Cancer's Enemy

CPRIT Funds Research, Prevention Projects  

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Public Health Feature – July 2011

Tex Med. 2011;107(7):31-37.

By Crystal Conde
Associate Editor

Ann Rydbeck vividly remembers the day her life changed forever: July 28, 2010. She was diagnosed with Stage I breast cancer that day.

The 51-year-old Weatherford resident felt a lump in her breast about a year earlier and didn't go to the doctor because she didn't have health insurance and she doesn't have a history of the disease in her family. She finally decided to get a mammogram when reality hit and she realized the lump wasn't going away on its own.

Given her diagnosis, under normal circumstances, she would have been frightened and felt alone in her quest to obtain care. But Ms. Rydbeck was fortunate. Although she had to pay for her mammogram out of pocket, her biopsy was free, thanks to funding provided to Fort Worth's Moncrief Cancer Institute by a grant from the Cancer Prevention and Research Institute of Texas (CPRIT).

"I don't know what I would have done without the CPRIT funds. It would have been very difficult. Everyone at Moncrief was wonderful; they went above and beyond," she said.

The Moncrief institute is an affiliate of The University of Texas Southwestern Medical Center at Dallas Simmons Cancer Center. It is a nonprofit, community-based cancer center serving patients' social, emotional, and health needs.

At press time, CPRIT had awarded 256 research, prevention, and commercialization grants in Texas totaling $382 million.

During the 2007 legislative session, the Texas Medical Association and Texas voters supported a constitutional amendment establishing CPRIT and authorizing the state to issue $3 billion in bonds to fund cancer research, prevention, and services in Texas. CPRIT awards grants for cancer-related research and for cancer prevention programs and services by public and private Texas entities.

Immediately after her diagnosis, Ms. Rydbeck says, breast specialists from the Joan Katz Breast Center at Baylor All Saints Medical Center at Fort Worth met with her to discuss her treatment options. With their help, she scheduled a mastectomy and subsequent reconstructive surgery. CPRIT funds don't cover cancer treatment, but Ms. Rydbeck qualified for Medicaid coverage.

"The breast specialists visited me in the hospital after my surgery both times. They let me know that if I needed anything, they were available to help 24/7," she said.

Ms. Rydbeck benefitted from a $999,960 two-year grant CPRIT awarded to Moncrief for the Breast Screening and Patient Navigation (BSPAN) project, headed by Keith Argenbright, MD, a TMA member.

Moncrief's breast screening program has a successful track record in Tarrant County, and CPRIT funds allowed it to expand into five surrounding counties: Denton, Wise, Parker, Hood, and Johnson. Dr. Argenbright says these counties are part of a region that has a higher incidence of invasive breast cancer than any other part of the state. "We are trying to determine why that is," he said. "We think there are many reasons – from the educational attainment levels of the population, to lack of access to health insurance, to the number of immigrants we have in this portion of the state, to geographic issues associated with access to screening facilities. How all of those interact with one another is something we're trying to figure out."

Dr. Argenbright hopes that by collecting data through the breast cancer screening program, researchers can start projects to analyze the information and ultimately answer that question. He adds that it will take years before the project has collected the volume of data that will allow for such in-depth analysis.

The breast cancer screening project works with local community leaders and health care professionals to increase access to breast cancer screening, diagnostic mammograms, and biopsies.

"Within the first 10 months of the project, 4,946 women have been reached. Of those, the Moncrief staff has done almost 1,500 mammograms and found 34 breast cancers. We're finding a majority of these cancers in their early stages when they're curable," Dr. Argenbright said.

He adds that about half of the women who've been diagnosed with breast cancer are younger than 50. He says Moncrief will submit a new proposal to CPRIT in September to expand the program into 11 additional counties.

Ms. Rydbeck hopes other Texans will be fortunate enough to take advantage of the services made possible through CPRIT funding.

