2006 State of the Institution Address

September 21, 2006

• Patient Care
• Research
• Our People

The last 10 years have been a period of extraordinary growth and accomplishment for The University of Texas M. D. Anderson Cancer Center. This was made possible by a unified and collaborative effort to achieve goals which we set together, and which - by almost any measure - we have achieved. We are a very different place today than we were a decade ago. Larger, certainly, but more accomplished, as well.

Here are a few data showing the expansion of our activities during this period. The changes are truly phenomenal.

Most importantly, we have achieved and deserve the reputation for being the world leaders in cancer care and translational cancer research - applying science to improvements in the diagnosis, treatment and prevention of cancer. I share with you tremendous pride in this track record.

But this is not just about winning a leadership competition. It's about conquering the disease which today is the leading cause of death for Americans under the age of 85. It's about achieving a mission that will require additional decades of hard work. We at M. D. Anderson today stand on the shoulders of those who preceded us. We in turn have both the opportunity and the obligation to pass the torch to those who will follow us. To these past and future colleagues, and to the many thousands of patients who entrust their care and their lives to us, we owe our continued commitment to advance science and apply it to reducing death and suffering from cancer.

This academic year we will reach the midpoint of our Strategic Vision for 2005-2010, which is built upon the seven Goals we collectively embraced two years ago. Each operating unit and department at M. D. Anderson has been asked to select strategies and tactics for reaching these goals, along with metrics that measure success in achieving them. These are posted on our intranet so we can share best practices, and so our leaders can facilitate accomplishing strategies that affect multiple operating units, due to the collaborative and multidisciplinary way we operate. Soon everyone will be able to review what has been posted on our intranet, so we all can bring ideas to our own work group for consideration.

Nearly 10 years ago we wrote a statement of our Vision: we shall be the premier cancer center in the world, based on the excellence of our people, our research-driven patient care and our science. Today, I want to convey my assessment of what M. D. Anderson will need to become, in order to maintain our success in advancing this vision. My ideas have been shaped by the advice of many who share our passionate belief that M. D. Anderson is uniquely qualified for Making Cancer History®.

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Patient Care

Let's begin with the core competency for which we are best known, the excellence of our care for cancer patients.

The United States has reached a critical juncture in health care delivery. The nation must address problems that haunt us: excessive costs, administrative inefficiencies, non-uniform patient records and billing procedures, uneven delivery of accepted standards of care, prevalence of medical errors, and non-application of best practices for prevention. M. D. Anderson is one of a few national centers of thought and expertise that can lead the way to identifying solutions for many of these problems. We are doing this, and will continue to do so.

The decision to organize cancer patient care around the patient's medical condition rather than around the physician's practice specialty has turned out to be brilliant and prescient. Our Multidisciplinary Care Centers of Excellence are a reality today, but we can continue to improve quality and efficiency of care and reduce costs by better integrating our care delivery systems. In many of our Multidisciplinary Care Centers the integration of clinical and laboratory research lags behind the integration of patient care. And the incorporation of specialists from Diagnostic Imaging and from Pathology and Laboratory Medicine into our Care Centers needs to be accelerated.

It is useful to consider our clinical activities as a continuum that involves a cycle of cancer care: from the earliest phase, which is prevention and risk assessment; to the middle phase involving diagnostic evaluation and therapeutic intervention; and finally to rehabilitation and long term follow up of survivors. Ideally, this should be an integrated continuum of care. The same approaches to process improvement that have been so useful in our hospital and clinics can be applied throughout the entire cancer care cycle. The product we seek is the very best outcome for individuals who entrust their care to us, as they enter and progress through each step of the cancer care cycle. A weak link anywhere in the cycle reduces the patient's chances for the best result.

At M. D. Anderson we are heavily invested in being the very best at the middle portions of this cancer care cycle, which involve comprehensive diagnostic and staging evaluations and administration of the best therapeutic interventions to achieve cure, prolongation of life, or palliation. At the front end of the care cycle we should aspire to provide our patients with the very best prevention and genetic counseling and personalized risk assessment, as well as sophisticated screening for the earliest sign of the presence of malignancy. At the other end of the cancer care cycle, we should provide the very best rehabilitation (physical, mental, social and occupational), the best follow up for timely detection of recurrences of the original cancer or new primary cancers, and research to reduce or prevent the toxicities of our therapies.

