been evolving, and what a treat to [be] on with my tremendous friend, colleague, someone I admire greatly, Kunle Odunsi, who’s also the chair of our cancer center’s EAB. So grateful for Kunle’s partnership and help on many levels.
So, what keeps me up at night, I think, are several things. I think foremost amongst them, I’m very concerned that if I am a really smart undergraduate or Ph.D. student that’s considering a career in biomedical science, that there’s a lot of headwinds there and that we’re going to lose people to possibly other careers on the basis of challenges that they’re facing, whether that’s individuals that are training in the U.S. or individuals that are in other countries that had contemplated coming to the U.S. for training and have decided to really forego that altogether, I think both of which are at tremendous threat. I think we all realize that we’re only as impactful as our people, the people we can recruit, the energy, the talent, the passion they bring to what they’re doing.
I think one of the things that is tremendously rewarding about focusing on cancer, as we all have, is just the importance of the mission. None of us have to close our eyes and think very hard to think of someone that we directly love that lost their lives to cancer, or went through that journey and it was a tough journey and we’re glad that they’re cancer survivors. But we’re all touched by it, it’s a very, very personal piece. So, that, I think, is foremost amongst them, how do we, again, try to get people through this period, to keep folks who have that as a spark in their mission, to keep them excited, to help them realize that… What the future looks like, none of us know for certain, but if we continue to focus on the mission, continue to work together, continue to engage new partners, continue to advocate for the impact that the cancer research that we have done, the impact that that really has made, I think the more impactful we’ll be.
How about yourself, Kunle, what keeps you up at night?
Kunle Odunsi: First of all, I’m so excited to be on this panel with my good friend, Ruben, and it’s really a great pleasure to be able to share our experiences about some of the opportunities that we have. I will not call them challenges, I think every challenge creates opportunities.
So, what keeps me up at night, many, and they revolve around our mission areas of providing outstanding patient care, research, education, and training.
So, if you think about it, we’ve made tremendous progress over the last 30 or so years, where we’ve reduced mortality in cancer by more than 30%. This is a tremendous accomplishment, and there has been so much progress with new technologies, new knowledge, understanding of cancer biology, that has provided us now with avenues to even go to the next step, to the next level.
So, the pace of cancer science, cancer biology, understanding of mechanisms of cancer development, provides, more than ever before, unique opportunities to intercept cancer before it starts, prevention and therapies, new therapies, and potentially cures for those with disease.
So, we’re just at this important threshold in the fight against cancer, and what do we have now? We have declining resources, funding rates have been cut, as you know, where I think the funding level now is fourth percentile. I have investigators in my institution who scored fifth percentile, seventh percentile, and guess what? They’re not going to be funded. How good can a grant get when you get fifth percentile in your score?
So, that keeps me up at night, and that leads to all the other components regarding our mission. How do we continue to innovate? How do we continue to make an impact? How do we continue to train the next generation? Because when you’re funded, you hire postdocs, you hire graduate students, everything fits into each other.
So, that is a challenge and it keeps me up at night, and I hope that this is just a temporary lull in the evolution of how we fund cancer science in our country.
Paul Goldberg: I was just looking at the three pictures, the three of us on the Zoom, and I just realized that all three of us came to this country as immigrants. I was a refugee on the refugee visa. Dr. Mesa, I guess your parents must have been refugees, correct?
Ruben Mesa: Correct. So, I was born in Chicago, but my parents were really fresh refugees from Cuba, so as my mother was sharing with me, a bit nervous, as there’s question about birthright citizenship, she was not a citizen when I was born. So, even someone like myself, again, born here, she had her green card and they were… Again, I’m always very sensitive as well that my parents, being Cuban refugees, they were welcomed, where other groups have not been. But they were here, they were refugees, and then I was born, but very much benefiting from that opportunity of them being able to immigrate to the U.S.
Paul Goldberg: Well, and Dr. Odunsi, of course, you must have been here on a student visa, and then did that ever become an H-1B?
