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Implementing ASCO’s Strategic Plan 2003: Diverse Membership Needs, Prevention, and Patient Partnerships

From the University of Colorado Cancer Center, Denver, CO.

Address reprint requests to Paul A. Bunn Jr, MD, University of Colorado Anschutz Centers for Advanced Medicine, 4200 E 9th Ave, Box B 188, Denver, CO 80262; e-mail: paul.bunn{at}uchsc.edu.

FIRST OF all, thank you for the incomparable opportunity to serve as your president this past year. As I am sure my predecessors will agree, the year flies by so quickly that it seems as though it has just begun, when, in fact, it is finished. Though the time in office seems brief, I am pleased about the many accomplishments of ASCO that will help reduce the cancer burden for our patients, who really are the central focus of our profession.

An ASCO president is confronted with an unbelievable array of issues. Guided by our strategic plan and personal experience, I would like to highlight some of our most important achievements of this past year.

ASCO is strong, diverse, respected, and growing. Membership continues to grow at an impressive rate, adding about 450 new members each quarter so that our total membership now exceeds 20,000 individuals. While the majority of members are American, ASCO is becoming increasingly international, with about a third of the new members coming from outside the United States (Fig 1).

View larger version (54K): [in this window] [in a new window]   Fig 1. ASCO membership (N = 20,196) by region.

View larger version (143K): [in this window] [in a new window]   Fig 2. ASCO membership by oncology specialty.

I am especially pleased that we were able to fund 49 Young Investigator and Career Development Awards this year, and a record number of Training Awards. The number of applications for these awards has more than doubled in the past year.

The financial status of our Society is sound. Last year, the total operating budget exceeded $45 million, and our long record of operating in the black continued. This year, both the projected revenues and projected income exceed those of last year.

ASCO now has over 145 staff personnel at its Alexandria, Virginia headquarters. Most importantly, The ASCO Foundation, under Larry Norton’s leadership, has increased both the amount and diversity of funds raised. Funds from The Foundation are critical for our training grants, our patient and public awareness efforts, our Web services, and many other initiatives.

I would like to focus on our Society’s mission of improving cancer care and prevention. The cancer patient lies at the heart of this mission. I want to highlight ASCO’s accomplishments by focusing on two areas of particular importance to me: honoring people with cancer, and tobacco control. These two topics were the themes of this year’s meeting.

The central nature of the cancer patient was recognized at the first ASCO Meeting (1964) in Chicago 39 years ago when A. Goudsmit, MD, one of ASCO’s founders, noted "the single most important factor behind our first meeting is our common concern for the patient with cancer — the overriding conviction that more can and, hence, should be done for the majority of cancer patients... ."

In support of this idea, I am proud we have dedicated the theme of the 2003 Meeting to be "Commitment Care Compassion Honoring People with Cancer." In addition, our award-winning patient Web site, People Living with Cancer, has received a record number of visits. I anticipate this Web site will only increase in size and value in future years.

I am also proud of our increasing partnerships with the patient advocacy organizations. These partnerships have allowed us to fund an increasing number and diversity of grants and have helped us advance many of our quality cancer care initiatives. For example, the support of the Susan G. Koman Breast Cancer Foundation has helped our national initiative on cancer care quality, or NICCQ, begun by Dr Joseph Bailes. The initial results from this landmark study were presented at this Meeting. We completed our prevention survey in partnership with the Cancer Research and Prevention Foundation (CRPF). Our partnerships with the National Coalition of Cancer Survivorship (NCCS) and Friends of Cancer Research have helped with our legislative advocacy efforts to pursue quality cancer care.

Since we have decided this is the year to honor patients with cancer, I want to extend my own personal appreciation to Ellen Stovall, of NCCS, and the many other patient advocates who assist us in our work.

Cancer prevention has always been a major element of the ASCO mission. To meet the increasing importance of prevention, we created a new Prevention Standing Committee. One of the first actions of this committee was to undertake a survey of current prevention practices of US physicians and patient attitudes, again, done in collaboration with the Cancer Research and Prevention Foundation. The initial results of this survey were presented at this Meeting. Of course, one of the most important prevention issues is that of tobacco control. The task force, chaired by Dr David Pfister, drafted bold revisions to our tobacco policy that the Board of Directors approved in May.