Today exciting scientific opportunities for research in both prevention and survivorship are ready to be tapped. Collaborative and multidisciplinary needs will be even greater than in our clinical care centers. Increased participation of faculty in the Department of Behavioral Science will be critical, because the most effective way to reduce cancer risk today involves altering lifestyle - especially, avoiding tobacco and improving diet and nutrition. The programs of the Centers for Molecular Markers and Advanced Biomedical Imaging Research will be critical for both research and provision of clinical advice. The Division of Internal Medicine will play an increasing role, especially in the follow up of cancer survivors.

To act on these challenges, M. D. Anderson faculty and staff are developing proposals for a new Center of Excellence focusing on Personalized Risk Assessment and a new Cancer Survivorship Clinical Program - each of which will be multidisciplinary. These received priority endorsement from faculty leaders at our current round of Research Strategy Retreats, which began again this summer and will continue into the fall.

As we consider ways of providing the very best cancer care through a continuum that starts with prevention and risk assessment and ends with survivorship, a number of new opportunities and questions present themselves for our consideration. Many of the activities at the two ends of the cancer care cycle need not take place in our central M. D. Anderson buildings, focused as they are on active interventions, complex protocols, and advanced technology. We are considering placing clinics for risk assessment, cancer screening and survivorship at a site on the Mid-Campus. Alternatively, long term follow up of survivors can be provided by selected referring physicians or primary care physicians with whom we partner, and who are actively included in multidisciplinary care planning.

It may be advantageous to select partners for long term follow up of patients in a number of locations throughout Houston, Texas and the surrounding states from which the majority of our patients come. This could evolve into a model of care delivery where highly specialized services in risk assessment, diagnosis and initiation of treatment are provided at M. D. Anderson's centralized facilities, and partnering providers elsewhere (physicians or hospitals) are incorporated into the multidisciplinary team to complete less complex stages in therapy and provide long term follow up. Such a system would leverage our highly specialized on-site resources for stages in the patient care cycle for which our level of expertise is not available elsewhere. In this model, M. D. Anderson physicians must continue to provide oversight for the full spectrum of care throughout the cancer care cycle. Advanced information systems can facilitate such collaborations, by enabling easy long distance communication and data sharing.

We also might leverage our expertise by partnering with carefully selected M. D. Anderson affiliates in other countries. Until now, with one exception, our international efforts have aimed primarily at developing research and educational partnerships and sister institution agreements with important cancer centers around the world. If our mission is to eradicate cancer in Texas, the nation and the world, and our vision is to be the world's premier cancer center, we must expand our international activities to include patient service. True leadership in the cancer field will require affecting the lives of patients worldwide, both in their own country and by caring for more of them here.

The models for "M. D. Anderson Global" include providing our special expertise for building a cancer center that delivers outstanding care in another nation, or partnering with skilled physicians to jointly deliver care both here and with international providers throughout a patient's entire cancer care cycle. The fact that other academic medical centers with strong cancer programs are gearing up on the international front means that we need to move forward aggressively.

As we seek to provide the very best patient experience in every aspect of cancer care managed at M. D. Anderson, partnering with experts here in Houston can help in achieving this goal. For example, we decided that the best way to expand our psychiatry program will be to partner with the Menninger Clinic, which is affiliated with Baylor College of Medicine.

We definitely plan to increase our space for clinical care in one area, inpatient beds. We need more beds to accommodate the continuing increase in new patients that seek our services since the opening of the Mays Clinic. An 8-story addition on top of the Alkek hospital was approved by the Board of Regents and planning is already underway.