"CPRIT is a wonderful organization. Through funding from the institute, Moncrief was able to step in and provide me with phenomenal care. Every physician that I've had has been unbelievably attentive, conscientious, patient, and instrumental in making this transition in my life smooth. I'm blessed and fortunate that all of this was taken care of so abundantly for me," she said.

Prevention Works

Prevention funds have led to some exciting results and an increase in programs and services available in Texas, according to CPRIT Chief Prevention Officer Becky Garcia, PhD. At press time, the institute had covered 85 percent of Texas counties with at least one CPRIT project.

Also, at press time, CPRIT reported 43,000 health care professionals and residents had received education, outreach, and navigation services. While CPRIT funds don't cover cancer treatment for diagnosed individuals, the institute will pay for navigation services, also known as case management.

Dr. Garcia explains that CPRIT largely funds programs with resources and the ability to help cancer patients navigate the health system and find treatment. She says finding cancer treatment for the uninsured and underinsured isn't easy. CPRIT-funded navigation services help patients determine whether they qualify for Medicare, Medicaid, or the Texas Breast and Cervical Cancer Program.

Thanks to CPRIT prevention funds, 12,000 Texans have been screened for cancer or have received some other clinical service, such as human papillomavirus vaccination.

"What CPRIT is really excited about is that of those 12,000, almost 40 percent are people who have never been screened before. Prevention funds focus on those who are underserved and haven't come into the system before. We have reports of 81 cancers that have been diagnosed. For this first reporting period, we're really excited to see these kinds of results," Dr. Garcia said.

For a list of currently funded grants, visit the CPRIT website.

Dr. Argenbright says accountability to ensure proper use of prevention funds and to measure the results of the projects is a priority for CPRIT. Grant recipients have to submit quarterly reports to the institute that outline spending line by line. CPRIT also requires an annual report.

"We get reimbursed by CPRIT if those reports are accurately reflective of what we proposed to do in the grant. CPRIT doesn't issue grants in full up front. The institute doesn't release funds until the end of the quarter, based on the accurate completion of the report," he said.

Additionally, 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.

Dr. Argenbright is grateful for CPRIT's work.

"I can say with 100-percent certainty that these CPRIT funds are making an impact on the health of Texans, especially those in the historically underserved communities where there might be high minority populations. I have the privilege of working every day with a team that gets stories back from patients who say a mammogram saved their lives," he said.

CPRIT's Reach

Lewis Foxhall, MD, chair of the TMA Physician Oncology Education Program (POEP) Steering Committee and a member of the TMA Board of Trustees, says the cancer prevention funding from CPRIT is a great resource for the state. He says all physicians, not just researchers, benefit from the institute's grant awards. He encourages his colleagues to consider submitting a grant proposal in an area of cancer prevention that interests them.

"In general, the grant offerings focus on addressing preventive needs in underserved communities or in those groups that have an excessive burden of cancer," Dr. Foxhall said.

He says CPRIT's focus dovetails nicely with the work of POEP, which receives funding from the institute. POEP uses those funds to advance prevention efforts in the physician's practice. (See "POEP Receives CPRIT Funds.")

"POEP works to improve knowledge and affect attitudes about cancer prevention and treatment among physicians. The program has made an effort to reach out to the primary care community to provide physicians with information and services so clinicians can do a better job of addressing cancer in their patients," he said.

He adds that CPRIT is interested in supporting projects that will encourage real change in how physicians deliver cancer care and show a measurable difference at the patient level. One such project involves a POEP initiative to improve the rate of colorectal cancer screening at a federally qualified health center (FQHC) in Conroe. POEP gives the center clinical guidelines on how to approach screenings and how to change its practices to make the screenings effective. The FQHC will measure rates over time to determine whether the intervention is working, Dr. Foxhall says.

"POEP and CPRIT want to ensure practitioners manage their cancer patients' care effectively and consistently, and efficiently deliver preventive services," he said.

The prevention efforts CPRIT funds could influence how physicians evaluate and treat their cancer patients, Dr. Garcia says. CPRIT funds public and professional education, clinical services, and policy and systems change.

