Training and Education
The Cancer Training Program
is a critical resource to the National Cancer Institute. It supports a broad
range of training activities in the finest institutions in the country,
individual fellowships and career awards, and education grants. Because
those trained in research today will form the intellectual foundation for
basic, clinical, and population sciences 10 years from now, training activities
sponsored by the NCI must continually anticipate the human resource needs
of cancer research in the future. The quality and progress of the Nation's
cancer research effort tomorrow will depend directly on the quantity and
quality of the individuals who are attracted to careers in cancer research
today, and on the appropriateness of the strategies used to train these
individuals. Rapid advances in our basic understanding of genetic and molecular
changes contributing to the growth and spread of cancer cells provide increasing
opportunities to move this knowledge into patient and population research
settings. In addition, these advances have a direct, more significant impact
on reducing cancer incidence and mortality through new screening, prevention,
diagnostic, and therapeutic interventions. Without adequate training, the
Nation's scientific and health care professionals will be unable to bring
these discoveries to the benefit of the people.
To meet this challenge, NCI is pursuing four interdependent training and
education strategies.
* First, maintaining the critical mass of independent basic scientists studying
cancer at the most fundamental levels of genetics and molecular biology;
basic discoveries will always generate the new knowledge critical for continued
progress in eliminating cancer.
* Second, encouraging a greater proportion of well-trained basic scientists
currently engaged in research on model systems to develop interests in model
systems for human biology and human disease; it is clear that the complex
objectives of cancer research will depend more and more on effective collaborations
between basic scientists and clinical and population scientists.
* Third, attracting more young physicians, other health care professionals,
and public health specialists into cancer research; of particular importance
will be developing and sustaining training programs that will markedly improve
the quality and quantity of physicians trained in the clinical sciences,
as well as continuing programs that will develop a larger contingent of
physicians, other health care professionals and public health specialists
in the biostatistical, epidemiological, behavioral and other prevention,
and control sciences.
* Fourth, using education grants to improve the curricula for health care
and public health students, and improving community education and information
dissemination programs; a critical issue is how to encourage those in the
health care arena and the lay public to maximize the effectiveness of current
information and knowledge. 
As part of these strategies, the NCI continues to support extensive training
and career development programs for minority individuals in order to increase
the number of biomedical scientists from under-represented population groups
and to increase the number of research personnel leading us into the next
century. This investment in intellectual resources is expected to pay off
through the expansion of the Nation's ability to identify and respond to
cancer trends among all sectors of the population. The Comprehensive Minority
Biomedical Training Program supports these activities through several mechanisms,
including recently developed minority medical oncology awards intended to
encourage newly trained clinicians to acquire clinical research experience
in oncology. Of particular importance is the emphasis the program places
on issues directly related to the health status of minority populations.
Other NCI training programs support minority students in the pre- and post-doctoral
phase of development, with awards made through the National Research Service
Awards, career development awards, supplements to institutional awards,
and cancer education grants.
Drug Discovery Using Contracts
The contract mechanism is extremely useful for research support when the
tasks to be performed can be identified at the outset of the program or
project. When a specific end product is desired or a project needs to be
conducted with the NCI's direct involvement, the contract mechanism is appropriate.
NCI uses contracts when grant mechanisms are inappropriate, such as for
the maintenance of public information services, research databases and drug
screening. A good example of NCI's use of the contract mechanism is the
operation of an in vitro cell-based drug screen to discover new agents with
potential therapeutic value for cancer and HIV. The drug screen has helped
to identify compounds with confirmed anti-cancer and/or anti-HIV activity
from either synthetic chemical compounds or natural products. Contracts
enable NCI to maintain a vigorous acquisition program for procuring both
chemically defined synthetic compounds and crude natural products from all
over the world for examination in this high-throughput screen. Since the
inception of the present screening program in 1990, approximately 50,000
pure compounds have been screened. About 700 exhibited a unique pattern
of activity and went on to further testing. Of these, NCI has selected five
for full-scale development to clinical trials.