Every effort we are envisioning to improve and expand our delivery of care will require increased input from our Department of Information Services. Ideally, we should be able to collect all relevant information about each patient, and then disseminate it to different user groups with particular interests and needs. The information would include all of a patient's attributes and history relevant to his or her cancer, all records of diagnostic studies and procedures and therapeutic interventions, outcomes, costs of each event, research data, and more. This elaborate electronic medical record would enable better delivery of care to the patient on a day by day basis. And it would enable M. D. Anderson faculty to carry out hypothesis-driven investigation of ways to improve care delivery, to test new diagnostic markers, and to study new therapeutic interventions. And most importantly, data collected in this manner will enable us to understand costs in relation to outcomes for each step in the cancer care cycle - from start to finish. Information on patient care outcomes and their costs will become the key data we will use in the future to market the value of M. D. Anderson care. I can think of no single advance that will prove more beneficial or essential to our mission than the further development of our electronic record of medical care and clinical research.

A picture of the future M. D. Anderson emerges that is different from the way we looked a decade ago or even today. We can envision an opportunity to increase substantially the number of cancer patients we care for by entering into formal, integrated, collaborative partnerships with physicians, clinics or hospitals, in the USA and abroad. This model is applicable to our adult, adolescent and pediatric patients, and in some instances it is already being applied - for example in our radiation therapy community treatment centers.

It is difficult to envision ways of significantly expanding our impact on patient care activity without considering some of these collaborative options, because the threat of becoming too large and unwieldy an institution can not be treated lightly. I welcome further discussion on how to continue to increase our patient care activities through some combination of: improved efficiency and effectiveness in current facilities, adding new facilities and staffing, and partnering nationally and internationally in a collaborative care model that integrates non-M. D. Anderson physicians into our practices.

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Research

Now let's turn to the second leg of our vision, science.

We take great pride in the fact that our patient care is research-driven and evidence-based. By this we mean that selection of diagnostic tests and therapeutic interventions for each patient is based, as far as is possible, on the results of research at M. D. Anderson and elsewhere. It also means that we are leading the world in experimenting with new diagnostics and treatments for cancer that improve efficacy and reduce risks of side effects.

How an institution nurtures an environment to achieve these approaches to cancer care is not a simple process. It involves a research commitment shared by all faculty and leadership. And it requires an atmosphere of respect and true collegiality between scientists and clinical investigators that is unique to M. D. Anderson. Holding 10 SPORE grants from the NCI documents our success at collaboration. Another measure of success is the nearly two dozen new therapeutic agents created by scientists at M. D. Anderson which have entered, or are about to enter, into clinical trials.

The scope of our research is broad. It includes for example, research on inherited risk factors for nicotine addiction, identification of genetically-driven malfunctions in critical signaling pathways, molecular explanations for site specificity of metastasis, genetic regulation of development in multiple biological systems, mechanisms of controlling gene transcription, creation of vaccines against a number of cancers, research on optimal clinical trial design, and 10,000 registrations of patients annually on therapeutic clinical trials, just to name a few.

"Multidisciplinary" has become the theme of our research, in parallel with its critical role in our patient care. The best example is the new McCombs Institute for the Early Detection and Treatment of Cancer, which grew out of faculty deliberations during a series of Research Strategy Retreats in 2002. The Institute is comprised of six Centers of Excellence selected for development four years ago by faculty leaders, based on three criteria: skills and expertise present at M. D. Anderson, availability of new enabling scientific discoveries and advances in technology, and importance to our mission of reducing death and suffering from cancer. Each Center of Excellence has an outstanding leader and an anchor research department, plus faculty from other departments who share an interest in and commitment to the focused research theme of the Center. Each Center has specialized shared equipment and resources. And each has a goal of bringing the fruits of collaborative science to the clinic. Four of the facilities housing these Centers are now standing, and we plan to break ground for the final two during the next 12 months.