Kunle Odunsi: Actually, I came as a resident. I was born in Nigeria, I grew up in Nigeria, I went to medical school in Nigeria, and then I did some of my training in England, in the United Kingdom.
At that time, I was really applying for residency positions. So, I was very welcome, so my residency in obstetrics and gynecology was at Yale School of Medicine, so it was a very welcoming environment.
In fact, many of us in my class, four out of six were international graduates, because Yale had the philosophy at the time that we’re just going to take the best from wherever, and that was my experience. I felt just as good as anyone else. It was a great time.
Paul Goldberg: But there was an H-1 visa situation that’s happening now, where you might have to pay $100,000 or $100,000 a year, maybe medical schools are exempted, maybe they’re not, who knows? I can’t imagine this field without thinking of it as an international happy place. Is this changing? Can you imagine it changing?
Ruben Mesa: I think the potential is tremendously harmful, certainly in medicine, in biomedical science, as well as in other areas. I think one of the things that is really rewarding about our field is that it’s very diverse in every way that you can imagine, in terms of race, ethnicity, background, different world experiences, that really enriches your experience.
I trained at Mayo Clinic, and when I was a resident and fellow, I think about some of the extraordinary individuals, folks like Kunle, again, who came and had trained from other countries, but were just exceptional individuals and really moved forward the science and brought tremendous skills also from their medical training.
There were pipelines that came from Singapore, from the UK, from Ireland, from Malta, there were many of these pipelines that were built-in, and they were just exceptionally well-trained individuals, and how much that enriched our environment, to really limit that, I think, is very self-defeating on many levels.
So, for one, I think it makes us less competitive as a medical community, and two, our communities that really benefit from all of that energy and expertise will benefit less. I think, again, of all of the different visa programs where you have tremendous physicians coming from around the world, this has always made our environment stronger, not weaker.
Kunle Odunsi: Yeah, I want to agree with you, Ruben, because when I look at the composition of folks doing research, even in my lab, it’s an international community, and the environment is so enriched when you have these folks interacting, sharing experiences, coming from different perspectives, and this is so critical as we think about our patients, because ultimately, we want to impact the care of our patients. How do we accelerate discovery? How do we move things very quickly, so that ultimately, it can have an impact?
So, you have folks from different diverse backgrounds coming together, asking difficult questions in cancer research, and now it’s going to be difficult. For someone like myself, I don’t think Yale would’ve paid $100,000 to get me an H-1B visa at the time, and I’m sure it’s going to be hard. But as I said, and as you pointed out, we have to keep our eyes on the target, on our target, and that is cancer. We have to keep our eyes on the mission, make sure we remain focused, doing whatever we can do, and hopefully, at some point, we will be able to come out of this temporary… I always look at the glass as half full, so I’m hoping that we’ll come out of this even stronger on the other side.
Paul Goldberg: Well, being Russian, I’m a catastrophist. But I think I actually might be wrong so far to catastrophize, because if you listen to what is said in Washington, you get one picture. But if you look at what’s actually happening, the administration tried to cut NIH by 40%, the House and Senate gave NIH an increase, both of them did, so things aren’t… What has changed in your lives? How has this actually affected the way you do business, just the numbers? Have you lost certain kinds of grants? What have the damages been so far for you?
Kunle Odunsi: For us, I think first of all, we’ve lost some grants based on some of the… In compliance with the executive orders, so we’ve lost some grants. But more importantly, because of the back and forth of Congress with regards to site neutrality, for example, on how to reimburse Medicare and Medicaid, that has created some unease, and while it is not entirely clear where this is going to land, but in the meantime, I think across the country, many medical centers, we are seeing budgetary cuts.
So, what else keeps me up at night is the budgetary constraints because of the uncertainty about how we’re going to land with reimbursement rates, with issues with site neutrality, and essentially, hospital finances. And when that happens, then it constrains you in recruiting faculty, in retaining faculty, it just has all of those downstream effects. So, that is what is going on, so we’re already facing some budgetary constraints as a consequence of all of the things that are going on.