Taxol is a recent example of a natural product derivative whose history
illustrates the scope of NCI's capabilities in developmental therapeutics,
as well as the need for collaboration with private industry. The original
extract of the substances was acquired through an NCI contract, and striking
antitumor activity was then identified in an earlier version of the NCI's
drug screening program. After purification of taxol from the extract, its
mechanism of action was elucidated by an NCI grantee. Acquisition of bark
from the Pacific yew tree by an NCI contractor provided sufficient amounts
of taxol for early clinical testing, once NCI staff and contractors had
developed improved chemical assay methods and an acceptable formulation
for clinical use. NCI-sponsored clinical trials then revealed very significant
levels of antitumor activity, at which point the drug became of interest
to commercial companies. After competitive awarding of a Cooperative Research
and Development Agreement (CRADA) to Bristol-Myers Squibb (BMS), the company
obtained sufficient drug for extensive clinical development and eventual
commercialization following FDA approval. BMS also developed semi-synthetic
methods so that the drug could be made from renewable parts of the yew tree;
this alleviated concerns about the environmental impact of obtaining enough
drug for clinical needs.
Barriers to the success of the four strategies are significant. Dwindling
resources for training have reduced the number of scientists being trained,
and there is little flexibility to emphasize one strategy without jeopardizing
the others. The resources for funding innovative, investigator-initiated
clinical as well as prevention and control studies are inadequate and provide
only minimal opportunities for well-trained physician scientists and population
scientists to compete for cancer research funding. Changes in the health
care system (i.e., managed care) are threatening the capability of institutions
to conduct clinical research and discouraging young physicians from pursuing
research careers. We must overcome these barriers. Cancer research training
strengthens our basic sciences and the collective ability of basic, clinical,
and population scientists to think and work together. It is an essential
underpinning of our efforts to improve public health by reducing the burden
of cancer.
Research Support Contracts
Research is a complex enterprise
that only flourishes in the context of a strong, reliable support infrastructure.
Contracts are a primary mechanism that the NCI uses to provide support for
research, information dissemination, and management. About 350 such contracts
are expected to be in force in FY 1996 with funding totaling $279 million.
Generally awarded on a competitive basis for 3 to 5 years depending on the
project, contracts are either completed or the project is recompeted at
the end of the contract period. Contracts support a variety of research
activities, such as components of drug development, cancer control, epidemiology,
surveillance, cancer biology, and information dissemination activities,
including the Cancer Information Service. Contracts principally support
program development activities in which the NCI defines the area of work,
provides guidelines as to how the work will be accomplished, and establishes
specific deliverables. The use of contracts is exemplified in the drug development
program where a range of services is acquired to support drug screening,
synthesis, acquisition, preclinical testing, pharmacology, toxicology, and
drug formulation--all sequential activities necessary to produce a new drug.
The programs that employ contracts are broad and diverse, with a vital role
in supporting laboratory, clinical and population-based research, NCI's
management infrastructure, and information dissemination to both the public
and the scientific community, here and abroad.
Cancer Control
Consensus among experts on the
usefulness of new medical knowledge does not guarantee its widespread application.
Cancer control, as supported by the NCI, addresses this challenge through
research on the behavioral, psychosocial, health services, communication,
and cancer surveillance aspects of translating proven technologies and tested
methodologies into routine practice in the community. Among the requirements
may be the removal of barriers to application often found in areas of information
dissemination, access to health care services, or cultural conventions.
These barriers may be present in the home, the community, the environment,
or at the interface with the health care system. They may require behavioral,
social, financial, or political solutions.
The NCI's cancer control activities include a special focus on population
groups who bear excessive risks for cancer or who lack access to state-of-the-art
cancer services. Research efforts have been undertaken with the collaboration
of community and private sector organizations that can be mobilized to assist
these population groups. Research networks of minority investigators and
leadership groups of community representatives have been established to
help accomplish the NCI's cancer control objectives.
Important to the process of technology transfer, the NCI's activities in
information dissemination include programs for both the public and health
care professionals. These programs are based on population needs identified
through epidemiologic studies and market research among specific population
groups. This allows for the design of programs that are relevant and understandable
to each group. Information can be disseminated nationally through the NCI's
patient education program, the leadership initiatives for special populations,
minority research networks, and the Cancer Information Service.
Tracking Progress: The Surveillance, Epidemiology, and End Results (SEER)
Program
The SEER Program is the most authoritative source of information on cancer
incidence, survival, and mortality in the United States. SEER is distinguished
by its broad scope and rigorous quality standards which have made it the
model for cancer registries throughout the world. Established in 1973, it
now includes 11 state and regional registries (covering about 14 percent
of the total U.S. population) that report data to the NCI. More than 1.7
million cancer cases are in the database, and approximately 150,000 new
cancers are registered annually. Data are collected on tumor site, morphology,
stage at diagnosis, first course of treatment, patient demographics, and
follow-up for vital status. To strengthen information about the cancer burden
borne by defined populations including minorities, the underserved, the
elderly, and rural residents, the SEER sample was expanded in 1992 to improve
representations of U.S. Hispanic, Asian/Pacific Islander, American Indian,
and African American populations.