Our recent discussions at the Research Strategy Retreats have brought out a difference in emphasis, compared with four years ago. The faculty leadership advises that we focus on excellence in our existing programs and build on our strengths, with reduced emphasis on constructing large new facilities. Resources should be directed to strengthening research programs that have proven their merit or are critical to our mission, by funding key recruitments, purchasing essential equipment and instrumentation, and supporting innovative start-up projects, infrastructure, and core laboratory facilities. We will take on a new area of research or expand existing areas, only if they are felt to be critical to our mission, and only if we are willing to provide adequate support to achieve nationally-recognized status. I believe this is very wise advice.

The other major theme coming out of deliberations at the retreats is the need for research to be even more multidisciplinary and collaborative. This is especially true, for example, in the areas of computer science, bioinformatics, computational biology and molecular modeling. This can be achieved partly by recruiting new faculty and nurturing current members of the faculty, and partly by increasing extramural collaborations with scientists in these disciplines at Rice and other universities.

Of course there is always going to be a central role for research conducted by a single investigator working in his or her own laboratory. This is the backbone of scientific discovery. But today more than ever, the opportunity to ask sophisticated and complicated research questions that apply current knowledge and technology to clinical problems requires collaboration.

We are considering a plan in which Centers of Excellence and research departments will be grouped into Institutes with broad research themes (shown in tan) that cluster around our cancer care cycle (shown in blue). In addition to the McCombs Institute for the Early Detection and Treatment of Cancer (translational research), we are discussing creation of Institutes for Cancer Prevention and Risk Assessment (population research), Personalized Cancer Therapy (clinical research), and Basic Cancer Research which feeds into each of them. And we will expand our Institute for Healthcare Excellence (including survivorship research).

This model builds on the success of the McCombs Institute for the Early Detection and Treatment of Cancer and the six Centers of Excellence it contains. Our plans for these five Institutes and for the Centers, Departments and Programs which each will contain are the topics for discussion at our Research Strategy Retreats. We are taking into account the value and success of our current departmental organizational structure, but we also must take into account the convergence of faculty interests on common research themes and the increasing needs for infrastructure and specialized equipment which cross departmental lines. If Centers of focused research excellence are to succeed, we also need to consider ways that their leaders will be empowered and have access to institutional resources.

When the current Research Strategy Retreats are completed (a month from now), we will circulate a draft plan for wide discussion and comment. In parallel we will need to update our capital plan, consider how to meet space requirements and set attainable goals for philanthropy over the next seven years. The result of blending these deliberations will be a six-year research plan starting in 2007, similar in scope and cost to the plan begun in 2002.

Let me give you a quick overview of current thinking.

The largest research investment will be in clinical investigation activities, grouped together in a virtual Institute for Personalized Cancer Therapy. More than $150 million in our six year philanthropy plan will be targeted to supporting innovative clinical trials and our Phase I trial program, providing the needed administrative and laboratory-based infrastructure, funding our Clinical and Translational Research Center, supporting intramural research that brings new drugs and biological agents discovered here to the clinic, and fostering collaborative research and integrating clinical data with tissue banks in our Multidisciplinary Care Centers.

The McCombs Institute will be expanded to include an innovative seventh Center for Systems and Computational Biology, and additional infrastructure support will be provided for the existing six Centers.

The Institute for Cancer Prevention and Risk Assessment which is under consideration will draw together activities in the Division of Cancer Prevention and Population Sciences, the Clinical Divisions, and the new Division of Quantitative Sciences. It will carry out research and provide personalized genetic counseling, risk assessment and cancer screening with the most sophisticated laboratory and clinical methodologies available, within a new Center for Personalized Risk Assessment. Collaboration with the Centers for Molecular Markers and Advanced Biomedical Imaging Research will be critical. And the Center for Targeted Therapy will contribute to clinical trials of chemopreventive agents for patients identified as having a high risk of cancer.

Discoveries in the basic sciences explain the genetic and environmental causes of cancer and the molecular mechanisms that produce the abnormal biological behaviors of cancer cells. We will place well deserved attention on expanding the excellent basic research programs at M. D. Anderson. Plans under discussion include recruitment of three nationally recognized investigators and creation of new Centers of Excellence focusing on Environmental and Molecular Carcinogenesis, Genetics and Epigenetics, Structure and Function of Biological Macromolecules, and Stem Cell Biology and Cellular Therapy. The programs in Cell Signaling will be expanded and integrated.