Ruben Mesa: I would share very much that same unease. I think there’s uncertainty. We’ve not had big changes yet. I’m grateful to work for an institution that is well-led and has some buffer-like capabilities. But there is very much this confluence of challenges that’s difficult.
Certainly, we all realize that in cancer, we’re able to make a difference really through a portfolio of activities and revenue. There’s grants, of course, but there has always been investment from the practice, which is a significant amount that occurs, there can be state or local-type support, clearly philanthropy, are all different pieces that contribute to this.
Unfortunately, each one of those has its own pretty significant headwinds. There are things that, again, if they occur, could be really damaging. We don’t know whether they’ll occur, and we’re hopeful that, again, cooler heads will prevail, very much like the NIH budget situation, 340B, site neutrality, these things occurred because they’re really important in terms of being able to care for patients.
I’ve had a leader use the quote, “I can explain healthcare economics, but it’s not my fault.” And in some ways, that’s true. We realize that, again, healthcare economics in the U.S., there are certain things that generate a margin, and the majority does not, and there’s a few things that really end up supporting everything that is needed.
If one looks at infectious diseases in isolation, this is something that, again, is in the red, if one looks in isolation. However, you need the care of infectious disease specialists if you’re going to be caring for people who are immunocompromised.
So, all these things are so interrelated, and that’s part of my concern, that if you come at all angles, Medicaid, the Affordable Care Act, people really can’t afford it, because the premiums go up dramatically, 340B, site neutrality, all of these really end up tackling a segment of the population in multiple ways that makes it very, very challenging to have very much of a for-all mission, which has been one that we very strongly try to maintain. So, that’s a huge piece. And at the same time, some of the same headwinds are hitting everyone’s 401(k), etc., that is really tied to philanthropy. Again, philanthropy largely drives… If people feel that they have enough resources to be able to share philanthropically, well, that takes a real hit if that’s getting attacked from other levels. So, that is a real concern.
So, I’d say we’re in the position of cautious optimism, as Kunle says. One bright spot that is important, I think you raised an important one, Paul, that when all is said and done, I think there is an appreciation for the importance of the NIH, of our entire biomedical research community, and that there is strong bipartisan support for that, and that is really important. Two, I do think, at the end of the day, the desire is really the same. As I see some of the discussion around the MAHA, or Make America Healthy Again movement, there are aspects of that, not all, but there are aspects of that that clearly are positive. Do we have rural health disparities? 100%. And by trying to tackle those, might that help everyone? It may, there’s many aspects, again, of that that are very important. Two, do chronic conditions play a role in the development of things like cancer and other diseases? Absolutely. So are there aspects of, again, really trying to get a chronic disease that we can learn from?
I lead the cancer service line, as does Kunle for his institution, but as I sit in the room with the leader of our cardiovascular service line or our neuroscience service line, we share many important priorities. Tobacco cessation, for example, is that a cancer issue? Is that a heart and vascular issue? Is it a stroke issue? It’s an issue for all of us, incredibly important. So I think there are some bright spots there. But the confluence of challenges is very difficult, because in many ways, historically, when one thing has struggled, another can kick in. I know when there has been, again, constraints around federal funding for research, institutions have largely stepped up with philanthropy or with practice dollars, but if they’re all under attack, it becomes a tremendous strength.
Kunle Odunsi: Yeah, so that’s a good point, Ruben. And one of the aspects that I want to bring up really is if you look at the catchment areas of many cancer centers, and I’ll use our cancer center as an example, there is diversity in terms of rural populations, urban populations and so on. So, in Chicago, for example, the University of Chicago Cancer Center, we have a catchment area of at least eight million people, and we have neighborhoods that are urban neighborhoods, but that are plagued by many socioeconomic issues that, frankly, really should not be going on in this country. So there are issues of affordability. These are people who depend on some of the support that we are talking about, so they lose their insurance, they’re uninsured or underinsured.