Personally, as a lung cancer specialist, I am sick and tired of watching cancer patients suffer and die from tobacco-induced cancer to satisfy the greed of tobacco companies. As an American, I am horrified that we are supporting this greed and fostering a death-inducing substance around the world. I am pleased that our 20,000 members agree. Our new international tobacco policy defines our ultimate goal: nothing less than a tobacco-free world.¹

This policy calls for the formation of an independent commission to develop a blueprint by which immediate reduction in tobacco use and eventual elimination become a reality. The commission’s plan must be comprehensive and it must include agricultural, regulatory, and trade issues, along with the legal issues of promotion and First Amendment Rights concerns. It must consider all the worldwide economic and social issues. This policy calls for increased tobacco taxes, expanded prevention programs, limitation on promotion, trade restrictions, and other measures. I trust that ASCO’s policy will inspire our governments to implement bold and definitive solutions to eliminate this true "weapon of mass destruction."

I chose to focus on international issues this year because a third of all of our new members are from non-US sites, and our strategic plan calls for us to meet all member needs. To understand national and regional society operations, I and other ASCO leaders met with the major societies at our Annual Meeting and undertook a trip around the world in June 2002 to meet with various organizations, such as Chinese Anti-Cancer Association (CACA) and Chinese Society of Clinical Oncology (CSCO) in China; Japanese Society of Clinical Oncology (JSCO) in Japan; International Union Against Cancer (UICC) in Norway; European Society for Medical Oncology (ESMO) in Nice, France; the Hong Kong International Cancer Conference; and the joint FECS/AACR/ASCO Workshop on Methods in Clinical Cancer Research in Switzerland.

We have created positions for representatives of these organizations on our International Affairs Committee. This committee has worked with the expanded International Affairs Department to accomplish many strategies. At this meeting, approved bylaw changes have created a second international seat on the Board of Directors. We have increased to 16 the number of international travel awards to the Annual Meeting. We have provided each awardee with a mentor and have made arrangements for each of these young oncologists from developing countries to visit one of our comprehensive cancer centers.

Medical oncology is a well-established specialty within the US and parts of Europe, but there are no established training programs in many parts of the world. We are working with our colleagues in ESMO to develop uniform training criteria for medical oncology certification. ESMO already has a great record for developing model guidelines for training certification in medical oncology for developing countries. The ASCO Board of Directors has approved funding for an international multidisciplinary management course. Our joint symposia with ESMO, the Federation of European Cancer Societies (FECS), and the Latin American Federation of Cancer Societies (FLASCA) will be expanded this fall when we hold a symposium in Argentina at the FLASCA meeting.

We jointly sponsored meetings with the International Association for the Study of Lung Cancer (IASLC) this year and are providing support for an expansion of the Fellows course in clinical trials to Australia with the Medical Oncology Group of Australia (MOGA).

As ASCO is guided by an unwavering commitment to our patients and their welfare, we are proud of our joint efforts to respond to those in the US Congress and the Federal Government, who would challenge and potentially undermine quality cancer care by imposing reimbursement cuts that would, indeed, threaten access to outpatient care as we know it.

Recent events highlight the perilous nature of the current situation. ASCO has long recognized the nature of the current system in distorting payments for both drugs and services. We cannot allow the Congress or Medicare to slash reimbursement for cancer drugs without a simultaneous correction for the serious underpayment for chemotherapy administration services and other essential outpatient services. ASCO has worked diligently with government officials to provide financial data on these outpatient services through our sponsored surveys.

We have worked with the Cancer Leadership Council and other advocacy groups to gather support for the Cancer Quality Care Preservation Act or HR-1622 recently introduced by Representative Charles Norwood (R-Georgia) and Representative Lois Capps (D-California). This bill proposes that chemotherapy drugs be reimbursed at their actual sales price (ASP) plus 20% rather than the current system of 95% of average wholesale price (AWP). In addition, the bill would establish payment codes for chemotherapy administration and for other outpatient services that reflect the actual cost of providing these critical services.

