National Cancer Institute

A N A N N U A L P L A N A N D B U D G E T 

P R O P O S A L F I S C A L Y E A R 2 0 1 1 

Connecting the Nation’s 

Cancer Community 

The Nation’s Investment in Cancer Research 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 
On the Cover 

Peter A. Pinto, M.D., NCI Urologic Oncology Branch 

Carole A. Parent, Ph.D., NCI Laboratory of 

Cellular and Molecular Biology 

Melanoma cell observed under ion-abrasion scanning 

electron microscopy, a strategy for 3D imaging of 

biological specimens/Credit: Donald Bliss (National Library 

of Medicine) and Sriram Subramaniam (NCI) 
 

 

 

Director’s Message
�

Grasping opportunity is rarely 

easy and never simple. Nor 

is it for the timid, requiring 

wisdom and forethought, grounded 

in a keen sense of the possible. Opportunity always involves some risktaking. For those of us at the National 

Cancer Institute, it is also built on an 

abiding sense of duty, of responsibility to every cancer patient. 

Indeed, cancer remains a scientific 

and medical challenge of singular difficulty. For everyone who comes to 

work at NCI, the urgency of our mission is ever present. Each day in our 

clinical center, we see the anguished 

faces of those who suffer from this 

disease. We understand the sting of 

cancer that grips far, far too many 

of our fellow citizens. We know that 

cancer’s losses sometimes seem unbearable — at a family dinner table 

where an empty place setting is the 

reminder of a loved one taken away, 

or in the laugh of a lost child now 

consigned to an increasingly distant 

memory. We dedicate our work to 

those who have faced cancer, to those 

who will face cancer, and to those 

who hold tight to their loved ones at 

the most vulnerable of moments. 

It is, thus, with the greatest sense 

of mission that NCI can report real 

progress against many forms of cancer and, even more importantly, exciting opportunities that lie ahead. 

Biomedical science’s understandings of the inner workings of the 

cancerous cell and the host tissue 

in which it resides are accelerating 

at an unprecedented pace. Genomic 

research is contributing — virtually 

on a daily basis, it often seems — to 

our catalogue of knowledge about 

the mutations, genomic alterations, 

and processes of cancer. In an era 

when targeted cancer therapies are no 

longer a prediction but an accumulating reality, the challenge we face is 

to continue to turn groundbreaking 

science into lifesaving care, at an even 

greater speed. 

This document is the story of opportunity: how NCI is exploiting the 

confluence of unexpected new financial resources and a steady stream of 

scientific and technological advances, 

in order to make strides in cancer risk reduction, early detection, 

patient care, and survivorship. 

T h e N a T i o N a l C a N C e r i N s T i T u T e | 1 
 

 

 

 

 

 

 

 

NCI has a vision for a unified, comprehensive system of cancer research and care, in 

which every new cancer patient is part of a 

nationwide research cohort — genomically 

characterized, tracked, secured, and linked 

through an electronic cancer health record. 

We see a future in which new therapies are 

tested more efficiently, beginning with evidence of efficacy, viewed from inside the 

tumor. We envision a care system where 

access to science and cancer treatment of the 

highest caliber are available to all patients, 

in our major university-based cancer centers 

and in the communities where they live. We 

are working for a day when the American 

story of all forms of cancer will be about 

survivorship, about a once-fatal disease — a 

disease that is cured or a disease turned into 

a chronic one. And we are committed to the 

kind of medical diplomacy that helps all 

nations of the world achieve greater success 

against their cancer burdens. 

This document is about the initiatives NCI 

has begun or strengthened, to guide cancer 

research through the remaining years of the 

21st century. These plans and programs, 

if nurtured in the years ahead, hold great 

promise of unprecedented progress. They 

also remind us of the economic force that 

is cancer research, bringing and sustaining 

quality jobs in communities across the nation. 

Over my career — as a physician-researcher, 

surgeon, professor, medical school administrator, NIH advisor, and cancer center 

director — I have been privileged to work 

with outstanding professionals deeply committed to cancer research and care. As 

National Cancer Institute director, I come 

to work each day with a dedicated group of 

individuals who are the envy of the world. 

Together we work to support the nation’s 

investment in cancer research, a workforce 

thousands strong and unflinchingly dedicated to a common purpose. It is an honor 

to lead them, both intramural and extramural, to represent their achievements, and to 

boldly promise that NCI recognizes, and will 

firmly grasp, every opportunity for continued progress. Our country and our patients 

are counting on it. 

John E. Niederhuber, M.D. 

Director, National Cancer Institute 

| 2 T h e N a T i o N a l C a N C e r i N s T i T u T e 
 

 

 

Introduction
�

n early February 2009, just weeks Iinto President Obama’s administration, the National Cancer Institute 

was poised for positive news. Congress 

appeared to be heading toward an omnibus spending bill for the 2009 fiscal year 

that would give NCI a budget increase of 

just over 2 percent. While still somewhat 

lower than the biomedical research inflation rate, such a potential raise — NCI’s 

first budget increase in four years — was 

a most welcome possibility, especially 

during a difficult economic downturn. 

Also that February, rumblings from Capitol Hill suggested that the Institute might 

receive as much as $125 million, to be 

spread across two years, through an economic stimulus package. It was clear that 

these two potential infusions of resources 

would require careful planning and coordination, to make sure every dollar had 

the greatest possible impact on the 

nation’s cancer research infrastructure. 

A month later, everything changed. 

