On the Brink of Fulfillment, 1973-2010
by Henry K. Sharp, Ph.D.
*edited for online viewing, see book for full text
“The National Cancer Institute has not funded a cancer center anywhere in the nation for the last five years. And you are not going to be the first…”1 Robert Wagner, a ten-year veteran of the difficult path to found a cancer center, had directed the University of Virginia Medical Center’s cancer committee since 1973. Thus, the above exchange in 1985 with a representative of the federal agency charged with coordinating the nation’s anti-cancer efforts did not deter him from his goal. This was Wagner’s indispensable gift: a combination of persistence, ability to motivate others, and coalition-building which brings an idea to realization. The story of cancer care at UVa is one defined by individuals, such as Wagner, pressing forward to create a premiere program in cancer research and treatment.
Wagner knew that properly treating patients required centralized care and that superior treatment for patients was dependent upon a strong research program. Dean Thomas H. Hunter and Kenneth R. Crispell, who succeeded Hunter as dean of the medical school, recognized this earlier. Crispell recruited five top scholars, including Wagner, to lead the basic science departments of anatomy, biochemistry, pharmacology, physiology, and microbiology. The University continued to expand its focus on research. A new medical school building, named for former dean Harvey E. Jordan, opened with seven floors of basic science laboratories and classrooms. Superior scholars in their respective fields, like J. Thomas Parsons and his wife Sally Parsons, were recruited.
This improved grounding in research increased the stature of the University of Virginia medical program, and in turn gave greater strength and impetus to the cancer center movement. UVa’s Medical Center partnered with the Southwest Oncology Group, which coordinated clinical trials of new chemotherapeutic agents in patient cohorts extending across many different institutions. This relationship came about as a result of the work of pediatric oncologist William Thurman and hematologists Daniel Mohler and Munsey Wheby.2
Mohler had begun his career at UVa in the 1950s when mortality rates from hematologic malignancies were overwhelmingly discouraging and research was just beginning to intensify. The strides researchers made with chemotherapy in the 1970s, however, communicated the effectiveness and necessity of coordinated research and clinical trials. This context led Mohler to declare that, “It is a goal of the Medical Center to develop an integrated, multidisciplinary cancer program (Cancer Center) supported by the National Cancer Institute.”3 Only a few months later, in February and March of 1978, the General Assembly of Virginia passed legislation mandating creation of a cancer center at the University of Virginia.
Yet it was not until 1984 that the University’s medical leadership formally established the cancer center as a distinct unit within the medical center organization. Wagner became the first director of the center, assisted by hematologist Peter J. Quesenberry, surgeon M. C. Wilhelm, gynecological oncologist Peyton T. Taylor, and assistant administrator Christina T. Wilhelm.4
The cancer center was to establish a new model of patient care and community education at UVa. Wagner argued that, “Identity as a true Cancer Center requires highly visible research and educational programs that support the patient care and cancer prevention operations… They must be integrated into a cohesive whole.”5 Wagner also asserted that, “A true Cancer Center, worthy of the name, must have a separate geographical identity as well as being tied to the general patient care facilities of the Hospital and to the research and educational facilities of the medical school.”6
Wagner hired Thomas J. O’Leary as the research administrator and director of programs for the cancer center and together they organized a slate of cancer center programs and assembled a grant application for official NCI recognition of the UVa Cancer Center.7 In 1981, gynecological oncologist Peyton T. Taylor, Jr., had become director of a newly-launched ambulatory cancer care service at the University, a clinical facility that coordinated the new divisions of surgical and gynecological oncology with hematology-oncology. The clinicians in these specialties admitted in-patients to the University hospital as necessary and provided out-patient therapies in the clinic. This ambulatory cancer care clinic proved to be an obvious choice for the offices of O’Leary and the Cancer Center.
