A Talk With Dr. Richard Klausner, Head of the NCI

BETHESDA, Md—Richard D. Klausner, MD, became the 11th director of the National Cancer Institute on Aug. 1, 1995. He took over a troubled organization, one torn by accusations of scientific misconduct against several of its researchers and grantees and the target of two critical evaluations.

One of these charged that an “absence of coordination” had led to research and service gaps in the National Cancer Program and “costly duplication of effort.” Another criticized NCI’s intramural research program as a “fragmented feudal structure.”

Dr. Klausner moved rapidly to make fundamental changes, including reshaping the intramural program, boosting the money for extramural research, and trimming middle management. Most of all, his energy, enthusiasm, and leadership jump-started lagging morale.

During an interview in his office at the National Institutes of Health, Dr. Klausner talked with Oncology News International Washington bureau chief Patrick Young about NCI and its relationship with practicing oncologists.

ONI: When you became director, you talked about the culture of NCI. How has it changed?

DR. KLAUSNER: It has changed quite dramatically. The major change I see is in the spirit in the Institute, both internal and external. It’s not that there are no problems, but I feel we have a shared sense that we are building something that is really going to make a difference. It’s invigorating and it’s reflected in a variety of very palpable changes, including an extraordinary new ability to recruit people. People want to come to NCI.

ONI: You speak about the future of fighting cancer through understanding the human genome. Is there a risk of overpromising?

DR. KLAUSNER: It is hard for me, and indeed for anyone that we bring in, to avoid the sense of the possibility of really understanding these diseases. The mistake we made in the 1970s was allowing the promise of progress to be turned into promises of timetables.

The only thing I feel comfortable promising is that there is a particular road we must go down, and it is the road of understanding the causes and the nature of cancer. I don’t know how long the road is, and I don’t know when we are going to stumble upon breakthroughs.

ONI: The incidence is down for many malignancies. Have we turned the corner on cancer? Where do we stand?

DR. KLAUSNER: When you ask us to analyze the data to see “how we are doing,” that in itself is very complex. How we are doing in what? Is it mortality? Is it quality of life? Is it knowledge? The reality is, as far as I can see, that most of the signs suggest progress in every area.

I don’t know how to predict when we are going to have a breakthrough. Yet the history of modern medicine is a history of both incremental advance and breakthroughs, and our approach to cancer is no different. So have we “turned the corner?” It’s an interesting metaphor, but I believe a more accurate description is that our progress against cancer has been real; it has been variable across these different diseases; and I suspect it’s going to accelerate in the future.

ONI: What do you see as the relationship between NCI and practicing oncologists, particularly the nonacademic oncologist?

DR. KLAUSNER: It is a very important relationship. I have tried very hard to connect with all of the professional societies as a conduit to the entire oncology community, from nursing to the surgical subspecialties, medical oncologists, and radiation oncologists.

I think success will not happen without a very active interaction between the practitioners of oncology and the practitioners of oncology research. We need to maintain an ethos where the practices of oncology and oncology research are extremely closely aligned and indeed married, so to speak.

That can take place in many ways, but I think it needs to include a much more accessible, user-friendly, and extensively distributed clinical research and clinical trial system that finds its way into the practice community.

ONI: Are managed care policies seriously affecting NCI’s ability to carry out clinical research?

DR. KLAUSNER: Everyone is worried about that. There are many signs, mostly anecdotal, that managed care in the broadest sense is making participation in clinical research and clinical trials, directly or indirectly, more difficult.

On the other hand, I am not willing to say that managed care, which represents many different models of practice and delivery, must be antagonistic to our vision of a very broad-based clinical research and clinical trial system.

ONI: Has managed care affected the care of cancer patients over and above the problems of clinical trials?

DR. KLAUSNER: There are data being accumulated. I’m very cognizant of examples in which managed care policies have affected cancer patients in ways that most of us would see as negative optimal care.

But I do want to be careful not to paint everyone with the same brush, and also to recognize that it’s not helpful to turn the health delivery world into “good guys and bad guys” and create a situation where it’s us versus them. We need to engage managed care, as we have tried to do, in a very serious discussion about the role of research in quality care.

ONI: What kind of contacts have you had with managed care and what has been the outcome?

DR. KLAUSNER: We have for the past two years been in ongoing discussions with a variety of managed care organizations about the questions specifically related to participation in clinical trials. We have tried to create some model agreements, such as those we have with the Department of Defense and the Veterans Administration system.

Those agreements are not perfect, but I am very proud of them. They have been part of framing the agenda of discussions throughout the government and elsewhere about the need of health delivery organizations and payers to confront the issues of clinical trials for cancer patients.

ONI: How about discussions with the for-profit organizations?

DR. KLAUSNER: As I have said, we have been in discussions. They are long. They are difficult. They are complex. And we will continue those discussions because I think it is very important that everyone can sit around the same table.

ONI: Your new consumer group, how does it relate to oncologists and their patients?

DR. KLAUSNER: We have set up the Director’s Consumer Liaison Group to make sure there is a clear voice at the NCI for consumers and their advocates. That group has very explicit functions—to advise me on how we can best serve the needs of consumers in terms of communications, education, and outreach information, and to advise me on individuals who can serve the NCI in many functions, such as advisory groups.

ONI: Is there a similar arrangement for oncologists?

DR. KLAUSNER: The Consumer Liaison Group is just part of our new liaison activities. One thing we are doing is meeting individually at least once a year with the leadership of each of the professional organizations that are involved in cancer. We review what NCI is doing, what they are doing, how we can work together, what the problems are. The goal is to produce a real set of action items, and a tremendous amount gets accomplished.

For example, we met with the Oncology Nursing Society and heard a whole list of needs for training, for access to grants. That allowed us to rewrite some of our guidelines and some of our communications, and to create a new way of communicating with the nursing research community.

Each organization has a variety of needs, and the single most important thing is to find ways to communicate.

ONI: How would you like to be remembered? What would you like your legacy to be when you leave NCI?

DR. KLAUSNER: Primarily I would like to be remembered as a scientist rather than as an NCI director. For the NCI, I hope I will be remembered for changing the relationship between the institution and the community it serves and for encouraging the NCI to be seen as an institution that is a marketplace for terrific ideas—one that is really capable of enhancing discoveries and application of those discoveries.

ONI: How long do you expect to stay at NCI?

DR. KLAUSNER: When I started, I felt that a job like this required a personal commitment of five years. I serve at the pleasure of the President, and I certainly intend, as long as the President doesn’t have any objections, to commit myself to five years and then to reevaluate.