It began February 17, at the Denver 

Museum of Nature and Science, where 

President Obama — sitting at a desk in 

front of a row of American flags, with 

Vice President Biden looking over his 

shoulder — put pen to paper and, four 

days after Congress’ passage, signed the 

American Recovery and Reinvestment 

Act into law. At its core, the $787 billion 

legislation was about jobs and the American 

President Obama 

signs ARRA into law 

in Denver, Colorado 

Credit: Official White House 

Photo by Pete Souza 

T h e N a T i o N a l C a N C e r i N s T i T u T e | 3 
 

economy: creating and preserving employment and spurring economic activity. 

“It’s about rising to the moment when the 

moment is hard, converting crisis into opportunity, and seeing to it that we emerge 

from whatever trials we face stronger than 

we were before,” the President said at the 

signing ceremony. 

This economic stimulus package — 

ARRA, as it became widely known — 

turned out to be much more. The law 

allocated $10.4 billion to the National Institutes of Health for biomedical research 

and support. President Obama expressed 

his hope that “this investment will ignite 

our imagination once more, spurring new 

discoveries and breakthroughs in science, 

in medicine, in energy, to make our economy stronger and our nation more secure 

and our planet safer for our children.” 

Ultimately, ARRA brought $1.26 billion 

in new funds to NCI, to be obligated in 

the remaining seven months of the 2009 

fiscal year and in 2010. But the news of 

2009 did not end there. 

On March 10, Congress completed action on the Omnibus Appropriations Act 

of 2009. Signed by the President the next 

day, this legislation brought NCI a budget 

increase of approximately $138 million, 

or 2.9 percent. With the enactment of that 

second bill, the careful planning and coordination NCI had begun a month before 

took on a new sense of urgency — and the 

air of a once-in-a-lifetime opportunity. 

Opportunity, however, is not created 

by dollars alone. It is the confluence of 

unexpected funding with progress in the 

nation’s outstanding cancer research laboratories that creates exceptional potential. 

Yet, at the NCI, our hopes for progress in 

the very fundamental aspects of scientific 

discovery are always balanced against human need. Cancer, we know all too well, 

remains a very complex and formidable 

foe. A recent study predicted that if more 

progress against the disease is not forthcoming, the number of cancer cases in 

the United States could reach 2.3 million 

by the year 2030, a 45 percent increase 

from the 1.6 million estimated new cases 

predicted in 2010. 

Management of an institute as large 

as NCI cannot ever be a static process. 

America’s cancer research enterprise is 

continually growing, as it should be, and 

at the same time, it is becoming more 

technologically intricate and sophisticated. Virtually any budgetary increase will 

quickly be overtaken by demand, particularly in an era of complex and expensive 

genomic research. In any year, NCI leadership must carefully look at the Institute’s 

| 4 T h e N a T i o N a l C a N C e r i N s T i T u T e 
 

 

 

entire portfolio, carefully considering 

where programs can be eliminated or curtailed, in order to redirect resources to 

pressing and emerging areas of research 

opportunity. That managerial process 

was no different for 2009, even with the 

increase to NCI’s appropriated budget. 

Increase or not, funding the best science 

requires clear-eyed analysis and foresight. 

The unexpected fiscal infusion from 

ARRA presented a unique set of challenges. First was the ever-present reminder 

that this was about employment. (As of 

January 2010, ARRA had created or saved 

about two million jobs). But it was also 

about the President’s challenge to advance 

science. ARRA came with unprecedented 

requirements for reporting — about dollars spent, jobs created, and the status of 

projects — all to be publicly available. 

In addition, it was mandated that ARRA 

funds and appropriated funds could not 

be mingled in any way, as if they were 

different colors of money. The hurdles of 

process and review for NCI were welldefined; in the months that followed, the 

staff of the Institute showed it was more 

than up to the challenge. 

setting clear priorities. Individual investigators conducting hypothesis-driven 

science remain the lifeblood of NCI. 

It was clear, from the beginning of NCI’s 

planning, that the majority of ARRA 

dollars would go to supporting their work. 

Quantum dots used 

to detect cancer shown 

in laboratory flask 

at the Johns Hopkins 

Engineering in 

Oncology Center 

“This investment will ignite our imagination once more, spurring new discoveries and breakthroughs in 

science, in medicine, in energy, to make our economy stronger and our nation more secure and our planet safer for 

our children.” —President Barack Obama 

T h e N a T i o N a l C a N C e r i N s T i T u T e | 5 
 

During deliberations on ARRA priorities, NCI’s executive leadership came to 

believe that these dollars could also be 

used to launch new initiatives that hold 

immense potential to alter the future of 

biomedical research: programs and projects of great magnitude with large-scale 

resource requirements that otherwise 

would have taken many years to begin. 

Among those initiatives, NCI is committed to even more deeply studying the 

human genome and the genetics of cancer; developing a manifest vision for the 

development of new, targeted therapies; 

devising streamlined and innovative approaches to clinical research and clinical 

trials; bringing the fruits of our science to 

patients in the communities where they 

live; eliminating the all too common inequities of cancer care; and investing in 

supporting technologies and infrastructure that will make it possible to enter 

this new era of personalized, highly prescriptive cancer medicine. 

It is our hope that this document will help 

you better understand the science — and 

the scientific careers — that ARRA has 

made possible and, in the end, the progress that we can more rapidly attain, if 

these initiatives see continued and robust 

financial support. It is truly a story of 

progress for cancer patients. 