Some innovative programs owed their existence to the interest and energy of individual practitioners rather than to a fully coordinated University-wide plan. For example, since 1971, surgeon Milton T. Edgerton had guided the newly established Department of Plastic Surgery into the field of cancer patient rehabilitation. Working closely with G. Slaughter Fitz-Hugh, chair of the Department of Otolaryngology and Head and Neck Surgery, Edgerton established a protocol for the immediate reconstruction of head and neck cancer patients, making UVa one of the first programs in the nation to do so.8 Immediate reconstruction of the breast after a mastectomy for breast cancer also became a standard procedure at UVa.9
Harold Carron, a professor of anesthesiology, was operating a pain clinic by January 1971, one of only a few in the U.S. Since many of the clinic’s patients had cancer, Carron encouraged medical oncologist Gerald Goldstein to travel to Italy in the late 1970s to study the palliative care given cancer patients there. Upon his return, Goldstein developed a palliative care service.10 After a lapse of several years following Goldstein’s retirement, Willie A. Andersen renewed palliative care as an in-house hospice unit. The Palliative Care Program at UVa was established under the direction of Carlos F. Gomez. Leslie J. Blackhall has fully integrated this service into the basic care available to patients at the cancer center since she became director in 2002.When radiation oncologist James M. Larner arrived in 1989, he took over from department chair Theodore Keats the mission to modernize the therapies available.11 In pediatric oncology, Sharon L. Hostler worked with William Thurman to establish a national reputation for children’s cancer care at the University, particularly after organization of the Children’s Rehabilitation Center (CRC) in 1968. Under Hostler’s directorship in the 1970s, the CRC was one of the first pediatric centers in the nation to combine clinical oncology with rehabilitation of patients.12 From the early 1980s, pediatric surgeon Bradley M. Rodgers coordinated solid tumor treatments with the work of the pediatric oncologists, then directed by Hernan Sabio, and encouraged the extension of pediatric oncology specializations into almost all fields of care. Rodgers and his colleagues ultimately united pediatric clinical trials groups in the early 2000s.
Thus, despite the lack of a cancer center or fully integrated cancer care at UVa, the University hospital emerged as a leader in various arenas of cancer treatment due to the work of individual physicians. By 1984, however, as discussed earlier, there finally was an institutionally-approved and legislatively-mandated plan for a cancer center. The Cancer Center’s leadership—Wagner, Taylor, O’Leary, Wilhelm, and Quesenberry—began working to coordinate the disparate cancer programs existing at the hospital and medical school, and to promote new initiatives.
The genius of Wagner’s approach, according to Peyton Taylor, was the choice to pursue NCI designation based on the strengths of the University’s basic science program.13 In 1987, the NCI awarded a grant to the University of Virginia for the maximum period of three years. When Wagner and his team applied for a renewal grant, the NCI examiners insisted that the University engage more actively in the clinical operations of a cancer center as a complement to the basic sciences, which Wagner brought about, and the NCI affirmed the grant for another renewal period. In 1995, the NCI officially recognized the program as a “clinical cancer center,” a status only seventeen other centers in the nation shared at that time. The University’s Cancer Center has successfully retained the prestigious and financially critical NCI designation since 1987.14
Federal cancer center designation opened up a new era for cancer research and treatment at the University. According to Wagner, “The best part of the grant is that it designates us as a cancer research center. This qualifies us for other types of support, such as collaborative research grants and construction grants.”15
Research at the University hospital shifted to the establishment of new patient-centered models, known as ‘translational research’, which expedited the application of research discoveries in the lab to the bedside of the patient as quickly as possible, streamlining the delivery of care to provide more effective and comprehensive services for patients. A more sophisticated understanding of cancer at the genetic and molecular level was now becoming possible. Scientific and technological advances have combined to affect every modality of cancer therapy, opening up new possibilities for diagnosis and treatment. Of critical importance to these shifts in the last several decades is the evolution of cellular pathology and its interaction with the development of specialized radiological imaging.16
The changes in the nature of diagnosis have been striking. M.C. Wilhelm recalls how mammograms, or radiologic images, changed the diagnosis of breast cancer in the 1970s: Ellen de Paredes, the University hospital’s mammographer, would review a woman’s mammogram and contact Wilhelm in the operating room to inform him what region of the patient’s breast contained a suspect density.17 Wilhelm would then attempt to locate and excise the tissue and have the sample tested while the patient was still on the operating table. By the early 1980s a technique called ‘needle localization’ had been developed,18 and by the early 1990s, ‘fine needle aspiration’ took the concept of needle localization a step further. The precise pinpointing of possible cancers enabled the surgeon to find the tissue with greater speed and accuracy. Other techniques which combine diagnosis and surgery also gained popularity. In 1993 the new chair of the Department of Dermatology at UVa, Kenneth E. Greer, recognized the increasing incidence of skin cancers and immediately recruited Harry L. Parlette to create a division of Mohs surgery.
