ROCKVILLE, Md--Last year, the National Cancer Institute established
the Office of Cancer Survivorship, and NCI director Richard D. Klausner,
MD, named Anna T. Meadows, MD, to head its efforts to explore issues of
the physical, psychological, and economic well being of cancer patients.
Dr. Meadows serves at NCI on a part-time basis while continuing as
director of the Division of Oncology and professor of pediatrics at the
University of Pennsylvania Medical School. She talked at her NCI office
with Oncology News Interna-tional's Washington Bureau Chief Patrick Young
about the goals and early progress of the new cancer survivorship program.
ONI: What is the purpose of the Office of Cancer Survivorship?
DR. MEADOWS: The idea is to focus on research that comes from
the scientific community and addresses the problems and issues that survivors
face. The reason is to be able to provide information to survivors and
to people who plan therapy. Cancer treatments should be based not just
on cure, remission, or survival, but on information about what happens
to survivors in the long-term.
ONI: Why is the NCI, which is essentially a medical research
institute, focusing on survivorship as an issue?
DR. MEADOWS: Survivors are what the whole thing is all about.
The purpose of medical research is to improve the lives of people, to reduce
the morbidity and mortality associated with cancer. If you find survivors
suffering untoward morbidity or dying five years after you thought they
would be cured because of something that occurred during their treatment,
you want to change the treatment.
You have to deal with cancer survivors in society, and if survivors
are going to require extraordinary rehabilitation and long-term medical
care resources, obviously you want to rethink how you treat their cancer
in the first place, and perhaps conduct the kind of research that is going
to help you identify better treatment alternatives.
ONI: What is the Office's annual budget?
DR. MEADOWS: We are going to spend about $2.5 million for this
fiscal year. I am hoping that for the next couple of years, we will have
at least $4 million a year.
ONI: What aspects of survivorship will the Office address?
DR. MEADOWS: The main problem that overrides every physiologic,
reproductive, and medical long-term effect of cancer and its treatment
is the way patients view what has happened to them and the quality of their
ONI: Will you direct research at these issues?
DR. MEADOWS: We've already sent out requests for proposals from
the scientific community. There hasn't been a major effort to look at survivors
in the long term. Many studies end in one or two years. So we expect to
find out more about what happens in the long-term.
One serious long-term side effect is second cancers--not a recurrence,
not a tumor in a paired organ, but a totally different kind of cancer.
Individuals get those second cancers not just because of their treatment,
but also because of some gene, or genes, that either makes them more sensitive
to the treatment or predisposes them to more than one cancer.
These occurrences are also important to the scientific community because
they can teach us about the genes that predispose to cancer and lead to
ONI: You held a meeting late last year to look at where the
office should go. Have you now set a direction for the near term?
DR. MEADOWS: There are many issues involved so we have enumerated
the type of things we want the scientific community to study. Some of those
have to do with physiological long-term effects (by which I mean 5, 10,
and 15 years). What are the effects on the heart, the kidney, and the brain
for the long-term after receiving certain treatments?
We are interested not just in the effects of single agents but also
in how drugs interact with radiation to the heart, and does that produce
congestive heart failure or pulmonary hypertension? What are the medical
long-term effects of those combinations, and what are the doses that are
safe in terms of what you can expect for the future of survivors?
We use a lot of platinum compounds and nobody has studied the long-term
effects of these drugs on the kidneys. Then there is the question of drugs
that impair sexual and reproductive function. And, of course, questions
concerning quality of life really pervade everything we study.
ONI: Do you have other research goals?
DR. MEADOWS: There are two more things I will mention. One, the
economic impact of following survivors is important. If we have many survivors
who are examined frequently for effects that occur extremely rarely, we
will not be using our resources wisely.
We don't know the best way to follow survivors. We don't know whether
it is important to do surveillance, laboratory studies, and scans, or whether
we just need to talk to patients to find out what problems they are experiencing.
So a big chunk of our health care system is devoted to following survivors.
The goal is to find the most efficient, most cost-effective way of doing
it and to get insurers to buy into it.
The last aspect has to do with intervention. What can you do to help
survivors while they are being treated and afterwards? How do you get those
individuals to comply with the recommended follow-up? How do you inform
them? Education is one thing, but getting people to do what you want them
to do, changing behavior and changing attitudes, is different from education.
ONI: How do you envision the program interacting with clinical
DR. MEADOWS: I expect that clinical oncologists are going to
be pushing to have this research so that they will have some information
on which to base their clinical decisions. I think the term "evidence-based
medicine" is so simple--to have evidence. And that's just the point
of this office. We need some evidence that will direct the physician at
all points in time of a cancer diagnosis.
We hope that the people interested in finding answers will develop research,
apply for funding, get the answers, write the papers, and disseminate the
We also hope to create agreements that will permit cooperative clinical
trials groups to track their patients in the long-term. Maybe that will
encourage more people to enroll in clinical trials and more physicians
to recommend clinical trials to their patients. But we also have to provide
the funds that will allow the clinical trial groups to keep track of what
happens to patients.
ONI: Does managed care pose any obstacles to these goals?
DR. MEADOWS: We have to educate managed care companies. If we
are more efficient in the way we treat patients because we produce fewer
long-term side effects, then people who take the long view are going to
be convinced that this is actually a cost-effective way to treat cancer
patients. And we hope that they will take the long view.