Melanoma cell 

observed under 

ion-abrasion scanning 

microscopy, a strategy 

used for 3-D imaging 

of biological specimens 

Credit: Donald Bliss, 

National Library of Medicine, 

and Sriram Subramaniam, NCI 

| 6 T h e N a T i o N a l C a N C e r i N s T i T u T e 
 

supporting individual 

investigators 

iomedical science clearly depends Bon ideas and on the researchers 

who pursue them: individual scientists, driven by hypotheses and dedicated 

to rigorous research methods that, over 

the course of time, lead to scientific discovery. These are dedicated women and 

men who work at the laboratory bench 

or in the clinic (or, in some cases, both), 

in the belief that intense investigation will 

make a life altering difference for cancer 

patients. At NCI, the RPG, or Research 

Project Grant, has long been the mainstay 

of scientific investment and progress. The 

researchers NCI supports, the majority 

of whom work in our country’s great research universities, are also the professors 

who nurture, develop, and mentor new, 

young scientists. Those scientific careers 

— both established and emerging — have 

been of great concern during the past five 

years. As budgets remained flat, when 

adjusted for medical inflation, NCI was 

required to reduce spending by up to $175 

million per year, in order to redirect or reprogram funds to be able to fund new initiatives. Over the past decade, anecdotes 

of dwindling laboratory staffs and young 

scientists turning away from biomedical 

research have echoed more and more frequently through the cancer community. 

Mindful of the clear and present need, 

it was NCI’s top priority in 2009 to bolster support of individual investigators. 

Using appropriated dollars, we were able 

to increase funds for established investigators and new grantees, the associate and 

assistant professors whose professional 

development and hopes for academic tenure are frequently hinged to an NIH grant. 

Using separate infusions of ARRA funds, 

we were able to fund even more investigators, although in many cases for just two 

years. All told, NCI awarded 5,461 RPGs 

in fiscal year 2009 (4,918 grants funded 

with appropriated dollars, bolstered by 

543 ARRA grants), a 5.5 percent increase 

over fiscal year 2008. 

Additional ARRA resources have been 

dedicated to supplementing existing 

grants. NCI has also developed recruitment packages that assist new faculty 

members, and the universities for which 

they work, in starting their research programs; incentives to help bring established 

investigators back to cancer research; and 

methods of support designed to draw 

together as diverse a research community 

as possible. 

The mere possibility of ARRA support 

led to a groundswell of applications, particularly through two trans-NIH opportunities: Challenge Grants, which address 

specific scientific and health research 

challenges in biomedical and behavioral 

research that will benefit from significant 

two year jumpstart funds, and Grand 

Opportunities grants, which are being 

used to support high impact ideas that 

lend themselves to short-term funding 

and may lay the foundation for new fields 

of scientific inquiry. While great care was 

taken to ensure that the finest science was 

funded, many meritorious proposals still 

went unsupported. Hence, NCI expects 

that many of those unsuccessful applicaT h e N a T i o N a l C a N C e r i N s T i T u T e | 7 
 

 

 

 

 

tions may come back as applications for 

RPG support in the 2011 fiscal year. 

The BoTToM liNe. Laboratory research is an 

iterative process that does not lend itself 

to showing progress according to a date 

on the calendar. Consequently, after ARRA 

funds are expended, there is no doubt that 

many investigators will return to NCI, seeking continued support. In order to continue 

funding promising research, and maintain 

the RPG success rates that ARRA made 

possible, NCI would require an additional 

$310 million in the 2011 fiscal year. 

advancing Genomic science 

ancer is an extraordinarily complex Cdisease of uncontrolled cellular 

growth, proliferation, and spread, 

combined with very unique networks of 

chemical interactions between the tumor 

and its host. 

The disease is not singular in definition, 

but differs according to the organ site of 

origin; it often has important genetic and 

phenotypic subtype differences within 

the same site — breast or lymphoma, for 

example — and differences between primary 

and metastatic sites, as well as between 

young patients and older patients. Cancer relies on many communication pathways in the cell, and it utilizes the seemingly normal microenvironment of the 

tumor for nourishment and support. Yet, 

cancer begins in our DNA. Its origins may 

come from the genes we inherit from our 

parents; it may arise from the changes to 

our genes that accumulate over a lifetime 

— or to the regulatory systems within the 

genome that control how the genes code 

for and assemble their specific proteins. 

Environmental factors, from tobacco use 

to pollutants in the air we breathe, to 

chemicals and infectious agents, may play 

roles as well. All of these areas clearly 

demonstrate the importance of studying 

the genome, both of healthy people and 

of the cancers they develop. 

Without any doubt, the completion of the 

Human Genome Project in 2003 opened 

a new era of science. That landmark 

effort completed a catalogue of the thousands of protein-encoding genes in the 

human genome. The challenge of cancer 

science is to apply that knowledge to the 

treatment of disease. 

In 2005, NCI and the National Human 

Genome Research Institute launched 

what has rapidly become one of the most 

significant efforts in genomic science: The 

Cancer Genome Atlas. TCGA is a largescale, high-throughput, multi-institutional effort to sequence and characterize the 

genetic and epigenetic changes associated 

with the development of cancer. It is an 

enterprise born of technological advances 

but sustained by scientific prowess. 

TCGA is this nation’s largest comprehensive effort to apply our knowledge of the 

normal human genome sequence to a very 

complex disease. 

| 8 T h e N a T i o N a l C a N C e r i N s T i T u T e 
 

 

 

 

Because of the investment in the Human 

Genome Project, today’s sequencing technology has greatly increased capacity and 

speed, with rapidly falling costs. What 

once took tens of millions of dollars and 

years to accomplish can now be done in 

about a week for $10,000 or less, thanks 

to next-generation sequencing technology. The day of the $1,000 genome, 

sequenced nearly in real time, is no longer 

a futurist’s vision. 

In its pilot phase, TCGA set out to 

sequence the genomes of three cancers: 

glioblastoma, lung cancer, and ovarian 

cancer. As important as sequencing — 

creating the catalogue, if you will — is 

genomic characterization. Such analysis takes huge volumes of raw sequencing data, from the hundreds of tumors 

sequenced, and documents the mutations, changes in gene copy number 

(duplications of the same gene), translocations, and other alterations of the 

genome and epigenome that are associated 

with the particular cancer under study. 