Our Institute for Healthcare Excellence, which up to now has been a clinical, hospital-based program that has focused on quality improvement and patient safety projects, will evolve into a unit carrying out research aimed at improved patient outcomes, publication of best practices, and competition for grant funding. We are considering including the new Cancer Survivorship Clinical Program, which will focus on outcomes research, risk assessment and prevention of sequellea of therapy. And it also may include our highly regarded Center for Research on Minority Health.

To accommodate growth in clinical and research activity, we are considering plans for building new moderate-sized facilities:

• A free-standing clinical and research facility, probably at a mid-campus location, for Pathology and Laboratory Medicine, including expanded facilities for our School of Health Sciences. This could grow into a clinical diagnostic center for new patient evaluation, an idea that will require further thought and discussion.
• A facility, also possibly on the mid-campus, to accommodate clinical activities and research in personalized risk assessment, genetic counseling and cancer screening, as well as a major portion of the clinical survivorship program.
• Increased laboratory research space on the South Campus equivalent to one additional facility.
• In addition, a number of ways of expanding laboratory research space on the main campus are under consideration.

We will seek funding for our research initiatives from a variety of sources. The efforts led by our Vice President for Translational Research to develop collaborative research projects funded by pharmaceutical companies are beginning to bring in new dollars for research. We are leveraging institutional funds through collaborations with industry and venture capitalists, as exemplified by the Proton Therapy Center which opened four months ago. Our Vice President for Technology Commercialization is expanding our sources of revenue from licensing and start-ups based on our intellectual property. The team led by our Vice President for Development has had another banner year, recording over $134 million in gifts, and we are developing plans to increase our fund raising efforts to sustain this level. And, in spite of federal budget cuts, our faculty continues to bring in increasing federal dollars and the largest amounts of grant and contract support from the NCI of any academic institution. We will continue to seek additional funds from the State and UT System. Of course, patient care revenues and our operating margins provide the largest share of the funding we need.

Let me sum up some of the ideas I have presented:

1. We have considered the value of organizing research at M. D. Anderson into Departments, which have a primary goal of discovering new knowledge and/or delivering research-driven care, and Centers, which have a collaborative goal of targeting a particular clinical or scientific problem. Both approaches are needed to fulfill our mission.
2. Centers of Excellence typically work well with a strong and talented leader and an anchor department, plus members from a number of other departments and programs that share in a targeted research focus.
3. Institutes group together Centers and departments that share a general theme and share in leadership. They serve to further collaboration and help in raising funds from philanthropy and granting agencies. We are considering three new institutes and expansion of two existing institutes, which, together, will address research priorities throughout the entire cancer care cycle. They would focus on:

• Basic Cancer Research: molecular causes and biological behavior of cancer. (new Institute for Basic Cancer Research)
• Translational Research: discovery and development of diagnostic tests and targeted therapies. (McCombs Institute for the Early Detection and Treatment of Cancer)
• Clinical Research: sophisticated clinical trials investigating new diagnostic tests and targeted therapies. (new Institute for Personalized Cancer Therapy)
• Population Research: leading to personalized risk assessment, counseling, screening and interventions. (new Institute for Cancer Prevention and Risk Assessment)
• Management of Care Delivery: improvements in the efficiency and efficacy (value) of cancer care delivery. (Institute for Healthcare Excellence)

I am fully aware of the potential complexity of this proposal and the risks of diluting authority and responsibility of the leaders in our current organizational structure - which could produce competition for resources rather than collaboration in research. This has not been a major problem with our Multidisciplinary Care Centers. I challenge us to consider this matrixed way of organizing our research. Just as it has in our clinics, I think that it will promote multidisciplinary investigation and provide greater chances for achieving the innovation and results we all seek.

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Our People

The third and final leg of our vision is the excellence of our people. Actually you come first, because without our employees and volunteers the rest could not happen.