We are delighted that all important oncology organizations, ranging from proprietary groups to patient advocates, have rallied around this legislation. I am particularly pleased that so many members traveled to Washington, DC, on May 20, 2003, to meet with their own Congressional representatives. However, much more remains to be done, and it is up to our members to follow through on this initiative.

Oral chemotherapies are increasing in number and effectiveness. We must continue to work with our patient partners in Congress to support the Access to Cancer Therapies Act providing Medicare coverage for these new, oral anticancer drugs.

The increased size and diversity of ASCO has created the need to provide educational and research venues beyond the Annual Meeting and beyond our journal. This need is especially critical, as each disease-oriented group desires to have its own meetings and its own journal. The splintering off of multiple disease-oriented groups is a real threat to ASCO, if we do not provide services that our various members require.

To address these services, we have experimented with several new meetings and meeting types. These events included a second educational meeting on molecular oncology for the practicing oncologists held in Chicago in Fall 2002. We held the first nonannual meeting that was abstract-driven on molecular therapeutics with the academic oncologists in November 2002 in San Diego. We held the first joint workshop with the disease-oriented group and the IASLC in Mirabella, Spain. The proceedings from this workshop will be published as an ASCO/IASLC Lung Cancer supplement, and distributed with the Journal of Clinical Oncology to all ASCO members. Another joint meeting with the IASLC will be held in Brazil in 2004. In addition, we held the first interactive education program via satellite with the Clinical Oncology Society of Australia in November 2002.

Next year we plan for a major new disease-oriented meeting on gastrointestinal cancers, jointly sponsored by ASCO, the American Gastroenterological Association (AGA), the American Society for Therapeutic Radiology and Oncology (ASTRO), and the Society of Surgical Oncology (SSO). The meeting will take place in San Francisco on January 22 to 24, 2004. It will include both abstract and educational sessions.

Another new meeting is the "Best of ASCO Meeting" sponsored jointly with regional affiliates. While the Annual Meeting has more than 25,000 attendees, many member physicians are unable to attend, but want to be exposed to abstracts that might change their practice. This year the Program Committee identified abstracts that would most influence standard practice. These identified abstracts were developed into a Best of ASCO Curriculum and are available to state and regional affiliates to use in planning Best of ASCO Meetings. The northeast regional affiliates will sponsor the first such meeting in Boston in September 2003. If this format is successful, the program will be expanded to other parts of the country in 2004. It is anticipated that these meetings will have far greater balance than many post-ASCO meetings sponsored by industry.

Although the Journal of Clinical Oncology is the premier clinical oncology journal, our member surveys have indicated that multidisciplinary disease-oriented monographs and clinical reviews in molecular oncology were unmet needs of high priority. To address this issue, the Board of Directors and the Publications Committee have developed plans to expand the JCO beginning in January 2005 to include molecular oncology and clinical reviews. We are also adding supplements to the JCO. The first supplement was published in May on ovarian cancer. We will be publishing future ASCO Educational Books from the Annual Meeting in a suitable form, so the abstracts can be cited in the literature.

Clinical research has always been a cornerstone of our mission. However, recent events and world publicized scandals have brought increasing public scrutiny to clinical trials. To maintain the integrity of and public trust in the system, we developed a Conflict of Interest Policy.² This policy calls for disclosure of all financial arrangements and sets prohibitions for general conduct of clinical trials for principal investigators and others who might inappropriately influence clinical trial results. The Standing Ethics Committee was established to provide guidance on these and other ASCO issues.

The Board of Directors also adopted a policy statement on the oversight of clinical trials.³ It calls for establishing regional review boards to oversee national trials sponsored by both industry and government. ASCO has begun working with the National Cancer Institute (NCI) to determine how to best implement this policy.

The Clinical Trials Task Force recognized that a large number of patients are entered into trials through community practice, and a small minority of practices is responsible for recruiting the vast majority of these patients. To reward these important practices, Community Practice Clinical Investigator Awards were established and presented at this meeting for the first time (Fig 3).