In glioblastoma, TCGA has identified 

four distinct subtypes of the disease that 

will help to stratify patients into different 

treatment regimens — to make clear what 

therapies would have greater or equally 

important benefit for certain patients. 

As will be discussed later in this document, TCGA will be a key driver of future 

research, as scientists translate this new 

knowledge into targeted therapies. 

Because of TCGA’s enormous potential, 

the National Institutes of Health chose it 

as one of seven Signature Projects to get 

special emphasis under ARRA. Utilizing 

the latest technologies and techniques, 

TCGA is expanding to probe 20 or so additional tumors in the next two years. 

NCI has, in the past, also supported a similar program directed at the genomic characterization of pediatric cancer known as 

Therapeutically Applicable Research to 

Generate Effective Treatments, or TARGET. The TARGET initiative utilizes 

the power of modern genomics research 

technologies to identify new therapeutic 

targets for childhood cancers. The success 

of this pediatric project and TCGA led to 

assigning $25 million in ARRA funding 

to TARGET, which will enable expanding 

the research scope from a current focus on 

acute lymphoblastic leukemia and neuroblastoma, to at least five more pediatric 

cancers for which current treatments are 

deemed inadequate. NCI is merging our 

efforts in pediatric tumor sequencing and 

genomic characterization to maximize the 

ability to bring the best minds and experience to work in this field, across the spectrum of all cancers — pediatric and adult 

— so that the knowledge gained can have 

optimal impact. 

The BoTToM liNe. The genomic analysis of 

all major tumors, along with a host of rarer 

types, will be critical to continued research 

progress against cancer and will continue long after ARRA funds are expended. 

NCI will be pushing the TCGA project to 

complete sequencing with FY 2011 funds 

of 2,400 cancer genomes and matched 

normal tissues from 17 tumor types. 

Continuing to support NCI’s activities in 

TCGA and TARGET would require an additional $27.5 million in the 2011 fiscal year. 

T h e N a T i o N a l C a N C e r i N s T i T u T e | 9 
 

ronald DePinho, M.D., Dana-Farber 

Comprehensive Cancer institute 

Generals and soldiers” and “enemies and holding the line” sound like battle paradigms for “the Army or Navy, but in the eyes of Ronald 

DePinho, M.D., professor of medicine at Dana-Farber 

Cancer Institute in Boston, these are perfect analogies 

for how TCGA is approaching cancer and its genetic 

underpinnings. “For the past several decades, we knew 

where 5 to 10 percent of the enemy troops were, meaning we had discovered about 5 to 10 percent of the 

genes responsible for cancer. Soon, TCGA will provide us 

with full visibility of the enemy troops, along with strong 

strategy opportunities and points of attack.” 

Many new genetic aberrations have come to light in 

just the few years that the TCGA project has been up 

and running — more than had been previously thought 

possible. Recent research at Dana-Farber demonstrates 

the progress that has been made in the area of genes 

and cancer causation. For example, the ALK (anaplastic 

lymphoma kinase) pathway has been identified as a 

significant target for intervention. A new investigational 

drug, developed to selectively attack the ALK mutation 

in lymphoma may also be a viable treatment option for 

people suffering from another form of cancer, non-small 

cell lung cancer, because researchers have found that 

this disease also demonstrates an aberrant ALK pathway 

alteration and activation. 

Although TCGA is providing a treasure trove of data, it 

is still a first step. The next step is to understand the 

functional relevance of these mutations. Moreover, 

said DePinho, “Cancer is not a simple collection of a few 

genetic alterations, occurring in a monotonous collection 

of tumor cells, but an intricate organ system with cellular 

complexities including interactions with surrounding 

host cells.” 

We now know that an increasing number of tumor genes 

will need to be identified in order to develop effective, 

targeted therapeutic agents 

for cancer. Scientists must first 

identify “driver” genes and distinguish these from irrelevant 

“bystander” genes. Then, those 

hundreds to several thousands 

of genetic elements of interest 

must be functionally analyzed 

to determine the mission critical events, which perhaps boil 

down to a few dozen genes that 

are driving the biology of these 

cancers and their response 

to therapies, DePinho added. 

“Moreover, we need to further 

distinguish those genes that initiate the cancer processes from 

those that are responsible for 

the maintenance of established 

tumors. These tumor maintenance events will represent 

the best strategic points of 

attack, leading to more durable 

responses.” 

Returning to his battlefield 

analogy, DePinho said that maintenance genes are the 

generals — their extinction will stop most tumors — but 

some genes develop bypass mechanisms. Investigators must identify how this bypass happens and combat 

these rogue genes with new combination drug therapies 

for cancer, similar to the multi-drug strategy that is often 

employed against bacterial infections. 

Today, DePinho continues to work in his lab discovering 

the underpinnings of cancer by using TCGA-generated 

data in conjunction with mouse models of human cancer. These studies evaluate the roles played by growthpromoting oncogenes and tumor suppressor genes that 

10 T h e N a T i o N a l C a N C e r i N s T i T u T e | 
 

 

 

 

 

 

 

 

 

Ronald DePinho, M.D., Dana-Farber Cancer Institute/ 

Credit: Sam Ogden, Dana-Farber 

constrain growth and/or stimulate differentiation. In recent 

work, with collaborators Samir M. Hanash, M.D., Ph.D., of 

the Fred Hutchinson Cancer Research Center in Seattle, and 

Nabeel Bardeesy, Ph.D., from the Massachusetts General 

Hospital in Boston, a panel of proteins linked to early development of pancreatic cancer in mice was identified that also 

applies to early stages of pancreatic cancer in humans. This is 

a breakthrough that brings scientists a significant step closer 

to developing a blood test to detect the disease early, when 

cure rates are highest. 