It has been in the field of imaging that diagnostics has made its greatest advances. In addition to mammography and ultrasound, four other imaging advances have greatly increased the ability of practitioners to locate and to define the positions of primary tumors and metastatic spread for biopsies and treatment: angiograms, computer tomography (CT or CAT scan), magnetic resonance imaging (MRI), and positron emission tomography (PET).
Technological advances on the therapeutic, as opposed to diagnostic, side of the equation have also engendered dramatic revisions in the kinds of procedures offered to cancer patients. In 1987, neurosurgeon John A. Jane, Sr., recruited Swedish neurosurgeon and researcher Ladislau E. Steiner, an inventor of the gamma knife, to work with UVa clinicians and scientists to install this equipment at the University hospital. The gamma knife is actually not a knife at all, but a machine which can project very highly concentrated beams of gamma rays onto a target. The gamma knife has come to have tremendous importance on the treatment of brain tumors and metastases.19 At UVa Steiner has continued to lead and to expand the application of this modality to the treatment of malignancies in various areas of the body.
Very recently, new mechanisms of robotic instrumentation have complemented the radiologic and surgical developments that accompanied the gamma knife. In 2003, UVa became one of the first medical schools in the country to offer training on the da Vinci Surgical System through the University’s Department of Urology—a specialty “always technique driven,” according to urologist Jay Y. Gillenwater. The machine constituted an impressive technological advance.20 The medical profession must be able to provide, and thus to educate, practitioners capable of using the new machines with proficiency. UVa has been at the forefront of the field. William D. Steers, chair of the Department of Urology since 1995, has developed a training program for resident accreditation and certification that is currently being instituted nationwide.
The development of flexible scopes with excellent optics and precise instruments has also brought major advancements in cancer diagnostics. Pathologist Stacey E. Mills states, “With such careful screening …” clinicians “can virtually assure that [a patient] will never get colon cancer.”21 Endoscopy is a vital component of treatment in many other fields. For example, thoracic surgeon Thomas Daniel relies upon bronchoscopy and mediastinoscopy, procedures that spare patients more difficult and invasive surgery. Endoscopic surgery is also a regular therapeutic modality in the hands of head and neck surgeons in close collaboration with neurosurgery for the excision of perinasal sinus tumors, according to neurosurgeon Jane and otolaryngologist Robert W. Cantrell.22
The surgical profession now recognizes that specialization results in an increasing level of skill and thus advancements in research and patient treatment. For example, surgeon R. Scott Jones specializes in operating on liver and pancreatic cancers, and says that specialized surgeries on metastases from these cancers—in addition to the primary sites—has brought five-year survival rates to patients where there were none before.23 Fellow surgeon John B. Hanks has operated extensively on thyroid cancers, and works closely with otolaryngologists, endocrinologists, pathologists, and genetic researchers, whose combined expertise has refined screening and surgical management of these cases.24
As advances in imaging, instrumentation, and specialization have changed surgical approaches to cancer, greater understanding of the disease at the molecular level has revolutionized clinical practice. UVa pathologist Mills has stood on the front lines as pathology has evolved from a purely diagnostic to a critical partner in cancer therapy.25 This partnership has become even more critical for, as hematologist-oncologist Michael E. Williams elaborates, “in the mid-1980s…only a handful of lymphomas were identified,” while today more than sixty are known.26 Testing at the molecular and cytogenetic, or cellular genetic, level makes possible targeted therapies, which have become increasingly critical to cancer care.
A longstanding research project at the University has proceeded since the early 1990s under the direction of surgical oncologist Craig L. Slingluff. In 1991, Slingluff began studying the immune response to melanoma and, in 1996, he initiated tests and clinical trials on a melanoma vaccine. The path thus far has been difficult. Slingluff contends that, “There is strong proof of principle for immunotherapy… But, the durable results are not what we’d like.”27 Clinical trials for vaccines against breast and ovarian cancer, as well as colon cancer, have been added to the protocols for melanoma, all coordinated by Slingluff, as director of the Human Immune Therapy Center.