"Prevention funds will allow CPRIT to focus on delivering more professional education and training in Texas. We know health care professionals are such an important part of prevention. One of the strongest predictors of whether a person will receive a screening, quit smoking, or take preventive action is if a health care professional recommends it," she said. (See "A Smoking Podcast.")

Joseph Bailes, MD, an Austin oncologist and TMA member and vice chair of the CPRIT Oversight Committee, says physicians in research and academia aren't the only ones who can benefit from CPRIT's work. For example, CPRIT devoted more than $25 million to establish the Statewide Clinical Trials Network of Texas. Dr. Bailes says academic institutions and community oncologists alike are part of the network and collaborate to enhance the local availability of cancer-related clinical trials for Texans.

The network, which received funding in June 2010, is a conduit for academic researchers, community physicians, biotechnology companies, and pharmaceutical firms to increase the pace of clinical oncology research by testing novel concepts, drugs, diagnostics, and medical devices, while providing Texas patients access to state-of-the art treatment.

TMA member C. Mark Chassay, MD, MBA, is a member of the CPRIT Scientific and Prevention Advisory Council. He says CPRIT's research and prevention initiatives have the potential to benefit Texas' physicians and residents. The council meets twice a year and provides advice and support to the CPRIT Oversight Committee. 

"Moving forward, our physicians will be better educated on prevention and ultimately be better served with grant-funded educational specialists who can aid in the maze of workups and treatment options for those fighting cancer," he said.

CPRIT's Operations

Requests for application (RFAs) for the next prevention program funding cycle are due Sept. 20, and CPRIT will announce awards in January 2012. To access the RFA release and peer review schedule for research and prevention programs, visit the CPRIT website.

When determining which cancer prevention programs to fund, Dr. Garcia says CPRIT is looking for projects that:   

  • Focus on underserved populations,
  • Demonstrate organizational capacity and sustainability,
  • Have a clear strategy,
  • Show potential to make a public health impact, and
  • Can report on tangible outcomes.  

On top of that, Dr. Garcia says CPRIT wants to fund innovative projects.

"I tell people CPRIT doesn't want just to fund a few more screening and education programs. We really want to stimulate innovation and new ways of thinking about approaching cancer prevention and treatment. That could include new partnerships, focusing on different populations or geographic areas. We want to see creativity," she said.

The prevention program grant awards for fiscal year 2011 will be announced July 27.

To receive all funding announcements and press releases, visit the CPRIT website and sign up for the newsletter. You can also follow CPRIT news on Twitter and Facebook.

CPRIT also awards grants for commercialization. CPRIT gives priority to proposals that expedite innovation and commercialization, attract private sector entities that drive job creation, and enhance higher education, applied science, or technological research capabilities in the state. At press time, CPRIT had invested $38 million in eight Texas companies that are developing promising cancer drugs, diagnostics, and devices with a potential return of more than $40 million, according to Dr. Bailes.

And the institute has recruited 10 CPRIT scholars in cancer research to Texas to conduct research.

"The inaugural class of CPRIT scholars represents the top talent recruited from outside the state. Attracting these scientists to Texas enhances the caliber of cancer research statewide," Dr. Bailes said.

CPRIT's Future

To date, CPRIT has awarded nearly $32 million in cancer prevention monies, funding 53 projects across Texas. Prevention grants cover a spectrum of activities from primary prevention to early cancer screening and detection to survivorship programs.

Vincent Fonseca, MD, MPH, is a member of the POEP Steering Committee and of CPRIT's advisory council. He praises CPRIT for the progress it has made in its first year-and-a-half of operation.

"What CPRIT has done is amazing. I've never seen a better evaluation process in terms of fairness and quality," he said.

The institute has room to improve, however, upon the groundbreaking work it has already done, says Dr. Fonseca, a TMA member. While the awards process is fair and balanced, he says the type of research CPRIT has funded is overwhelmingly skewed in favor of T1 translational research.

