Concerns Raised Over Need for Cancer Research Center

The already-crowded cancer research and treatment field in San Diego is getting another entrant, a private experimental treatment center that many in the existing research community see as unnecessary.

Immunologist Dr. Ivor Royston labels his plans for the new San Diego Regional Cancer Center as an opportunity for San Diegans to get better access to promising new cancer treatments.

“There are in San Diego many individual groups and organizations that do very excellent basic science research and very good clinical care in oncology,” Royston said. “But these activities are not well coordinated, and not brought together in the way that I would like to see it happen for a city like San Diego.”

But he also acknowledges what his critics hint: that leaving UC San Diego after 13 years is in part a way to deal with his frustration at being unable to influence the course of planning for the Gildred Cancer Center at UCSD.

“I don’t have any sour grapes about the academic side of things,” Royston said. “But I like to feel more in control of what’s happening, rather than just be passive. I guess I am interested in having a little more authority. I have a certain vision that I’d like to achieve, and I don’t think I can do that within the university.”

The cancer research program Royston and a group of local physicians have put together will focus on potential cancer treatments that are already being explored in San Diego: gene therapy, biological response modifiers such as interferon, and the field in which Royston has pioneered, monoclonal antibodies.

Still, Royston’s critics are being careful about what they say. If anyone can make an idea succeed, they reason, it is Royston--who became one of biotechnology’s first scientist-millionaires after co-founding Hybritech in 1978.

Royston emphasizes that the San Diego Regional Cancer Center will be nonprofit and aimed solely at getting promising new treatments to patients, but even friends and acquaintances are acting as though it were otherwise.

“They keep asking me, ‘How do I buy into this?’ ” Royston said. San Diego-based Hybritech sold to Eli Lilly Co. for $480 million in 1986.

Although Royston won’t directly criticize anyone, the very idea for a Regional Cancer Center calls into question how good a job he thinks these institutions have done at bringing frontier treatments to San Diegans.

Royston and colleagues even hint that federal officials are eager to bless their new cancer center with money as well as eventual designation as San Diego’s premier center for experimental cancer treatments, over expected competitors UCSD and Scripps Clinic.

In the immediate geographical vicinity of Royston’s new clinic are the Salk Institute and La Jolla Cancer Research Foundation, which do basic research on cancer; Scripps Clinic, which does both basic research and experimental treatments, and the clinically oriented Stevens Cancer Center at Scripps Memorial Hospital-La Jolla.

UCSD also will be expanding its cancer center with 29 beds at the new Thornton Hospital, being built east of Interstate 5 near Scripps Memorial, and an outpatient facility next door. The center itself will stay in Hillcrest, however.

In addition, San Diego County also has many established cancer treatment programs affiliated with community hospitals.

Officials at these institutions carefully phrase their reactions to the Royston plan.

A spokesman for Dr. John Trombold, medical director of the Stevens Cancer Center at Scripps Memorial Hospitals, said Trombold considers commenting “not appropriate.”

Dr. Lawrence Piro, director of the cancer center at Scripps Clinic, was definitive: “I don’t think there’s anything that Royston could do that we can’t do.”

At UCSD, Medical Dean Dr. Gerard N. Burrow notes that the university has known of Royston’s desire to go out on his own for the last year. They had originally discussed the possibility of setting up the private cancer center next door to Thornton Hospital, but delays in planning frustrated Royston, Burrow said.

And Royston’s stated plan to eventually move the new center from basic research into broad clinical treatment of cancer has Burrow puzzled.

“At no time in our conversations did we ever have a conversation about a clinical program (at the new cancer center),” Burrow said. “I would unequivocally say that our cancer center has been offering and will continue to offer even in a greater way state-of-the-art cancer therapy.”

R. Douglas Armstrong, executive vice president of the La Jolla Cancer Research Foundation, suggested there is no need for another cancer center at all.

“Perhaps, there may already be in place existing clinical programs which could be the basis for accomplishing the same goals of the Regional Cancer Center,” Armstrong said.

For their part, Royston and colleagues express confidence that their program will prove worthwhile to San Diegans.

