The Next Generation of Cancer Research and Prevention

CPRIT Funds Help Train Future Physicians and Attract Top Talent to Texas

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Cover Story — March 2015 

Tex Med. 2015;111(3):20-27.

By Kara Nuzback

Before David McClellan, MD, became an assistant professor with the family medicine residency program at Texas A&M Health Science Center, he was a family physician in Spearman, a small, rural town just north of Amarillo. With no specialists in the area, Dr. McClellan started performing flexible sigmoidoscopies himself to screen his patients for colorectal cancer.

"It made perfect sense to me," he said. Now, using a grant from the Cancer Prevention and Research Institute of Texas (CPRIT), Dr. McClellan and his colleagues train family medicine residents at Texas A&M to perform colonoscopies — a similar, more thorough procedure — to examine and remove polyps from the large intestine.

Texas voters approved a constitutional amendment in 2007 to create CPRIT. The state-funded organization awards grants for cancer-related research, cancer prevention programs, and cancer-related services by public and private Texas entities.

Using funds from CPRIT, Dr. McClellan and the family residency program teamed up with the Texas A&M School of Public Health to create the Texas Cancer Screening, Training, Education, and Prevention (C-STEP) program. C-STEP provides free cancer screenings to residents of the Brazos Valley region who are uninsured or low-income qualifiers through the Texas A&M Physicians Family Medicine Center. 

"It was a really beautiful blending of two major parts of the Texas A&M Health Center," he said. In addition to providing training opportunities for residents, Dr. McClellan says, the program serves patients who would not otherwise get screened for colorectal cancer.

"The CPRIT funding has really been a boon to the people in the Brazos Valley area," he said. "We're providing a needed service to patients, and we're really doing something good for colon cancer prevention."

Since its creation, CPRIT has put an emphasis on funding cancer prevention projects and recruiting top cancer researchers to Texas institutions, says Chief Executive Officer Wayne Roberts. But the organization suffered a setback in 2012, when a top official awarded an $11 million grant without going through the necessary channels. 

The state placed a moratorium on grants but later replenished the funds. Now, CPRIT is bouncing back with renewed gusto, and Mr. Roberts says the organization is making rare and hard-to-treat cancers, including juvenile and adolescent cancers, a priority in 2015. 

Training Rural Doctors, Helping Rural Patients

Mr. Roberts says CPRIT puts great importance on funding cancer prevention projects like C-STEP.

"Prevention efforts present our best opportunity for immediate results," he said. Mr. Roberts added the organization plans to focus on prevention for populations in which significant disparities in cancer incidence and mortality exist.

Last year, in addition to continuing and expanding the grant for colorectal cancer screening and prevention, CPRIT awarded Texas A&M another grant to train family medicine residents and nursing students to screen for breast and cervical cancer. Dr. McClellan says though the program is still new, it has already identified one breast cancer case.

"A grant like this that allows us to do good clinical work and help the citizens in our region is helpful on a number of fronts," he said.

CPRIT grant recipients must submit quarterly and annual reports to the institute that outline spending line by line. Grantees collect data that can lead to scientific publication, allowing others in Texas and around the nation to learn from the projects' best practices and outcomes. 

Jane Bolin, PhD, interim department chair and professor of Health Policy and Management at the Texas A&M School of Public Health, is principal investigator for both grants. She handles community outreach to let patients know about the free screenings, and she reports back to CPRIT with results showing how the grants have helped improve access to care.

She says in the three years since C-STEP was created, Texas A&M residents have performed 1,155 colonoscopies, removed precancerous polyps in 27 percent of those cases, and diagnosed 11 cases of colorectal cancer. Medicaid often covers cancer treatment for the uninsured, but, Dr. Bolin said, "income eligibility for Medicaid insurance in Texas is more difficult to meet than in some other states. Consequently, many individuals who are low-income and who should be screened do not qualify. This is especially true for adult men between the ages of 50 and 65."

While CPRIT funds don't cover cancer treatment for patients, the institute will pay for navigation services, also known as case management. CPRIT-funded navigation services help patients determine whether they qualify for Medicare, Medicaid, or the Texas Breast and Cervical Cancer Services program. 