Official designation as a cancer center has facilitated the expansion of a conceptual and physical structure through which diverse activities and discoveries have been integrated into a sophisticated and effective cancer research and treatment program at the University of Virginia. Of equal importance in the evolution of cancer therapy has been the recognition of the values and desires of cancer patients themselves—and their families and friends—in the therapeutic process. According to health educator Diane Cole, this change in mentality has shifted primary attention from treatment or cure of the specific malady to healing of the whole person.28
Exemplary of this development is the Department of Surgery’s Breast Resource Center, established by Wilhelm in 1988. At the Breast Resource Center, individuals such as Diane Cole not only counseled women about self-examination, diet, and exercise, but also offered lessons in the disease and its treatment. In response to growing popular interest, Cole organized a committee to explore the fields of alternative, complementary, and integrative care of the cancer patient which is now a standard service in the cancer center. In an important respect, Wilhelm and Cole’s Breast Resource Center served as a model for the kind of educational services which Wagner had envisioned on a larger scale for the Cancer Center itself.
Taylor and Wilhelm had taken the structural and organizational problem of a cancer center to heart and had worked with designers and patient focus groups to imagine and realize the kinds of spaces that an integrated, patient-centered cancer unit would offer. At the time, Taylor explained, “Rather than having patients going from one place to another to see doctors, we want to have a central patient treatment area and have the doctors come to them.”29 The new Cancer Center structure modeled on the Mayo Clinic’s patient care proved immensely popular with patients.30 In the new facility, natural light flooded the examination, chemotherapy infusion, and waiting rooms on the exterior of the clinic. The new spatial and organizational arrangement also more readily brought psychosocial and educational resources into the mix. Nurse coordinators were introduced and guided individuals through the array of services and specialists that made up this more holistic therapeutic regime.31
Robert Wagner stepped down from the overall directorship in 1991, remaining as associate director for basic sciences research until 1994. During his twenty years at UVa, Wagner had taken the Cancer Center from a failed idea to a fully-integrated, albeit not independent, facility. Charles E. Myers, Jr., took over leadership of the center and appointed another microbiologist, Michael J. Weber, to succeed Wagner as head of the basic science division. Weber, recruited to the University by Wagner, had been studying the processes of signal transduction. Weber stated, “If there’s going to be a quantum leap in cancer treatment, it has to be based on understanding the basic ‘look’ of cancer cells.”32 Microbiology was the key to progress in the cancer arena. Michael Weber became the new director of the Cancer Center in 1999 and guided it into the twenty-first century.
The concurrent shifts toward patient-centered clinical care and greater translational research were not the only factors motivating the integration of educational, support, and outreach services into the center’s cancer therapy regimes. Another major change was the reconceptualization of cancer as a chronic disease. Cancer patients at University Hospital now often face a long future of living with the disease. Learning the art of living with cancer becomes, for the patient, as significant as the science of treatment is for the practitioner. Furthermore, this “tapestry of care”—the phrase of social worker and former patient care services manager David Cattell-Gordon—extends not only to individual patients who enter the system, but also to the community at large. Alliances between the Cancer Center and local groups and individuals have developed. The Charlottesville Track Club sponsors the Women’s Four Miler with the Cancer Center. State Senator Emily Couric, a rising star in the Virginia political landscape, became a strong advocate for integrated patient care services when she entered the doors of the hospital as a cancer patient herself. As a peer and colleague of the men and women at the highest levels of University administration, Couric put a human face on the hope and pain that many individuals confront when diagnosed with cancer.