As models, they point to the Fred Hutchison Cancer Research Center in Seattle and the Dana-Farber Cancer Institute in Boston. These are among the few federally designated “comprehensive cancer centers” not operated by a university.

Cancer centers can perform a variety of functions. Among the typical models are:

Facilities at community hospitals, which are mainly treatment programs. If any experimental therapies are used there, it is under the auspices of projects run out of research programs headquartered elsewhere.

Federal basic research centers, funded by the federal government to look at cellular and molecular aspects of cancer. Salk, La Jolla Cancer Research Foundation and UCSD all have this designation. Scripps Clinic also does a large amount of basic research applicable to cancer.

Federal clinical research centers, where promising new drugs and other therapies are tested. One of these is at UCSD. Scripps Clinic also does clinical trials of cancer drugs, but without the federal designation.

Comprehensive cancer centers, the designation that is held by 24 of the premier cancer treatment centers in the nation. These centers must have strong programs in basic research, clinical trial of new therapies, transfer of technology to community oncologists, and cancer education programs. It is this status that Scripps Clinic and UCSD both already plan to seek, and which the Royston group also is eventually eyeing. Currently, the closest comprehensive center to San Diego is at UCLA.

But the private cancer centers that have achieved this status were founded during the heyday of federal funding of medical research and construction.

“It’s harder to get money today than it was in the ‘70s,” said Dr. Emil Frei III, physician in chief at Dana-Farber. “Twenty years ago there was money for construction, there was money for all kinds of things. Now money is much more limited.”

Under the Royston group’s plan, on Nov. 1 Royston will leave his position as head of clinical immunology at UCSD and become scientific director of the new cancer center. He will remain an unsalaried professor at UCSD.

The trustees of the new cancer center already have decided that the work will concentrate on three frontier areas in cancer treatment: Royston’s main field of using monoclonal antibodies as “magic bullets” against cancer cells; biological response modifiers such as interleukins, to boost the body’s immune system, and gene therapy in which cancer-suppressing genes are inserted into people.

All are extremely complicated areas, each of which can preoccupy several research labs by itself. Yet organizers say the center will not only do basic research but also function as a clearinghouse for oncologists to find new treatment options and for San Diego’s 90 biotechnology companies to find patients willing to try their new drugs.

Royston sees himself as a unique bridge between basic research and the biotechnology industry. “There just aren’t that many bridging scientists that can grasp concepts, move quickly to develop new clinical treatments, work with the basic scientists and so on. The only other institutions that can do that are the university and Scripps Clinic, but there’s just a limited number of people,” he said.

Initially, the work will largely be funded by about $600,000 a year in federal research grants that Royston said he and other scientists will bring with them to the new center.

The rest of the $900,000 to $1 million budget is being donated by the trustees themselves, and other private funding also will be sought, Royston said.

Other trustees of the new center are its chairman, oncologist Dr. Thomas A. Shiftan; surgeon Dr. Allan H. Goodman; Sidney Green, a founder of the La Jolla Cancer Research Foundation; oncologist Dr. Christine White, and oncologist Dr. Robert Barone.

The organizers say they are looking to unify, not divide, the oncology community.

“In the bread and butter, everyday cancer, the treatment (in San Diego) is superb,” Goodman said. “What’s needed is something to draw it all together, and I think that’s the goal this cancer center has. It’s the tragedy of medical care--that fractionation develops and nobody puts the pieces together.”

Trustees chairman Shiftan, himself a private-practice oncologist, said the regional cancer center would help physicians help their patients.

“The patients would be treated in the same place by the same people, but there would be a more coordinated effort to bring them better treatments, newer drugs, and make drugs more available that are perhaps difficult to get today,” Shiftan said.

But the fact that the new cancer center eventually may have its own facilities for treating patients still is a sensitive issue. Both of the San Diego center’s model programs--Fred Hutchison and Dana-Farber--use community or university hospitals for their patients. But Hutchison has sparked controversy in Seattle with a proposal to build its own hospital within the next few years.

Royston says that a hospital isn’t in the San Diego Regional Cancer Center’s near future, although smaller clinical facilities at the center’s La Jolla location might be.