As we all know, one of the goals in our Strategic Vision 2005-2010 is for M. D. Anderson to be an employer of choice for all who work here. We want each of our 16,000 employees to find M. D. Anderson to be a place that provides them with considerate and nurturing leadership, and opportunities to grow and advance their personal careers.

Our approaches to this goal are multiple and evolving. We were particularly challenged by the responses to our first employee opinion survey, which told us that some employees felt that their voices were not being heard by their supervisors. Feedback such as this suggests that our leaders need to focus their attention more actively on the needs of those they supervise.

We responded by establishing leadership training programs for faculty and senior administrators. These have been well subscribed and successful. This year we will be extending training to mid-level managers. The Executive Vice Presidents and I participate as instructors in these courses, and I personally have learned more than I have taught. For example, it was an obvious but critical insight to again be reminded that communication involves both telling and listening - and the more of the listening the better!

Another initiative that has been disseminated widely is "I Am M. D. Anderson." This was the result of the deliberations of our Cultural Principles Working Group, which was charged with elaborating on our three core values to derive principles of conduct that promote respect, collegiality, teamwork and a helping attitude. These principles of conduct are listed in a short document entitled "Our Values Guide our Actions," which I trust you all have seen.

We are incorporating assessments of how well we live by and act on our values in the yearly performance evaluations that all employees have with their supervisors and that supervisors have with theirs. In my opinion M. D. Anderson employees work in accordance with the institution's values far better than in other comparable academic medical centers. But we aspire to be as good as the best can be, which means that self-evaluation and continued attention to improving the work environment will always be important for us.

Our expanded Ombuds Program, which provides confidential advice and skilled mediation services for all employees, is currently being consulted at a rate of one employee per day. I am pleased to report that the results have been satisfactory resolution of misunderstandings and potential conflicts in nearly all cases. We also are designing mentoring programs to help employees advance their positions and increase their contributions to our mission.

The challenge of treating everyone respectfully and supportively leads directly into the challenge of our diversity. Our employees, volunteers and patients are representative of the peoples of the world. Our Office of Institutional Diversity is helping us to better understand how differences in opportunity and mentoring occur as a result of differences in people's ethnicity, gender and cultural background. The true test of our success will be data demonstrating, for example, equal opportunities for mobility and advancement within the organization, and equal chances of being selected for appointment to open positions.

The commitment of all of our employees to M. D. Anderson and their pride in our mission was "off the charts" in our employee opinion survey, when responses from our employees were compared to those from comparable institutions. Nowhere has this been more evident than in facing the unexpected $16 million revenue deficit that occurred in the months following hurricane Katrina's dislocation of New Orleans citizens into Houston and the reduction in our clinical activities caused by the threat of Hurricane Rita. We have more than made up this deficit in the last 8 months of FY 2006, due to increased activity in the delivery of clinical care, continued improvements in our billing and collections, a reduced rate of filling new positions, and increased grant funds and philanthropy. Everyone pitched in! I am proud and grateful. Thank you very much.

Of course our people include the thousands of students and trainees that we educate each year. These programs have grown in size and stature, and we will continue our commitment to training future leaders in the cancer field. Formal accreditation of our graduate training program by the Southern Association of Colleges and Schools is a goal we finally achieved!

I am told that our first president, Dr. R. Lee Clark's, approach to the future was the adage "Make no little plans." I am proud and pleased that M. D. Anderson continues to be characterized by bold plans and continual innovation. Based on where our research and patient care are heading today, we can say: "Make bold plans that embrace collaboration."

I look forward to exploring with you the ideas we are considering today. Once we have reached agreement and chart our course, I know that we can count on the support of the governor and Texas legislature, the Board of Regents and UT System, our Board of Visitors, and countless others who volunteer their services, their loyalty and their philanthropy. We also can count on an incredibly talented team of employees at every level of M. D. Anderson, who fully support achieving our mission. We must use our human, financial and physical resources prudently and creatively to accomplish what we want to achieve.

So, let's accept and embrace our opportunities, leverage our unique competencies and culture through teamwork and collaboration, and move forward Making Cancer History®.

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