Facilitating Genomic study
�

he Cancer Genome Atlas — in Taddition to NCI’s other major 

efforts at whole genome scanning, 

such as the Cancer Genetic Markers of 

Susceptibility (CGEMS) program — is 

continually contributing more and more 

volumes to the catalogue of cancer information. NCI has established a data sharing 

policy to ensure that de-identified human 

genomicdataareavailabletotheentirecancer 

research community. Genome-wide association studies of cancer risk, conducted through 

CGEMS and other closely related programs, 

have identified more than 400 loci, or 

locations along the genome, that indicate 

an association with predetermined cancer 

risk. These regions will need further study 

to determine the biologic significance 

of their increased risk and prognosis, as 

well. These discoveries should point to 

genetic regions that are most susceptible to 

alteration and the interacting environmental exposures that drive later carcinogenic changes over the course of a person’s 

life. The next generation of genome-wide 

association studies will be conducted in 

conjunction with clinical studies, with the 

aid of comprehensive treatment and survival data, in order to assess determinants 

of tumor progression, therapy response, 

and late effects of treatment. 

One of NCI’s responsibilities will be to 

provide leadership and coordination of 

the many projects underway now and 

planned in the future in this field of study. 

TCGA, CGEMS, and other projects 

directly sponsored by federal dollars 

T h e N a T i o N a l C a N C e r i N s T i T u T e 11 | 
 

 

 

 

should be coordinated, as much as possible, with similar projects supported by 

foundations, private resources, and by 

other governments. We must lead the way 

in knowledge sharing, through publicly 

accessible databases, and we must strive 

to ensure, as best possible, that our efforts 

are complementary, representing the best 

use of precious resources: dollars and patient tissues. 

In the years ahead, there is no question 

that NCI’s most pressing challenge will 

be to take the information from that 

catalogue and turn it into a cancer repair 

manual. This will not be easy; many are 

concerned about expectations being created by our efforts. Translation of this new, 

and certainly empowering, knowledge 

will require diligence as scientists work toward understanding how that knowledge 

can ultimately be used in making a difference for patients. Many coordinated steps 

will be involved, from understanding the 

biological function to chemistry to drug 

development to first-in-human testing. A 

common starting point among them all 

will be the management of information. 

The cancer Biomedical informatics Grid. 

caBIG® has a deceptively simple mission: 

electronically connecting the cancer 

research community. It begins with information from genomic and other research, 

measured by the petabyte (109 megabytes) 

that is safely and securely stored and accessible. Data are also annotated with 

clinical information and protected. caBIG 

connects scientists, in the laboratory and 

the clinic, through a single infrastructure, 

with standard rules and common language 

developed for information sharing. caBIG 

builds and develops tools for collecting, 

analyzing, and disseminating information 

associated with cancer research and care. 

caBIG also is the information backbone of 

TCGA, providing tools and connectivity 

to collect, organize, share and analyze its 

data. Developing the new age of analytical tools and mathematical models needed 

to maximally utilize such large and varied sets of information will require a significant investment in the years ahead. 

The magnitude of this is yet to be well 

realized. As discoveries move toward the 

clinic, caBIG also provides tools for the 

management of clinical trials and specimen acquisition — and most importantly, 

a pace-setting initiative to implement the 

use of the electronic health records. The 

knowledge gained through caBIG will 

benefit not only cancer research, but the 

entire biomedical research enterprise. 

The BoTToM liNe. ARRA funding is enabling 

the expansion of caBIG, both in scope and 

mission, particularly toward its goal of developing an interactive online knowledge 

base of all-important cancer information. 

Continuing support of caBIG would require 

an additional $103 million in the 2011 

fiscal year. 

The cancer human Biobank. Inasmuch as 

caBIG relies on rigorously collected, carefully protected and stored data, genomic 

studies through TCGA and other initiatives demand the highest quality tissue, 

blood, and tumor samples, rigorously and 

ethically collected, properly stored, and 

extensively annotated. In short, that is the 

message of one of NCI’s new initiatives, 

the cancer Human Biobank, or caHUB. 

| 12 T h e N a T i o N a l C a N C e r i N s T i T u T e 
 

Brian henderson, M.D., usC Norris Comprehensive Cancer Center

T

wenty years of planning, cajoling, meeting, and 

organizing are now paying off in big ways for NCI’s 

cohort consortium, an effort to link many individual groups of research subjects into a more informative 

whole. NCI’s wide-ranging research cohorts, along with 

the extremely large amounts of resources and data they 

collectively make available, will help the Institute rapidly 

advance its understanding of genomic changes and environmental influences in cancer across large, ethnically 

diverse populations. 

One of the deans of these efforts is Brian Henderson, 

M.D., from the USC Norris Comprehensive Cancer Center 

in Los Angeles who, for the past 15 years, has headed up 

a multi-ethnic cohort with Laurence Kolonel, M.D., Ph.D., 

of the Cancer Research Center of Hawaii. By pooling 

biospecimens from 10 large study populations, investigative teams now have a much better understanding 

of the relationship between genes and environmental 

influences that play a role in prostate, colorectal, and 

breast cancer for native Hawaiians, Japanese, AfricanAmericans, and Latinos. 