“We’ve got plenty of good hospitals,” Royston said. “We’re not going to build hospitals. We’re going to build ideas.”

“I’m not gonna say we’re never going to build a hospital,” Royston added. “What I am saying though, is that San Diego has an overabundance of good hospitals. What we’re going to do is work with the existing hospitals.”

At least initially, Royston hopes to contract to conduct his clinical research on patients at UCSD.

Royston also is very careful to avoid criticizing UCSD’s cancer efforts.

“I’m interested in being part of an organization where the only priority is cancer research and improved therapy,” he said.

“I think there are things that UCSD will continue to do very well. It has its own strengths, but there are other things that can be done better through an independent organization,” he said. “What I think can be improved are programs that bridge the laboratory and the clinic.”

But Roystan stammered through an explanation of what UCSD’s relative strengths and weaknesses are: “It’s very good in basic research, it’s very good in training students, but . . . umm . . . but I just think that--I have to be very careful . . . It’s very difficult.”

He tried again: “The university’s strongest suit is doing lab research and providing . . . it’s very difficult to . . . uh . . . what I don’t want to do is really talk about the university.”

Dr. William Stanton, a community oncologist, expressed puzzlement at the assumption behind the new cancer center’s founding that novel cancer therapies are not easily available through UCSD. Scripps Clinic doctors also seek patients from the community for novel cancer therapies.

“From the standpoint of my practice, I think the UCSD Cancer Center has done a magnificent job of technology transfer and bringing state-of-the-art therapy to San Diego,” Stanton said. “It’s just a simple matter of picking up the telephone (to gain access for patients).”

Most of the oncologists in the county have had some connection with UCSD in the past, so they know how to do this, Stanton said.

Goodman, whose 20-year-old son died of leukemia about a year ago, used the case as an example of why he believes better cancer programs are needed in San Diego.

Among other special procedures, the young man needed an unmatched bone marrow transplant, which requires treatment of the marrow to avoid rejection, Goodman said. He was treated at Stanford University and at the Fred Hutchison center in Seattle.

“There wasn’t anybody I spoke to, not one person--and I talked to a lot of people at the National Cancer Institute and to everybody I could find in San Diego--and not one person even suggested that it would be something to do in San Diego,” Goodman said.

“I began to realize as a physician practicing that there really was something missing in San Diego,” Goodman said. “My son particularly felt bad about leaving the city. You have to go through that experience with a sick family member--to pack up and leave, even if it’s just to Los Angeles, is a tremendous hardship.”

Both Scripps Clinic and UCSD have bone marrow programs, but they are not as advanced as Seattle’s. However, both facilities also are in the middle of efforts to expand and strengthen their cancer centers.

It is neither realistic nor cost-effective for the most high-tech cancer treatments to be available in every major city, Stanton contended.

“There are always going to be technologies which are going to be limited to a few institutions throughout the United States,” Stanton said. “And I think it would be extraordinarily costly for every community to duplicate every service. Our resources in health care are just too limited to do that.”

Dr. Bruce D. Cheson, chief of the medicine section of the cancer therapy evaluation unit at the National Cancer Institute, said regional affiliates of national oncology cooperatives are a common way to get more people involved in clinical trials of new therapies.

But those are programs, not independent research facilities, Cheson noted. He questioned the need for a private cancer center in a city that already has leading research and treatment centers.

“It’s more than economic resources,” Cheson said. “There are intellectual resources and there are patient numbers. To have more and more independent shops being set up is a tragedy.”

Aware of such criticisms, organizers of the San Diego Regional Cancer Center are meeting with officials of other programs to reassure them and to set up cooperative efforts.

They stress that the goal is to help patients through cooperation.

“I’ve come to the opinion that the best way to further cancer research and treatment is to come at it through an independent type of organization that is unencumbered by other kinds of priorities that exist at other institutions,” Royston said.

“The best of all possible worlds is to have an independent cancer center that works with UCSD and other institutions to develop a much greater cancer center than would be possible from any institution alone,” he added. “If we all work together, we’ll have the very best cancer center in the United States.”