And yet, we have, on the other side, at UChicago, and I’m sure at your cancer center as well, we have these incredible new therapies that are coming up that are very expensive. So, guess what? It leads to financial hardship for patients. And some of the folks in our group, and I’m sure at your institution, have been studying this phenomenon that we are all calling financial toxicity as one of the side effects of cancer therapies, financial toxicity. But I have to say that what we have found is that even patients with insurance, with some of these new therapies, incur substantial debt, which can then delay them from having the necessary access to care. So, in our catchment area, there’s clear evidence of health inequities, there’s frankly disparities across socioeconomic status, across race, issues of transportation, all of those things exist, they are real. And I think there is a move also to minimize those issues in the national discourse, which, I think, as cancer center directors, we should make sure we bring this to the fore.
Ruben Mesa: It really is so key, what you said, Kunle, in that, again, at the same time we’re seeing important advances, this gap continues to grow. Our center was the first to develop a formal financial toxicity tumor board, led by one of our investigators, Greg Knight, and a very dedicated team. And it was a really interesting approach of taking the same multidisciplinary approach we would take in a GYN tumor board and do it with financial toxicity, with pharmacy, with social workers, with their care team, again, trying to solve… At a high level, we have a screen that really is a pharmacy piece, to really maximize the drug replacement programs and other things, to decrease the drug financial toxicity piece, because there’s so many dollars associated with that. But then a narrower financial toxicity tumor board, again, to try to help to overcome issues, whether that be child care or transportation or any number of specialized things, and leveraging state, county, local type programs. But that ability to navigate these things is so key.
I think one of you two had really raised that issue of the window. As I think about cancer and try to think about it from a 100,000-foot view, with any one individual, they have a window, the key window between the cancer being fatal or not. It was this week, my mother, she reached out to me and she said, “Ruben,” she was like, “this week, I am a 15-year breast cancer survivor,” and she’s this feisty 79-year-old Latina, and she’s fabulous. And I reflected, I’m like, why do I get to celebrate that with her as opposed to now be just remembering her memory? Because I lost my father to lung cancer in 2006 before we had the advent of the checkpoint inhibitors, and who knows if he would’ve done better if he had had it later. But why was my mother a survivor?
And there were really two things. One, clearly research. I share with the people, I chat with them, she is a survivor because of everything that went into them understanding how to do the surgery, how to leverage adjuvant radiation therapy. She was hormone receptor-positive, someone found the hormone receptor and then blockade and then which therapy to use. So all of that benefit of research really translated into directly saving her. But two, that she had her cancer found early, and that was the crucial difference, that she had the access to be able to be screened for her breast cancer, that the screening recommendations for her at her age, post-menopausal, were still appropriate, so it was found in time and that she had access to care and received that care.
But if that had been delayed, because she was afraid to go in for care, or she was afraid to incur a medical expense, or she was afraid that someone would question her immigration status, then she comes in with advanced breast cancer, and then she’s not a breast cancer survivor. So it’s very much like when the ER docs speak about the golden window, the golden hour, that if someone has a trauma, they’ve got an hour to stabilize them. In cancer, we have that window. And one of my things that really keeps me up at night when we’re in periods like this, is how many people, like we had during COVID, do we lose the window, because they screen late, they come in late, they’re afraid to come in, and when they come in, it’s too late?
Kunle Odunsi: Yeah. I like your analogy about the window, and if we take it one step further, what is the window for us about training the next generation of cancer scientists and researchers? Because we are having a lot of folks who, frankly, are quitting right now because of lack of morale. So, one of the things that keeps me up at night as well is, how do I help with boosting morale? How do I ensure that we retain the pipeline for grad students who are going into cancer research, for postdocs, for junior faculty, maintain the pipeline and retain them in the field? So, that is a challenge, because when these folks hear the news, they see what’s going on, the funding cuts, the difficulty with getting grants, it is discouraging. So, the question is, what measures are we taking, as cancer center directors, to sustain morale and make sure we continue to… The kind of success that you described with your mom, how do we replicate that story many, many times with regards to prevention? It does require maintaining the workforce, building the next generation who will discover the next hormone receptor or whatever is necessary.