Updated annually and provided as a public service in print and electronic
formats, SEER data are used by thousands of people each year. Users include
researchers, people planning public health interventions, as well as legislators
and health planners who want to assess progress and make policy and funding
decisions. The public is exposed to SEER data virtually every day, though
they may not know its source. Researchers use SEER to identify geographic
and population differences in cancer patterns and to study possible links
between cancer incidence and occupational, environmental, and lifestyle
influences. SEER data increasingly are being used to answer questions about
cancer causation, prevention, treatment, and control. For example, the database
is now used to study patterns and outcomes of cancer care and to assess
the extent to which state-of-the-art treatments are used across the country.
An innovative linking of SEER and Medicare data now permits important research
on patterns and sources of cancer care and the costs of cancer among the
elderly.
Cancer surveillance is a critical component of cancer control and, in fact,
underlies the entire NCI research portfolio. The tracking and analysis of
trends in cancer incidence, mortality, and survival rates stimulate new
activities and monitor the effects of ongoing programs. The cornerstone
of this effort is the Surveillance, Epidemiology, and End Results (SEER)
Program, which monitors the Nation's cancer burden and provides the basis
for assessing individual, organizational, and societal factors that can
mediate cancer rates.
Spreading the Word: The NCI's Information
Dissemination Mandate
Information dissemination is a central component of the NCI's mission
and mandate. The NCI reaches all segments of our diverse population with
needed cancer information and speeds the assimilation of clinical advances
in cancer into standard medical practice through vital programs including:
The Cancer Information Service (CIS)
The CIS provides accurate, up-to-date cancer information to patients
and their families, the public, and health care professionals in all 50
states through 19 offices located at NCI-funded Cancer Centers and other
health care institutions. By dialing 1-800-4-CANCER, callers are automatically
connected, free of charge, to the office serving their region. Information
on specific cancer types, state-of-the-art care, clinical trials, prevention
and detection, and resources such as support groups or screening and smoking
cessation programs is provided in English or Spanish by information specialists
who respond to more than 600,000 inquiries annually. The CIS regional offices
are also the NCI's focal point for state and local-level cancer education
efforts that particularly target underserved, high-risk, and low-literacy
populations. The CIS offices also catalog local cancer-related services,
catalyze community outreach efforts, and provide print materials and technical
assistance to help local organizations sponsor cancer education programs,
media campaigns, and other community programs.
The International Cancer Information Center (ICIC)
The ICIC, recently designated a government Reinvention Laboratory, provides
an array of cancer information for scientists, health professionals, and
the public. The Physician's Data Query (PDQ) is NCI's comprehensive clinical
cancer database, available on-line and via CD-ROM. Updated monthly, PDQ
contains the most current information on treatment of over 80 types of cancer,
clinical trials open for patient accrual, and cancer prevention, detection,
and supportive care updates. PDQ includes directories of over 21,000 physicians
and 8,000 organizations active in cancer care, including FDA-approved screening
mammography facilities. The CIS uses these directories daily to provide
local referrals to callers. Abstracts from CANCERLIT, NCI's comprehensive
bibliographic database describing cancer research results published over
the past 20 years, are also available through PDQ. Portions of PDQ information,
news bulletins, and other materials are available in Spanish and English
24 hours a day, seven days a week through NCI's CancerFax facsimile system
and CancerNet, an e-mail service. The ICIC also provides easy access to
its information through the World Wide Web (http://wwwicic.nci.nih.gov).
Easily updated, the ICIC's Web page is used to transmit important, late-breaking
news and findings from the NCI and NIH and provides access to some of the
ICIC's information products. Additional links include access to a patient
referral process for cancer clinical trials open at the NIH Clinical Center
and to NCI tissue registries for breast cancer and AIDS malignancies. The
Web page provides extensive information for patients and the general public,
including a site for children, and also has links to other Web sites of
interest worldwide including Cancer Centers, cancer support groups, and
many scientific and government sites.