Transforming cancer care

By Bryant Boutwell and Charles M. Balch

Perhaps Norman Vincent Peale said it best, “Shoot for the moon. Even if you miss, you’ll land among the stars.” There was a certain swagger about Dr. R. Lee Clark. He was talented, confident, and never afraid of a good challenge, no matter how daunting. He saw opportunities for greatness where others saw obstacles and MD Anderson to this day exemplifies his outlook. In fact, from day one he was making no small plans and envisioned building something much bigger than a state cancer hospital serving only Texas. Rather, he set out to transform cancer care at the national level—a topic not to be overlooked in this series honoring his legacy.

As a medical consultant for the Army Air Force Surgeon General during World War II he travelled the country given he was assigned to integrate the contemporary standards of surgical care of Army Air Force surgeons throughout the war. He was a leader among leaders at an early age on a much bigger stage than the young man from Hereford, Texas ever dreamed. Networking on the national stage was a forte he carried forward as he built the new state cancer hospital in Houston. In doing so, he changed the trajectory of both MD Anderson and cancer care throughout the nation.

We should stop for a moment and explore his impact on the national and international stage given he had a major leadership role in transforming cancer care and research through his positions as president of the American Cancer Society, founding president of the American Association of Cancer Institutes, as chairman of the Committee on Cancer (now Commission on Cancer), as co-chair of the advisory committee that led directly to the pivotal National Cancer Act in 1971, and as a member of the President’s three-person Cancer Panel. His efforts dramatically increased the National Cancer Institute’s (NCI) support for research, training, prevention, and building new cancer facilities, while improving the access and delivery of cancer care at the community level nationwide.

Today, 71 NCI-designated cancer centers are located all across the nation, and quality cancer care is geographically available to all. Comprehensive cancer centers like MD Anderson, manage the more uncommon and complicated cancer cases, conduct clinical and translational research that represents the future of cancer care, and train the next generation of cancer physicians. Because of Dr. Clark’s organizational ability to bring together the NCI-approved cancer centers and the cancer organization community, cancer research today has never been more robust and new cancer diagnostics and treatment are being delivered regularly. Doctors are abler to keep abreast of the rapid advances because of the continuing education programs for practicing cancer doctors and the availability of well-trained graduates of oncology and surgery fellowships. Cancer patients can have the confidence that their local accredited cancer center has been reviewed and approved by peers, and their outcomes of care at the community level have been reported.

The delivery of cancer care wasn’t always this good. If one looks back fifty years ago, cancer care delivery, research and teaching was at its infancy, and most cancer patients did not have access to multidisciplinary cancer management. There was a public fear that cancer was contagious, and the disease was so stigmatized that doctors often did not use the word “cancer” in reporting the diagnosis. Cancer patients had to travel long distances to get seen at MD Anderson in Houston, Memorial Hospital in New York City, or the Roswell Park Cancer Institute in Buffalo for these were the only NCI-designated cancer centers in America. Prior to

1971, the National Cancer Institute (established in 1937) was unable to support some of the worthiest cancer research projects. In fact, the NCI had to reduce its existing grants by 10-15% in order to fund new grants. Lung cancer was on the rise because of generations of chain smokers. Breast cancer screening was non-existent. Only one in two persons diagnosed with cancer survived at least five years.

Looking back on his career, Dr. Clark was a contributing member of the American College of Surgeons (ACS) for over 35 years, beginning in 1942. He was a leader on the organization’s Committee on Cancer (CoC), beginning in 1947, and had a major role in promoting tumor registries and end results reporting for cancer staging, in developing the Regionalization Cancer Program, and then leading the CoC in a pivotal reorganization that emerged as the Commission on Cancer in 1965.

It was back in September 1959, five years after he opened his new cancer hospital in the Texas Medical Center, that he was appointed as chair of the CoC. With his typical leadership style to improve the functions and value of organizations, he reorganized and revitalized the program over the next five years. Through his leadership the CoC developed more uniform standards of cancer registries, implemented the American Joint Committee on Cancer Staging and End Results Reporting (led by MD Anderson’s Dr. Murray Copeland), published a Manual for Cancer Programs (which defined minimum standards requisite for approval of a cancer service), established a new regionalization program (with liaison surgeons from each state), and planned all the cancer educational programs for the College’s annual clinical congress and sectional meetings.