In the first nine months of the new breast and cervical cancer screening grant, Texas A&M performed more than 100 Pap tests, clinical breast exams, and mammograms, Dr. Bolin says. In addition, family medicine residents performed 15 colposcopies when a Pap test resulted in abnormal findings, one removal of a lesion from the cervix, nine breast ultrasounds, and four breast biopsies, she says.

"This is all being done in the context of training family medicine doctors," Dr. Bolin said. "The majority of them will stay in Texas, practice in smaller areas. These types of skills are important." Dr. Bolin says the program recently expanded to include a 10-county region — all in underserved areas, where many patients live in poverty.

"The CPRIT grant has been a real blessing," she said. "It's basically training the next generation of family physicians."

Dr. McClellan says only about half the people who should see a doctor for a colorectal cancer screening actually get a colonoscopy. "We're making a dent in that 50 percent of the population that wouldn't otherwise be getting screened," he said.

The training program is not an effort to cut into the business of gastrointestinal (GI) specialists, but rather a chance to teach future rural family physicians a new skill set, he says.

"We very much appreciate our GI colleagues," he said. But, he added, "Well-trained family physicians can do a lot of care that is somewhat specialized."

In rural communities, he says, patients often put a lot of trust in their local physician and are more likely to go to him or her than travel to a more metropolitan area to see a specialist. He adds many Texas A&M graduates will put this skill to use in their own practices. 

"It gives them a more in-depth understanding of the need for their patients to be screened," he said. Dr. McClellan also admits a personal stake in the game: His mother died of colon cancer at age 67.

"If she had had a screening colonoscopy, she might be alive today," he said. He notes other faculty involved in C-STEP have lost family members to colon cancer.

"All of us have some skin in the game and are passionate about this because we realize the importance of early detection," he said. 

Scandal Strips Funding

Mr. Roberts says CPRIT funding supports a variety of measures to prevent cancer across the state. 

"To date, CPRIT grants have supported cancer prevention, education and training, evidence-based screening for the early detection of cancer, and survivorship services for nearly 2 million Texans," he said. 

The Texas Public Health Coalition declared its support for CPRIT at its December meeting. In a one-pager, the group says, "CPRIT is leading the charge against cancer in Texas. We must continue to support strong public health activities that complement CPRIT's work and making sure prevention, early detection, and survivorship programs remain strong."

Mr. Roberts also notes the economic impact of the organization. "A report by The Perryman Group shows that through the end of fiscal year 2014, CPRIT's activities and investments resulted in $3.6 billion in Texas business activity, 37,690 jobs created through direct and indirect economic activity, and $197 million in state tax receipts, along with $92.1 million in local government tax receipts."

But the righteous path wasn't without its hiccups. Five years after the legislature created CPRIT, the institute's oversight committee disclosed that it had awarded an $11 million grant for Dallas-based Peloton Therapeutics without proper scientific review. State leaders placed a moratorium on new grants in December 2012. In addition, former Chief Commercialization Officer Jerry Cobbs, who was responsible for presenting the Peloton grant to the CPRIT oversight board for approval, resigned shortly after the disclosure. A Travis County grand jury indicted him on first-degree felony charges in December 2013. 

Lawmakers restored funding during the 2013 legislative session, when they passed Senate Bill 149, spearheaded by Sen. Jane Nelson (R-Flower Mound) and Rep. Jim Keffer (R-Eastland) and supported by the Texas Medical Association, to overhaul CPRIT operations, ensure transparency within the organization, and restore its multimillion-dollar budget. 

Before the legislature approved the bill, TMA testified before the Senate Health and Human Services Committee in its favor. TMA noted the bill modified CPRIT's structure, established salary restrictions, and changed the composition of the oversight committee. SB 149 also established conflict-of-interest rules that govern institute committees and employees. The bill required the oversight committee to adopt a code of conduct applicable to the members of the oversight and program integration committees and CPRIT employees. 

CPRIT is now up and running again, and Mr. Roberts says the statutory changes allowed the agency to make a new start with an increased focus on transparency and accountability. 

"CPRIT's grant award processes include numerous checks and balances, and the agency has sought public input on important initiatives such as administrative rule changes and establishing program policies," he said.