View larger version (78K): [in this window] [in a new window]   Fig 3. ASCO Community Practice Clinical Investigator Awards recipients.

The Clinical Trials Task Force also recognized that many of the most important clinical trials have difficulty recruiting patients because of the complex nature of the trials. To facilitate accrual to such difficult trials, we instituted a new educational symposium at this meeting on high priority trials. ASCO has begun working with the NCI to develop a national clinical trial informatics system.

Finally, recognizing that rapid and rational United States Food and Drug Administration approval is the goal of new drug discovery, we established a partnership with the United States Food and Drug Administration to establish end points on a disease-by-disease basis for drug approvals. This joint effort of ASCO and the United States Food and Drug Administration includes advocates, industry, oncologists, and statisticians to consider end points for lung cancer trials, and next year will be expanded to include prostrate and colorectal cancer trials.

This year has been an amazingly educational one for me and it has been made extremely enjoyable by ASCO’s outstanding volunteers and staff. It has been a delight to work with ASCO’s full-time staff. They are amazingly efficient and unbelievably dedicated.

There is no way to pay sufficient credit to ASCO’s staff full directors (Fig 4). I began to understand their diligence when my cell phone went off on a Sunday morning when I was out snowmobiling with Dr Charles Balch, ASCO Executive Vice President. That day was the morning the New York Times article on the cancer concession broke.

View larger version (102K): [in this window] [in a new window]   Fig 4. ASCO staff full directors.

ASCO’s staff is the best and ASCO is respected because of their work. I think I will miss their phone calls and their e-mails and, I might even miss speaking with the media.

ASCO has an unbelievable Board of Directors (Fig 5). They are willing to debate issues and to think and act strategically. They never say "no" and they are always available for emergency executive phone calls. I will miss you all.

View larger version (94K): [in this window] [in a new window]   Fig 5. 2003 ASCO board of directors.

Final thoughts: any ASCO President has to wonder, "How did I get there?" "Did I do my job?" " Was it worth it?" " What was the cost?" As a famous educator once said, "Much of it I learned from my teachers, more from my patients, but from my students, most of all."

At Amherst College, my professors taught me to think. My fraternity brothers and coaches taught me about teamwork and compromise. Many medical school faculty members were well-versed in memorization, but the important ones taught me about the central role of the patient and how to communicate with patients. Richard Silver led me to the NCI. At University of California-San Francisco I learned how to be a physician and an internist. At the NCI, the great "gang of five," Dr De Vita, Dr Canellos, Dr Young, Dr Chabner, and Dr Schein, taught me about the importance of clinical trials. My cofellows taught me how to be a medical oncologist. My subsequent NCI colleagues taught me about lung cancer and translational research combining lab and bedside studies.

I have had the privilege of working at the University of Colorado Cancer Center since 1984. There is no finer faculty or staff anywhere. The many fellows that I have had the honor of working with at the NCI and in Colorado have kept me young, vigorous, and informed over these many years. Yes, it is worth it.

I continue to advise those in training that a career in clinical trials in an academic or a community setting will keep you young, vigorous, and enthusiastic.

Finally, my family. What can one say? My parents gave me my values. My family is my constant anchor and balance. Not only would the ASCO presidency not be possible without their support, it would not be fun. They have suffered from my lack of everyday support, and I pray that I can repay their love and affection over the years.

REFERENCES

1. American Society Of Clinical Oncology: American Society of Clinical Oncology policy statement update: Tobacco control—Reducing cancer incidence and saving lives. J Clin Oncol 21:2777–2786, 2003[Abstract/Free Full Text]

2. American Society Of Clinical Oncology: American Society of Clinical Oncology: Revised conflict of interest policy. J Clin Oncol 21:2394–2396, 2003[Free Full Text]

3. American Society Of Clinical Oncology: American Society of Clinical Oncology policy statement: Oversight of clinical research. J Clin Oncol 21:2377–2386, 2003[Abstract/Free Full Text]

Submitted September 30, 2003; accepted September 30, 2003.

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