Thursday, July 30, 2009

On the Struggles of Cancer Centers
Vincent T. DeVita Jr. and Elizabeth DeVita Raeburn
My daughter, Elizabeth, and I are writing a book about the War on Cancer. So,I’ve been doing a lot of reflecting on how things have played out since the Cancer Act was passed in 1971. Cancer Centers were a major theme of the Cancer Act.
Before it was passed, we had three freestanding cancer centers. Now we have 63—the vast majority “matrix centers,” meaning they are integrated within the structure of university medical schools and hospitals. The matrix set-up helped us get new cancer centers up and running across the country much faster, and at less cost than building new, free-standing ones.
The downside, however, is that, historically, “matrix” centers have often run afoul of the departmental structure of medical schools. They are often centers in name only. More energy is often expended over turf struggles between the departments of medicine and cancer centers over the operation of the sections of Medical Oncology than over innovations in cancer care. This is a recurring theme that has dogged NCI cancer centers since their inception in 1972.
Was there a better model? Possibly. Columbia College of Physicians and Surgeons (C P&S) had the first University based freestanding cancer hospital. But even it was dogged by some of the problems that affect the matrix model.
In November of 2007, while researching the upcoming book, Elizabeth and I interviewed Dr. Alfred Gellhorn the first Director of the Francis Delafield Cancer Hospital.
Gellhorn was trained as a general surgeon but re trained himself in Internal Medicine. When we interviewed Dr. Gellhorn, he was involved in his fourth successful career since leaving the Delafield.
Here’s an excerpt of our conversation:
“Dr. Gellhorn how did the Delafield get started?”
“It started in 1952. A CP&S breast surgeon by the name of Christian Hagenson persuaded the city to build a cancer hospital. Hagenson could never find anybody in Internal Medicine who was interested in cancer because the Chairman of the Medicine, Robert Loeb, felt that this was a disease that a good internist would have nothing to do with, because you couldn’t cure it.
I had absolutely unbounded admiration for Bob Loeb. He was a magnificent clinician…and a wonderful teacher. I think he just had a blind spot when it came to cancer. I think that the reason that Medical Oncology got such a slow start had to do with the attitude of people in Internal Medicine.
Loeb would not consider rotating CP&S house staff through a cancer hospital, but we were able to eventually get approval for our own residency program. I was able to recruit some wonderful colleagues, like Paul Marks, Elliot Osserman, John Ultmann, Bernie Weinstein, Helen Ranney among others. And my first chief resident was Jim Holland.
I was then the Director of the Institute of Cancer Research. The Delafield was its clinical arm where we also had labs.
Loeb tolerated me. But he was fond of saying rather openly, “Alfred, you’re a part of the lunatic fringe.”
And then Loeb retired and an even more pessimistic and indifferent clinician came in as Chair of Medicine, Stanley Bradley. Stan Bradley sent two guys to replace me in ’68 who had no connection to cancer and it was closed shortly thereafter.”
Despite the obvious need for, and the success of the Delafield, two Chairs of Medicine closed it. Their actions set the template for most NCI matrix centers today. Delafield was a good model just not free standing enough.
CP&S received its NCI designation in 1974. Since then, like a lot of matrix centers, they have struggled to find their Cancer Center identity. I am sure, for those who knew of the Delafield, there have been many times when they wished they still had it.
Dr Gellhorn died peacefully in March 2008 at the age of 94. He was a great mentor and a pioneer in the cancer field. Not many people, having been told they were part of the “lunatic fringe” by one of the greats in medicine, would have had the fortitude to continue. He did. And for that, and all the many luminaries he trained, we all owe him a debt of gratitude. Thanks Alfred.

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