Prior to these studies, most cohort gene studies were 

done in homogenous European populations. One of the 

least studied populations, at least from a genetic variant 

perspective, is Native Americans. “Because Latino populations, particularly in Mexico, have up to 50 percent 

Native American ancestry, the cohorts we’ve assembled 

there will be most useful in helping us elucidate some of 

the genetic variants and risk factors for Native Americans,” said Henderson. Individual cohort studies alone 

seldom gave us sufficient power to obtain highly reliable 

data, he noted. “Because we’re all now using just a couple 

of the same gene analyzer machines with the same 

basic chips, some of which will soon be able to store five 

million samples per chip, we expect to rapidly accelerate 

our ability to collect and analyze specimens so that we 

can apply those findings to prevention and treatment 

modalities for some of the most prevalent cancers.” 

One of the key understandings to come out of the 

consortia research is that prostate cancer has virtually 

no environmental variables associated with it. Thus, 

through deep re-sequencing, the multi-ethnic consortia 

are looking for rare functional variants in high-risk populations, such as African-Americans, to try to find those 

inherited variants that may confer greatest risk.

The cohort consortia effort has been a truly collaborative 

one, involving many NCI-sponsored research institutes, 

such as the Broad Institute of MIT and Harvard in 

Cambridge, Mass., among others. The consortium now 

includes more than 20 cohorts and is facilitating almost 

instantaneous replication of each other’s findings, giving a high degree of confidence in findings that show a 

strong association between gene variants, hormones, 

and growth factors that can all influence the risk of cancer. “We’ve now assembled truly global consortia, as we 

know we can’t do these studies on our own, and I expect 

that future cohort studies will be quite collegial and 

fruitful,” said Henderson. Brian Henderson, M.D., University of Southern California 

Norris Comprehensive Cancer Center/ Credit: USC Norris 

T h e N a T i o N a l C a N C e r i N s T i T u T e 13 | 
 

susan love, M.D., Dr. susan love research Foundation

Susan Love, M.D., (second from right) 

Dr. Susan Love Research Foundation 

Credit: Dr. Susan Love Research Foundation 

Aunique collaboration is using the tools of caBIG 

to help bring together a million women to 

participate in breast cancer research. The Army 

of Women initiative, launched in October 2008, is the 

brainchild of the Dr. Susan Love Research Foundation. 

The Army of Women had recruited over 320,000 women 

for 18 different studies by the beginning of 2010. The Dr. 

Susan Love Research Foundation in Santa Monica, Calif., 

working in concert with City of Hope’s Beckman Research 

Institute in Duarte, Calif., and NCI, will now be recruiting women (and men) of all ages and ethnicities for the 

Health of Women study, which will follow long-term 

cancer survivors to identify both predictors of longevity 

and consequences of therapy. It will also look at healthy 

women in order to develop a better understanding of 

potential new risk factors for breast cancer. 

“Women have repeatedly demonstrated through fundraising and advocacy their personal dedication to ending 

this disease,” said Susan Love, M.D., the foundation’s 

president. “This initiative gives women the opportunity 

to take the next steps and be part of the research itself.”

caBIG tools are enabling the secure online submission 

and handling of data for the study. Using web technology, women can respond to periodic short questionnaires 

or modules about their personal or family health history, 

reproductive health, breast cancer (for those with the 

disease) experiences, and much more. Because fewer 

than 20 percent of women who get the disease demonstrate any of the known risk factors for breast cancer, 

information gathered in this study should provide valuable insight for researchers in the field. 

Additionally, the Health of Women study allows researchers to rapidly pose questions, using a larger 

sample population than has ever been feasible. That, in 

turn, will make research more dynamic and let investigators be more flexible in their studies. The hope is that research studies that used to take months or years can be 

done in days or weeks, as data become more accessible. 

“Many of the researchers using the Army of Women have 

recruited everyone they needed for their studies within 

24 hours. In many cases, we even recruited more people 

than they needed. This has amazed the research community and pleased all of us,” said Love. The collaboration also has the potential to empower participants to 

feel involved in research while they are 

healthy or if they are diagnosed with 

the disease. 

14 T h e N a T i o N a l C a N C e r i N s T i T u T e | 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A microarray at NCI’s 

Core Genotyping 

Facility, capable of over 

2,000 high-throughput 

assays at a time. 

Begun in 2009, as the culmination of 

several years of work in developing techniques and best practices, caHUB will 

be a national biobank, a repository of 

biological materials and associated data, 

acquired within an ethical framework, 

that can be used for medical research. 

caHUB will help ensure that a continuous 

supply of biospecimens is available to the 

cancer research community. caHUB is 

also advancing technology development 

to support biobanking practices. 

caHUB will, on one hand, help solve the 

longstanding problem of many scientists who face great obstacles in obtaining high-quality research samples; on 

the other hand, this initiative will also 

advance science in its own right, through 

connections to caBIG, which will enable the combination of biospecimens 

with data derived from research on those 

specimens at the molecular level. Each 

specimen, then, will be the source of a 

uniquely rich data profile. 

The BoTToM liNe. An ARRA investment of 

$60 million has helped caHUB become an 

established program ahead of its original 

timetable. Because of the critical importance of biospecimens to leading-edge 

cancer research, to maintain caHUB as 

a first-class resource, would require an 

additional $60 million in the 2011 fiscal 

year. 

Patient Characterization Center. As genomic science rapidly moves forward, cancer science is pushing toward an era when 

the molecular characteristics of patients 

and their tumors (primary and metastatic) 

will be more clinically significant than the 

organ site where the cancer originated. 

Consequently, the need for characterization 

of individual cancer patients will grow in 

significance — and likely quite soon. NCI’s 

proposed model to support that future is its 

Molecular Characterization/Clinical Assay 

Development Center, which will include a 

Patient Characterization Center. 