On the Agenda

The legislature appropriated $600 million in bond proceeds for 2014-15 and required a transfer of $6 million in bond proceeds to the Texas Department of State Health Services (DSHS) to support the Texas Cancer Registry. By law, CPRIT can allocate a maximum of 10 percent of total annual grant awards to prevention. That means up to $30 million will be available to fund prevention initiatives in 2015.

CPRIT funding is split among research, prevention efforts, and product development. In November, CPRIT announced it awarded 32 new grants — 20 through its product development program, five through its prevention program, and seven recruitment grants through its research program — totaling more than $65 million toward advancing the fight against cancer. Recipients included Baylor College of Medicine, several branches of The University of Texas, including MD Anderson Cancer Center, and Texas Tech University. CPRIT did not award any new grants to private businesses.

Mr. Roberts says the organization's biggest challenge is finding ways to leverage its $300 million a year. 

"We want to make sure we're not just mimicking what is going on elsewhere in cancer research," he said. The oversight committee's new annual process of setting program priorities provides for greater transparency in how the agency allocates its funding and helps staff decide which grant applications it approves, he says. CPRIT now reviews and adjusts its priorities every year as circumstances change and new information surfaces, Mr. Roberts says.

The oversight committee adopted its first set of priorities at its November meeting, where it decided to focus on prevention and research of rare and hard-to-treat cancers, including juvenile and adolescent cancers. 

"The private sector tends to focus on cancers where they can produce a product or drug for the maximum number of patients to increase profits. Children's cancers are relatively rare to begin with, and some people believe these and other rare cancers haven't received the attention they deserve," Mr. Roberts says.

CPRIT also plans to continue recruiting top cancer researchers to Texas, Mr. Roberts says. 

"A talented researcher, particularly a young one, represents 25 to 30 years of research. By the time we're done, I predict we will have created in Texas the finest cluster of cancer expertise in the world," he said.

New Hurdles

A new bill seeks to end funding to CPRIT forever. Senate Bill 197, prefiled in December by Sen. Charles Schwertner, MD (R-Georgetown), would terminate state funding to CPRIT upon its sunset date in 2021. The bill tasks the organization with finding a way to operate without state funds. Senator Schwertner did not respond to a request for comment.

Mr. Roberts says the bill instructs CPRIT to plan for the future. 

"It's still early in the process, and at this point quite a lot remains to be considered, but we appreciate lawmakers thinking ahead and planning for the future of the agency. We look forward to this dialogue," he said.

Austin oncologist Debra Patt, MD, is director of public policy for Texas Oncology and a member of TMA's Committee on Cancer. She understands the legislature's desire to spend state funds wisely, but cutting off CPRIT too early could jeopardize Texas' investment, she says. 

"There were some flaws in the system," she said. But, she says, CPRIT has done much to correct transparency issues and ensure oversight.

She says not only does the organization work to lower cancer rates in Texas, but it also serves as a "carrot" to bring talent to the state. Dr. Patt credits CPRIT with bringing researcher James Allison, PhD, to MD Anderson Cancer Center to chair the Department of Immunology. Dr. Allison is known for his groundbreaking research toward a drug that helps the immune system recognize and destroy cancer cells. He arrived at MD Anderson in 2012 with the help of a $10 million CPRIT scientific recruitment grant for established investigators.

She says the organization also led CPRIT scholar Sean Morrison, PhD, to The University of Texas Southwestern Medical Center, where he is the founding director of the Children’s Research Institute and the Mary McDermott Cook Chair in Pediatric Genetics. Dr. Morrison investigates the role of stem cells in cancer treatment.

"It's attracting truly first-rate scientists to Texas institutions," she said. "That will then drive health care innovation for decades." 

Kara Nuzback can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.

All articles in Texas Medicine that mention Texas Medical Association's stance on state legislation are defined as "legislative advertising," according to Texas Govt. Code Ann. §305.027. That law requires disclosure of the name and address of the person who contracts with the printer to publish the legislative advertising in Texas Medicine: Louis J. Goodman, PhD, Executive Vice President, TMA, 401 W. 15th St., Austin, TX 78701.

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