The Institute of Medicine's Clinical Research Roundtable describes T1 research as "the transfer of new understandings of disease mechanisms gained in the laboratory into the development of new methods for diagnosis, therapy, and prevention and their first testing in humans." It defines T2 research as "the translation of results from clinical studies into everyday clinical practice and health decision making."

T1 research takes place in a laboratory, while T2 occurs in community and ambulatory care settings and brings T1 research results to the public, ensuring proper implementation of new treatments and research within the intended populations.

CPRIT Executive Director Bill Gimson says the institute wants to enhance the safety and therapeutic benefit of promising treatments essential in translating new knowledge into tangible benefits for patients with cancer.

"Cancer patients generally do better if enrolled in a clinical trial. However, it is estimated that only 3 percent take advantage of these opportunities," Mr. Gimson said.

He adds CPRIT selects and funds "the very best of the best projects submitted – without quotas. We do have guidance in our mandate to focus on scientific breakthroughs, those that provide hope and better treatments for Texans where there has not been hope previously."

He points to CPRIT funding that falls into the T2 category, including Comparative Effectiveness Research on Cancer in Texas, a multidisciplinary consortium of investigators at the University of Texas Medical Branch, M.D. Anderson Cancer Center, The University of Texas School of Public Health, Rice University, Baylor College of Medicine, and the Texas Cancer Registry. He says the consortium's four projects will focus on:  

  • Screening tests for breast, colorectal, and prostate cancer;
  • Quality of cancer treatment;
  • Post-treatment surveillance testing; and
  • Quality of supportive care.             

A 2008 article published in the Journal of the American Medical Association (JAMA) titled "The Meaning of Translational Research and Why It Matters" states that T1 research draws more funding than T2 and gets more attention in the United States.

The JAMA article calls on those who fund research to "strike a balance between areas of research – T1 vs. T2, clinical vs. population-based research – and emphasize each endeavor in proportion to its ability to improve health."

"In my opinion, CPRIT can't wait to make improvements in the balance of T1 and T2 research. Experts have been writing about this imbalance in translational research for decades. We've stepped into the same minefield here in Texas. We still have time to change and start funding more T2 research," Dr. Fonseca said.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.


Funding for CPRIT

The Texas Constitution authorizes the Cancer Prevention and Research Institute of Texas (CPRIT) to issue up to 10 percent of funding, or a maximum of $30 million, annually to pay for cancer prevention and control programs. The remaining 90 percent goes toward research and commercialization projects.

According to CPRIT Chief Prevention Officer Becky Garcia, PhD, the legislature allocated $22.5 million per year for prevention for fiscal years 2010-11. Instead of fully funding CPRIT with $600 million for the biennium, the legislature approved $450 million.

For the 2012-13 biennium, the legislature awarded CPRIT full funding of $600 million. At press time, CPRIT awaited approval of some portions of Senate Bill 1 related to the institute’s bond authority to ensure appropriation of the full funding amount.

Dr. Garcia says one of the advantages CPRIT has is its funding mechanism – the sale of general obligation bonds.

"CPRIT doesn't have much of an impact on the state's general revenue, aside from the cost of the debt service," she said.

"The institute proposed to the Legislative Budget Board that CPRIT be issued bonds as needed to pay project costs, rather than issuing them all up front. This would allow CPRIT to manage the bond process better and save the state some money," Dr. Garcia said.

House Bill 2251 by Rep. Dennis Bonnen (R-Brazoria) passed and had been sent to the governor. The bill contained a sunset provision to allow CPRIT to issue bonds as needed to pay for project costs. Debt service for fiscal years 2010-11 was $35.5 million. Issuing bonds on a pay-as-you-go basis reduces CPRIT’s debt service cost to approximately $9 million.  


CPRIT's Impact

According to the American Cancer Society, last year, 101,120 Texans were diagnosed with cancer, and 36,540 died from the disease.