Paul Goldberg: Well, can I insert a footnote into what was said some minutes ago about financial toxicity? The term, I believe, originated at UChicago, I think it was Mark Ratain who first used that. We should look at it more carefully, but I think that will be confirmed, and in my spare time, I will.
But what’s really interesting, maybe it would be useful to keep a ledger of everything that has been attempted by this administration and everything that’s still in the pipeline.
So, the 40% cut didn’t happen. The 15% ceiling on indirect cost probably will not happen. Medicaid may happen, it’s slated to happen, but will it? We don’t know. 340B reform, maybe. Site neutrality, maybe. So far, it’s not a 100% win for the administration and the Republican side, who’s been really not supporting this. So, maybe that’s helpful in terms of keeping the young investigators less… Keeping them from catastrophizing like I do.
Ruben Mesa: One thing I would raise that’s a bright spot, because I think there have been some real bright spots, and one of them is how our professional organizations have really stepped up to try to fill the void. So, the American Society of Hematology really dug deep into their reserves to really expand grant programs dramatically, to really help with bridge funding and junior investigator grants.
The American Association of Cancer Research, I’m helping to lead a subgroup that Marge and the team put there along the Cancer Center Alliance, to really try to find ways that we can help to better support trainees.
So, working along with Ben Toll, who’s the AD of CRTEC at MUSC, we’re doing a survey that’s gone out as we speak, both to ADs of CRTEC but also to cancer trainees across AACR to try to understand needs, and again, how can they really jump to help.
Further granting programs, of course, but other educational type things, things that, again, they can really leverage to be successful, as well as that sense of community.
Kunle, you raised an important one in terms of the window. One key thing as well is there’s a pipeline, because we all know that the new person in the lab, who trains that new person in the lab? Probably the person that was the new person in the lab the year before. There’s a momentum to these things that is important. There’s a lot of steps between the entry person into the lab and being yourself as the cancer center director, and they need to see people at every level of that to know what sort of trajectory really is possible. So, I’d say that is a plus. AACI has really jumped in very strongly, great community amongst cancer centers. Yourself, Paul, The Cancer Letter has done a tremendous job throughout this year, I think, in particular. I would imagine that your readership and viewership is up quite a bit, because you really provide a public square for us to really both have information, but really be able to share ideas, thoughts, and advocate for things that we’re very passionate about in trying to impact cancer.
Kunle Odunsi: Yeah.
Paul Goldberg: Well, thank you.
Kunle Odunsi: Let me just add another dimension to this discussion, and that is the fact that in every crisis, there’s always an opportunity to look out for. So, think about the 2008 financial market crash, think about the COVID crisis, mRNA vaccines came out of that. So, there’s several examples where you have a crisis, and then something good comes out at the end. In the meantime, you are feeling the pain. You’re feeling pain, but in the end, you learn something.
So, one of the areas that I think we need to be thinking about as a community, cancer centers, is how do you reduce the dependence on federal funding to power the enterprise? Again, I love the federal funding, I think we should restore it to where it is. But even beyond that, how are we thinking about reducing the dependence? What are the alternative revenue sources that we can begin to explore in order to power our mission and our vision regarding the fight against cancer? And I say this because here at the University of Chicago, for example, we’re asking those types of questions. Of course, we can all go to philanthropy, but there’s so much you can get from philanthropy.
What has become clear is that many academic institutions, including ourselves, have not taken full advantage of the intellectual power that we are generating. We get IPs, investigators make these discoveries, they publish a paper, they get a grant and then they get promoted, and many places, that’s what happens. So perhaps to begin to think of a model where we are actually converting those intellectual firepower, for lack of a better word, into revenue streams… I know we tend to have our tech transfer offices, we do a little IP licensing and so on and so forth. But I was just looking around UChicago and I thought, if this place was industry, think about how they would have leveraged all of the discoveries to be self-sustaining, to the extent that maybe you need very little federal funding.