The Cancer Center model for integrative care has repeatedly demonstrated its worth to the community in positive patient experiences. It is a testament to the patients and to the effectiveness of the current Cancer Center that the Medical Center and University leaders have made the commitment which no other administration in the history of the institution has. The Emily Couric Clinical Cancer Center building, a state-of-the-art, free-standing, integrated cancer care facility, will be officially dedicated on Thomas Jefferson’s birthday in 2011. Completion of this long-sought facility will be an asset to the University, the community, and the cause of humane and effective medical care. “Institutions are often slow to realize what they have,” concluded microbiologist J. Thomas Parsons, “and I think it takes people like Bob Wagner and M. C. Wilhelm, who had the respect of the people, the leadership …. We all worry that in these days of competing resources and difficult times that we will forget why we are at the University of Virginia and why we’re actually doing this, which is to make sure that the next generation lives better than we did.”33
- Thomas O’Leary, interview by M.C. Wilhelm, video recording, 29 May 2008, UVa History of Cancer Care Project, Charlottesville, Va.; Michael Weber, interview by M.C. Wilhelm, video recording, 4 June 2008, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- Sharon L. Hostler, interview by M.C. Wilhelm, video recording, 8 October 2010, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- “Dean’s Page: Cancer,” UVa Medical AlumNews 4, no. 3 (Fall 1977): 8. [↩]
- “Wagner Named Head of Cancer Center,” Helix 2, no. 2 (Spring 1984): 20. [↩]
- Ibid. [↩]
- Ibid. [↩]
- University of Virginia Cancer Center, Cancer Center Annual Report, 1985-86 (Charlottesville, Va.: The Center, ), 1 and 11. [↩]
- “Dr. Milton Edgerton Heads New Department of Plastic Surgery,” Medical Alumni News 23, no. 2 (January-February 1971): 3; Robert W. Cantrell, interview by M.C. Wilhelm, video recording, 5 June 2008, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- Milton Edgerton, interview by M.C. Wilhelm, video recording, 8 December 2009, UVa History of Cancer Care Project, Charlottesville, Va. The procedure had initially met with resistance from members of the America College of Surgeons and its safety has continued to be a focus of continued study in the last decade. See, for example, Ana M. Fernández-Frías, José Aguilar, Juan A. Sánchez, Belén Merck, Antonio Piñero and Rafael Calpena, “Immediate Reconstruction after Mastectomy for Breast Cancer: Which Factors Affect Its Course and Final Outcome?” Journal of the American College of Surgeons, published online 31 October 2008. [↩]
- Gerald Goldstein, interview by M.C. Wilhelm, video recording, 8 May 2008, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- Theodore E. Keats, interview by M.C. Wilhelm, video recording, 28 January 2009, UVa History of Cancer Care Project, Charlottesville, Va.; James Larner, interview by M.C. Wilhelm, video recording, 29 May 2008, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- Hostler, interview. [↩]
- Peyton T. Taylor, Jr., conversation with Henry Sharp, 29 March 2010. [↩]
- Michael Weber, interview; Thomas O’Leary, interview; Peyton T. Taylor, Jr., conversation with Henry Sharp; “NCI Names UVa Clinical Cancer Center,” Helix 13, no. 2 (Winter 1995/1996): 32. [↩]
- “Cancer Center Gets $2 Million Grant,” The Draw Sheet 36, no. 10 (June 1987): 1. [↩]
- M.C. Wilhelm, conversation with Henry Sharp, 16 February 2010. [↩]
- Morton C. (M.C.) Wilhelm, interview by Thomas O’Leary, video recording, 12 June 2008, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- “UVA Bolsters Arsenal Against Cancer,” Helix 1, no.4 (Autumn 1983): 22. [↩]
- John A. Jane, Sr., interview; “Radiosurgery Targets Brain Tumors,” Oncologue 1, no. 1 (Winter 1987): 1. [↩]
- Why is the product called the da Vinci® Surgical System? Intuitive Surgical website: http://www.intuitivesurgical.com/products/faq/index.aspx, accessed 11 November 2010. [↩]
- Stacey E. Mills, interview by M.C. Wilhelm, video recording, 26 June 2008, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- “Laser Surgery, Powerful Force Destroys to Heal,” The Draw Sheet 37, no. 3 (February 1988), 4-5; Robert W. Cantrell, interview; John A. Jane, Sr., interview. [↩]
- R. Scott Jones, conversation with M.C. Wilhelm, 18 February 2008, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- John B. Hanks, “Evolution of the Clinical Experience of Thyroid Cancer at the University of Virginia, 1982-2002,” no page numbers, paper prepared for the Cancer Center project. [↩]
- Stacey E. Mills, interview. [↩]
- Michael E. Williams, interview by M.C. Wilhelm, video recording, 30 January 2009, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- Craig L. Slingluff, interview by M.C. Wilhelm, video recording, 26 June 2008, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- Diane D. Cole, interview by M.C. Wilhelm, video recording, 8 May 2008, UVa History of Cancer Care Project, Charlottesville, Va. [↩]
- “Cancer Center Grows,” Helix 12, no. 2 (Spring/Summer 1994): 28. [↩]
- “Cancer Center Streamlines Services,” Helix 13, no. 1 (Autumn 1995): 30. [↩]
- Peyton T. Taylor, Jr., interview; M.C. Wilhelm, interview; Diane D. Cole, interview; David Cattell-Gordon, interview. [↩]
- “Cancer Center Grows,” Helix 12, no. 2 (Spring/Summer 1994): 28. [↩]
- J. Thomas Parsons, interview by M.C. Wilhelm, video recording, 19 June 2008, UVa History of Cancer Care Project, Charlottesville, Va. [↩]