The National Institutes of Health estimates 2010 cancer costs in the United States were $263.8 billion – $102.8 billion in direct medical costs, $20.9 billion in lost productivity due to illness, and $140.1 billion in lost productivity due to premature death. 

In a report prepared for CPRIT, the Perryman Group estimates that in 2010, the annual direct medical costs and morbidity and mortality losses associated with cancer in Texas were about $25.3 billion, an increase of 15.8 percent since 2007. The report found CPRIT-funded programs in cancer research and prevention have had a total economic impact of $852.3 million in output (real gross product) and 11,537 jobs.

Additionally, the report says CPRIT operations and programs generated an estimated $265.6 million in annual state revenue, along with $169.7 million in annual revenue to various local governments. The full report, A War Worth Waging: An Economic Assessment of the Cost of Cancer and the Benefits of the Cancer Prevention and Research Institute of Texas (CPRIT) and Its Programs, is available online [PDF].  


POEP Receives CPRIT Funds

In September 2009, the Cancer Prevention and Research Institute of Texas (CPRIT) awarded the Physician Oncology Education Program (POEP) $467,425 for its prevention initiatives through August of this year. POEP has applied for $399,633 from CPRIT this year to cover September 2011 through August 2012.

Proposed POEP core projects for fiscal year 2012 include:  

  • Live educational activities that provide statewide clinical symposia in cancer prevention, early detection, screening, and control, in collaboration with relevant organizations;
  • Speakers' Bureau lectures that feature volunteer experts who speak to physicians and other health care professionals on cancer prevention, screening, early detection, and control;
  • A continuing education video to improve cancer clinical trials knowledge among Texas nurses and physicians, in collaboration with the Nurse Oncology Education Program;
  • Medical Student Section human papillomavirus (HPV) and cervical cancer education activity that consists of one-hour lectures on cervical cancer at five Texas medical schools;
  • Electronic materials such as podcasts and online modules;
  • iPhone and iPad applications for skin and childhood cancers based on the current POEP pocket guides; and
  • A seminar on HPV, tobacco cessation, and obesity that health care professionals can use to counsel college students.   

In addition, POEP applied to CPRIT for a separate, two-year $205,191 grant to increase HPV vaccination rates.

According to the August 2009 Cancer Epidemiology, Biomarkers & Prevention, fewer than half of respondents to POEP's 2008 survey indicated they always recommend the HPV vaccine to 11- and 12-year-old girls. The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of girls in this age group with three doses of HPV vaccine. According to ACIP, the vaccination series can begin in girls as young as 9 years. 

Should POEP receive funding, the performance improvement project would consist of a chart review of patients who are at an appropriate age to receive the vaccine, an interactive webinar, and more emphasis on recommending vaccination to increase HPV vaccination rates. At the end of the project, physicians would complete another chart review to determine any increase in the number of patients to whom the vaccine was recommended.

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A Smoking Podcast

TMA's Physician Oncology Education Program (POEP) is using part of the Cancer Prevention and Research Institute of Texas' current prevention funding to develop a podcast on smoking cessation billing codes. TMA has developed a calculator to be featured in the podcast that will help physicians determine how they can get paid for counseling their patients about tobacco cessation.

The podcast will launch in August and can be accessed on the TMA website.

The podcast is part of a larger project in collaboration with TMA's Council on Health Promotion, the TMA Foundation, and the TMA Alliance. The smoking cessation project targets physicians and their staff members and intends to accomplish four goals:  

  1. Increase the number of physicians who counsel and educate their patients to never start smoking or to stop smoking. 
  2. Make more physicians' offices cancer detection and prevention centers by increasing their use of POEP tobacco cessation resources. 
  3. Improve the health of the population through physician leadership in preventing disease and illness for their patients. 
  4. Create a multiyear strategy to help physicians improve their preventive practices with tobacco control through evidence-based education from POEP to promote use of codes to pay for tobacco counseling.  

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