So, that is a challenge that we have put out, that’s a question we’re asking ourselves, and looking at potential opportunities of how to create platforms within these academic institutions that potentially will fully take advantage of all of the discoveries and everything else that’s going on. So, I wonder what your thoughts are about that kind of notion.
Ruben Mesa: Well, I think you’re spot on, Kunle. I think as I get together with our institutional leaders, there’s no question that diversifying the portfolio of how we support ourselves in research is key.
I was having this conversation with our dean, Dr. Ebony Boulware, who is a tremendous dean, but again, how do we really diversify that? How do we think of our comprehensive cancer center as a translational center of excellence?
So, our comprehensive cancer center now is part of a really large health system, Advocate Health, third-largest health system non-profit in the United States. How do we do this in a symbiotic way? Federal funding is key, but I think it doesn’t take a rocket scientist for any of us to see the complexities of the federal budget and realize that dramatic increases in cancer funding are unlikely. There’s just so many pieces between defense, Social Security, on and on, there’s just not enough money in that bucket to do that. So, how does one really diversify that?
You’re right, I think we generate a lot of ideas that really have an impact. I see, again, the entirety of the pharmaceutical industry and then academic biomedical medicine, our share of the IP on that has been really too small. I’ve often wondered as well, again, even things like the NIH, if you think about all the IP that’s been generated from NIH-supported work, the fact that none of that IP really goes back to really support that. Again, are there are other models even within there that really could help to generate some support within there?
I do wonder as well whether there’s further opportunities to really cross-pollinate between centers as well. Again, there’s been a bit of a history of, well, we’re going to do this, but we’re going to do this on our own, because it makes us more competitive for this particular grant mechanism. But if you took that away and said, “Boy, what is the most cost-effective way for us to be able to do this research?” We might do it in a very different way, to say, “Okay, we’re going to have a shared resource, Kunle, we both have a presence in the south side of Chicago, let’s do some stuff, we’ll just split it.” It might look very different if we’re not necessarily chasing a federal grant as part of that. But again, just trying to make that impact in the most cost-effective way that we can.
Kunle Odunsi: Yeah.
Paul Goldberg: I have a thought about that. Looking at what’s happening now, I’m not seeing the pulling back. UChicago is about to open a cancer hospital, that’s new and fantastic, Emory just did, so did Huntsman, and so will soon Ohio State, which actually would make it the second-largest cancer care provider, or cancer hospitals network, in the country.
So, people are moving forward, the plans are not being pulled back. And Ruben, I’m sure you’re doing some stuff that you’re proud of that moves the enterprise forward. So, I’m not really seeing that. So, maybe we’ll all survive this. People are certainly betting, some very smart people are betting on survival here.
Ruben Mesa: The core of it, which is what I share with our teams, is that the mission is the same. Unfortunately, cancer is not in retreat. I think the ACS estimated two million Americans will have cancer in 2025, and 600,000 people will pass away from it, and the need for places for excellent care, advances in research, clinical trials, that need is greater than it’s ever been. So, I think that’s the main driver.
I think all of our systems have a clear concern, yet still realize that the need is there, as well as the commitment of we’re going to try to find a way to get this done, but always with the knowledge that if several of these things that are maybes all hit at the same time, it could have a real dampening effect downstream.
But for the moment, I think there’s enough of a, “Boy, cancer’s not going anywhere, we’ve got to really rise to meet it.” And again, there are things that may occur that will make our needs even greater. I’m hopeful that our, let’s say, cellular-based therapies and their impact on solid tumors, if and when that really hits, that’s going to be a dramatic impact.
But it has real impact on where are we going to be caring for those folks? Who’s trained to do them? What is the impact on hospital beds? Apheresis capabilities, on and on. So, there’s a bit of that hoping for the best, planning for the worst, type of phenomenon.