This center will be a model for the development of personalized, highly prescriptive 

cancer care, based on traditional epidemiological and risk-factor analysis combined 

with molecular characterization of a patient’s tumor as well as the pharmacogenetics and pharmacogenomics of the patient. 

Ultimately, the center will have the capacity to perform complete genomic characterization of patient specimens (normal and 

tumor). This characterization will evolve, 

as technology and cost permit, to include 

proteomic and metabolomic key information relevant to the patient’s tumor process. 

While NCI has responsibility for innovative 

technology development and proof-of-principle standards, it also must lead the way 

in distribution of this science to appropriate sites across the country. In the end, all 

patients must have access to characterization 

technologies to inform personalized care. 

The BoTToM liNe. ARRA funds have made 

possible the launch of an initiative that 

might otherwise have taken years to move 

forward. Continuing development of the 

Patient Characterization Center would 

require an additional $12 million in the 2011 

fiscal year. 

T h e N a T i o N a l C a N C e r i N s T i T u T e 15 | 
 

 

Taking the Genome to the Clinic

he results of genomic studies, as Tpreviously discussed, are extremely 

important science. Yet they remain, 

for the time being, largely fascinating information which we must further refine, 

in order to turn them into new therapies. 

The reason, simply stated, is that genes do 

not have an active role in disease. Rather, 

genes “express” themselves by initiating 

the deeply complex process of creating 

the cell’s functional molecules: proteins. 

The intricacy of such processes is, in fact, 

where cancer research is finding important 

opportunities. But the process begins with 

knowledge of a gene gone awry. For example, in a non-invasive breast cancer known 

as ductal carcinoma in situ, or DCIS, cases of DCIS were highly correlated with 

mutations in the gene p53. 

Turning information about genomic and 

genetic aberrations into knowledge of 

biologic function — about proteins and 

pathways that control cancer’s development and growth — is becoming an ever 

more crucial role of NCI. New knowledge 

from programs like TCGA is spurring 

laboratory research to turn cancer cell 

signaling pathways and epigenetic regulatory mechanisms, once considered too 

complex and difficult to hit, into targets 

for new therapies. NCI is using ARRA 

resources to bolster a platform of initiatives designed to take knowledge of function derived from genomic discoveries and 

turn that knowledge into therapies. However, the mechanisms used to drive these 

initiatives forward are somewhat unique 

and thus optimally will involve numerous university-based researchers, who will 

be joined into several consortia, to tackle 

specific tasks. This will bring to bear 

greater amounts of resources — including 

teams of scientists — than any one institution could bring together. These coordinated programs are doing important work 

today that will help NCI continue to play 

a unique role as a facilitating institution. 

Chemical Biology Consortium. Probing 

cancer’s complex networks of signaling 

pathways requires cutting-edge chemical tools, which often exceed the capacity of an individual laboratory or, for that 

matter, an individual research university. 

Along with NCI’s functional biology efforts, NCI’s Chemical Biology Consortium (CBC), which sits at the intersection 

of chemical biology and molecular oncology, is designed to be a flexible network of 

hundreds of scientists working to increase 

the flow of early-stage drug candidates 

into the developmental pipeline. By establishing this network — including government, academia, and industry — the CBC 

will focus on the chemistry needed to optimize compounds or small molecules and 

to improve efficacy and reduce toxicity 

in pre-clinical assays and animal models 

prior to first-in-human testing. 

The CBC will revolve around task-oriented science, involving projects with clear 

objectives, deadlines, and milestones. Of 

vital importance to this initiative will be 

the selection of projects. Without question, there is great demand for refinement 

and definition of potential targets and 

targeted agents; consequently, we must 

carefully prioritize those efforts in order 

to push the most promising concepts more 

rapidly toward the clinic. That is why 

the CBC is employing a Special Emphasis Panel: outside experts who will meet 

periodically to recommend which projects 

the consortium should focus on. Their 

16 T h e N a T i o N a l C a N C e r i N s T i T u T e | 
 

 

 

 

Dr. Ingrid Fernando, a 

postdoctoral fellow in 

the lab of Dr. Claudia 

Palena, NCI, harvesting cells from tissue 

culture dishes. 

challenges in the years ahead will be steep: 

selecting between worthy applicants to 

make sure only the most promising agents 

enter the pipeline. Already many dozens of 

applications, representing a variety of scientific approaches, have been reviewed, including, just to name a few, small molecule 

inhibitors; a new, low molecular weight 

imaging agent; and several agents targeted 

against various cancer proteins. In 2009, 

the first meetings of the Special Emphasis 

Panel began the process of selecting which 

compounds of the highest scientific priority 

were ready to move forward. 

The BoTToM liNe. ARRA funds have enabled 

NCI to more rapidly establish the Chemical 

Biology Consortium and begin work on an 

initial list of projects. In order to sustain the 

project and further its momentum, the CBC 

would require an additional $11 million in the 

2011 fiscal year. 

The NCi experimental Therapeutics Program. NCI’s functional biology efforts 

and its Chemical Biology Consortium are 

key components of the NCI Experimental 

Therapeutics Program (NExT), a wideranging initiative that is making possible a 

more unified approach to drug therapy development. NCI, using the specific, highly 

specialized programs that comprise NExT, 

is committed to optimally using that environment to nimbly and rapidly facilitate the 

many back-and-forth handoffs that must 

occur between academic research laboratories, the NExT platform, and the private 

sector, in order to achieve the ultimate goal 

of translation to patients. NExT combines 

the anti-cancer drug development expertise of NCI’s Division of Cancer Treatment 

and Diagnosis with the depth of research 

capacity in NCI’s intramural Center for 

Cancer Research. The goal of NExT is to 

shorten the typical 10-year to 12-year drug 

development timeline by up to six years, 

getting promising drugs into human trials 

more quickly — and more rapidly eliminating drugs unlikely to be effective. 