Importantly, Clark led a 10-year strategic plan (called the “Program of the Sixties”) to expand and revitalize the scale and scope of CoC activities and to reorganize the organization’s

structure by including liaison members from other physician, oncologic, and hospital organizations. In October 1964, he formally recommended a reorganization of the CoC to the American College of Surgeon Board of Regents to assume an even greater role in the cancer community. In this way the name Committee on Cancer became the Commission on Cancer. Currently, more than 56 organizations are represented as members of the Commission on Cancer. These organizations include medical specialty societies, government agencies, patient advocacy and support groups, and others involved in the care of the cancer patient.

Probably the most impactful of all of Lee Clark’s national leadership roles was in 1970, when he served as co-chair of Advisory Committee to the United States Senate Labor and Public Welfare Committee. This resulted in Senate Resolution 376 “to make the conquest of cancer a national goal of the highest priority.” The committee’s report submitted on November 25, 1970 led directly to the enactment of the National Cancer Act of 1971 which created the environment and the funding for building a coordinated national cancer program with an annually updated five-year plan. The Cancer Act authorized the National Cancer Institute’s director to submit the budget directly to the President and for the President to directly appoint the director of the NCI.

Clark’s notable contributions as a member and the medical director of the President’s Cancer Panel included: his insistence upon the inclusion of the development of new comprehensive cancer centers; the development of the International Cancer Research Data Bank; and the establishment of programs for cooperation with state and other health agencies or the diagnosis, prevention, and treatment of cancer.

The Cancer Act of 1971 mandated the creation of fifteen new comprehensive cancer centers to join with the three existing comprehensive centers (MD Anderson, Memorial Sloan

Kettering, and Roswell Park). It also resulted in the International Cancer Research Data Bank, accessible to all interested physicians and scientists in the world.

Other major accomplishments of the National Cancer Act included:

• More cancer-related research funding than at any other time in the history of mankind
• Creation of a cancer control program at the NCI
• Creation of a multidisciplinary Organ Site Task Force
• Creation of the International Cancer Research Data Bank
• Creation of a national Clearinghouse on Environmental Carcinogens

Dr Andrew C. von Eschenbach, former chair of urology at MD Anderson Cancer Center and director of the NCI (2002-2006) reflected that “The National Cancer Act is one of the most transformational pieces of legislation to occur in the 20th century… Beyond the focus and resources, it provided to the NCI, the legislation changed the way we were approaching our ability to understand and manage disease.”

Clark continued to be an advisor at the national level, reporting directly to the President on barriers to progress in reducing the burden of cancer. His two-year appointment to President Nixon’s Cancer Panel was followed by a second three-year term in 1974 under President Ford and a third term in 1977 under President Carter.

Once this National Cancer Act was implemented, Dr Clark organized the directors of the new comprehensive cancer centers into the American Association of Cancer Institutes (AACI) so they could better collaborate together. Clark served the AACI as its first president, 1972-1977. What began with only three members (MD Anderson, Memorial Sloan Kettering, and Roswell Park), expanded to fifteen by 1976 and today has 103 members. AACI promotes research programs, networking and collaboration among its members, and promotes national policy involving cancer management, research, education, and prevention.

Additionally, Lee Clark served the American Cancer Society (ACS) on sixteen separate committees over three decades from 1946 to 1976, the year he served as national president. He proposed the Expeditor Program, whereby the 2.3 million ACS volunteers were urged to donate blood to address a national shortage of blood products for cancer treatments. He promoted breast cancer screening through the ACS/NCI Breast Cancer Detection Demonstration Project and its 27 participation sites. In its third year, that national effort screened more than 280,000 women and detected over 2,500 breast cancers. Although Dr Clark had major heart surgery during the year he was ACS president, he still managed to travel approximately 57,000 air miles for the organization.

Truly, it can be said that Dr R. Lee Clark played a major role throughout his career transforming cancer care delivery, cancer research and training at the national level in ways that benefit the lives of every cancer patient today. While he is most often remembered for his accomplishments building MD Anderson itself, we should never forget his national vision and tireless work over many years to expand the nation’s capacity for cancer care in ways that continue to benefit cancer patients worldwide. One can summarize with confidence that his transformative efforts at the national level supported over the years by the talented faculty and staff of MD Anderson Cancer Center rapidly elevated the institution’s status from a small Houston-based cancer hospital with temporary quarters and surplus army barracks to the bright star and international trendsetter MD Anderson is today.

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