Kunle Odunsi: So, Paul, what you describe is actually a nice observation, how many of the cancer centers have remained focused on the mission and not pulling back. So, all the new cancer hospitals that are springing up across the country, they are springing up in places that can provide very complex care for patients, and I think it’s for the benefit of patients ultimately.
So, at UChicago, for example, we have a Cancer Pavilion that is going up, it’s going to open in the spring of 2027, fantastic facility. In fact, we had a town hall yesterday, where we talked about beginning to transition, what is the transition plan, what is the activation plan, and so on and so forth.
The point is, you can have this beautiful building, we have to keep this in mind, what really matters is the people, the people that walk in that building to provide compassionate care to patients is the people, and I think that’s where the rubber meets the road in terms of resources.
Do you have resources, again, based on all the uncertainties, to recruit, retain, train, and do all of the things that you need to make the building functional? That keeps me awake at night.
So, now, I have this building, which, by the way, we started the planning and construction pre-COVID, the planning pre-COVID, construction started post-COVID, and started pre-current administration, so now you have all these uncertainties and you’re asking yourself, how am I going to sustain? How am I going to do all the things that we envisioned in this building?
Because you need people, you need hands, you need to recruit, you need all of these things to make the place really fulfill the purpose, the vision that we have for it. So, in all of these places where these buildings are going up, it’s great and I think we should continue to keep our eyes on the ball, but bearing in mind that there may be a little downward trend in terms of recruiting and so on over the next few years. So, I’m hoping it’s short-lived.
Paul Goldberg: Yeah. Actually, I should be careful with my lists, because I forgot Rutgers, and I probably forgot a few other places. But Rutgers, when I was talking with Steve Libutti, when they just opened their gorgeous billion-dollar hospital, he said, “This thing doesn’t mean very much without NCI, the world without NCI is not a good world.” And this was when that 40% cut was still a possibility. So, it’s the people who work there, but also the people who design the strategy for what we’re describing, what we’re talking about.
Ruben Mesa: I’ve shared with folks, the value of the NCI, it goes well beyond just the financial support of the research, although that’s clearly a key piece, but it really has been such a driver both in terms of the strategy of that research, as well as really bringing a tremendous cancer community.
I had this conversation both with Ned Sharpless, as well as Kim Rathmell, regarding the Cancer Centers Program, for example. And the Cancer Center Program, I think, probably has the best return on investment of any dollar spent at the federal government, because for any one of the cancer centers, the investment in both dollars and sweat equity by the institutions that are NCI cancer centers, or aspiring to be, dramatically exceeds the actual dollars that they receive from the NCI, and the value that it brings is tremendous.
Certainly, the dollars are valuable, without question, but there’s so much more that comes with it, the inclusion in that community, the opportunity to really be able to access other funding streams that are very important for the mission, the ability to recruit and retain the best and the brightest that really have an impact on cancer.
All of these things are huge, so that return on investment is really incredibly important.
And having been at three different NCI cancer centers during my career, I can say that the value of aspiring and maintaining that important designation is an incredibly important part of the success of those institutions. So, Steve is 100% correct.
One, that’s an amazing facility, he showed me around a bit as well when I was out there, and it’s a fabulous place, and what a great resource for the people of New Jersey, being able to receive that care in Central New Jersey without having to travel for that. But two, how it really brings together those teams is really inspirational.
Kunle Odunsi: Yeah. So, I completely agree with you, Ruben. The NCI Cancer Centers Program. I think it’s probably the most impactful program by the NCI, maybe even by the NIH, over the last 50 years—the way this program has transformed cancer care, cancer prevention.
Look at all the outputs from the cancer centers nationwide, it’s remarkable. And because of the NCI, this country has the leadership around the world in cancer research and how best to take care of cancer patients. So, I think to maintain that leadership, preserving the NCI is something that we should all advocate for, preserving the structure of the Cancer Centers Program is something we should also advocate for, they have been a tremendous success.
And in fact, here, at the University of Chicago, we brag about the NCI designation, I’m sure you do at your institution as well, and it actually gives a lot of credibility to everything we’re trying to do, and you’re able to leverage it to gain additional resources, as you pointed out. I would think that perhaps, going forward, in order to even demonstrate greater impact, I think, back to your point about the NCI centers coming together, collaborating in a more coordinated way…
I know we talk about it a lot, we’ve been talking about it at meetings, how do we work together, how do we leverage our strength and so on and so forth, but I think to truly come together, even create regional consortia of these NCI centers, starting with two or three, and then coordinate nationally so that there’s true collaboration among these NCI centers, I think the impact is going to be tremendous. We always say the whole is greater than the sum of the parts, we will see exponential impact when these things happen.
One thing that I am sad about during this era, that I do hope changes, is the loss of the site visits for the cancer centers. And the reason for that is that, yes, there’s some expense with that, although I don’t think it’s really enormous, but that in terms of community building and leadership development for the people at our centers was such a powerful tool.
One, I think it really brings the cancer team together in a way that few other things can. Two, I think it really helps keep cancer toward the top of the institutional priorities, because the institutional leaders, they really have to be there and speak to their center in front of external reviewers in a way that is very unique. And three, I think participating in those reviews really enriches our faculty, it creates collaborations between cancer centers. If you’re a site visit reviewer, you learn what’s going on at other centers, and that creates opportunities and cross-pollination. So it strikes me, it’s such an own goal to cut this piece, because that’s such an enriching piece of our cancer community for really a relatively modest expense that was held in the past.
Paul Goldberg: Well, I should be very careful with my running lists, because one of the things that we were all worried about was an NCI director who would not come from this community, and now we have an NCI director who comes very much from this community and who is respected within this community. So my question is, what would be the most positive thing, message, you’re capable of right now? So we’ll begin always with the same question and we end with the same question. The first question is, what keeps you up at night, the second is, what’s the most positive thing you can say?
Kunle Odunsi: I think we’re at a moment where we need to just continue to drive hard, push the pedal down on trying to find a cure, whether it’s through prevention, new therapies. We didn’t even address survivorship, think about survivors, there are more than 20 million survivors in this country right now. So, just to keep pushing hard in all of those areas, all of those domains, across the cancer continuum, because we’re at a point where we have tremendous knowledge, where we have tremendous technologies, to be able to address some of the most difficult questions in cancer. And with keeping an eye on the patient as the ultimate goal, we always say, it’s not enough to do your research and let it sit on the bench, paying attention to translation.
How do we take those discoveries across the finish line and make it to be of benefit to our patients? That is the positive message that I have, that we have opportunity, even though the clouds are dark a little bit, but there are opportunities for us in the cancer community.
Ruben Mesa: What I would share is, again, how do we have this period really push us to another level? I’m mindful of the pandemic, where one of the positive outcomes was I think we were able to leverage virtual care in a way that really enriched our ability to care for individuals, and that all got jump-started in part because of sheer necessity. I think here, part of the necessity is, how do we really tell the story of the value of cancer research, and how do we use it to really engage a broader group of partners more broadly? Where, again, as a field, we had really refined how we try to tell that story to study sections at the NIH, but perhaps have opportunities to better refine that impact of cancer research for the general public, for other agencies, for state, local, county governments, for industry partners, so that, again, that sense of urgency, that sense of need is broadened, and we’re able to bring others into the fight against cancer, in a way, to really be able to have an impact.
Again, this is an amazing community. One of the things I find most rewarding about being in the cancer community is really the people we have a chance to work with, because they’re incredibly creative, they’re bright, they’re passionate, they chase a cure in cancer with passion and dedication, and how do we continue to really recruit people into that fight against cancer so that we can move forward? So I know that together, we will find a way.
Paul Goldberg: Well, thank you very much. Thank you for finding the time to be here.
Ruben Mesa: Thank you, Paul.
Paul Goldberg: Thank you.
Kunle Odunsi: Okay. Thank you, Paul.
Paul Goldberg: Thank you.