Only 5 percent of applications for new 

oncology drugs submitted to FDA under 

an Investigational New Drug (IND) application are actually successful. Some of the 

reasons for this low approval rate include 

a lack of preclinical systems, such as genetically engineered mouse models and appropriate stem cells, to predict the efficacy 

and toxicity of new drugs; long timelines 

for drug development; high costs; and the 

increasing complexity of clinical trials involving 

molecularly-targeted agents and advanced 

technologies. Once oncology drugs make 

it to the second phase of clinical testing, 

T h e N a T i o N a l C a N C e r i N s T i T u T e 17 | 
 

approximately 70 percent do not advance, often 

because of a lack of efficacy. NExT is designed 

to address many of these problems earlier in the 

drug development process and to continue to 

evolve the process, always striving to decrease 

cost and time. 

NExT includes toxicology testing and drug 

manufacturing (when there is no commercially 

produced option), along with early phase clinical trials, including Phase 0 trials, in which 

non-toxic doses of an agent are tested in a small 

number of patients, utilizing advanced imaging to determine in weeks, not years, whether a 

drug is reaching its intended target and having 

its intended biologic effects. 

Specifically, a Phase 0 clinical trial is designed 

to study the pharmacodynamic and pharmacokinetic properties of a drug. Pharmacodynamics describes the biochemical and physiological 

effects of a drug on the body, including how the 

drug binds to various structures, and interacts 

with certain molecules within target tissues. 

Pharmacokinetics describes the activity of a 

drug in the body over a period of time. This includes the process by which drugs are absorbed, 

distributed in the body, localized in the tissues, 

and excreted. Considered together, data from 

pharmacodynamic and pharmacokinetic studies help researchers determine a rational dosage 

regimen for testing in subsequent clinical trials. 

In a Phase 0 trial, a limited number of doses 

and much lower concentrations of the drug are 

administered, therefore there is little risk to the 

participant. Fewer patients are needed (about 

10 to 12, on average, in a Phase 0 study compared to about 20 to 25 in a Phase 1 trial). By 

studying pharmacodynamics and pharmacokinetics, researchers can determine which agents 

are hitting their targets and weed out the drugs 

that are not producing the desired effects much 

John reed, M.D., Ph.D., 

Burnham institute for Medical research
�

For a quarter of a century, NCI has acquired, 

through its Natural Products branch, plants and 

marine organisms from more than 25 tropical 

and subtropical countries worldwide, including Africa, 

Madagascar, Central and South America, and Southeast Asia. During the same period, over 10,000 marine 

invertebrates and marine algae have been collected, 

mainly from the Indo-Pacific region. Important drugs, 

such as taxol, which comes from the bark of the Pacific 

Yew tree, were developed based on these collection 

efforts. But many drugs that have already been developed were based upon cell culture toxicities, which 

would be considered a rather crude marker today compared to more modern molecularly targeted therapies. 

Thanks to the establishment of the NCI-sponsored 

Chemical Biology Consortium, newly discovered or 

synthesized compounds will now be screened with 

highly specialized techniques to see if the drugs can be 

directed at carefully validated biological targets. 

“One of the more interesting series of compounds that 

we’re looking at are those that neutralize apoptotic, or 

cell death, targets,” said John C. Reed, M.D., Ph.D., president of the Burnham Institute for Medical Research 

in La Jolla, Calif. “Some marine species can’t outrun 

their predators so they use chemicals to ward them off, 

and it turns out that these chemicals have properties 

that can induce tumor cell death by neutralizing cell 

survival gene products that are over-produced in malignant cells, which is a very common event in cancer.” 

Burnham is at the forefront of screening these types 

of natural products using high throughput technology and advancing translational research to optimize 

development of these agents into highly targeted 

therapies. 

Eight years ago Burnham put a plan in place to transition the institute from a primarily basic science institution to one that had an active translational mission 

18 T h e N a T i o N a l C a N C e r i N s T i T u T e | 
 

as well, and chemical biology research is one of 

the key elements in this new mission. Reed notes 

that they have 80 researchers in both La Jolla and 

their campus in Orlando, Fla., working in this area. 

Between the two locations combined, Burnham has 

high throughput robots that are capable of screening nearly three million compounds per day. 

“Because a lot of biotechnology companies are no 

longer doing early stage discovery research, we feel 

that we’re filling that void quite well — we are going 

after the more difficult and challenging targets, 

such as protein-protein interactions,” Reed said. 

“Funding is a major issue; venture capitalists these 

days are primarily interested in funding product 

opportunities that have reached Phase II trials, so 

the Chemical Biology Consortium plays a vital role 

in early discovery.” 

John Reed, M.D., Ph.D., Burnham Institute for 

Medical Research/ Credit: Nadia Borowski Scott 

In particular, Reed noted, scientists at Burnham 

are looking intensively at cellular processes like 

autophagy, or the breakdown of a cell. Autophagy 

has recently been implicated as a possible agent 

of cancer causation, and trying to find valid targets 

that affect this process is going to be one of the 

important consortium projects done at Burnham. 

T h e N a T i o N a l C a N C e r i N s T i T u T e 19 | 
 

 

 

 

 

 

 

 

 

 

more quickly, and they can avoid moving those 

drugs into further trials. 

By conducting a Phase 0 trial on a particular 

drug, the process for Phase I and II trials on that 

drug is accelerated. Additionally, because Phase 

0 trials study how the body reacts to the drug 

and how the drug acts in the body, if a drug 

is found to react poorly or to have serious side 

effects, the testing for that drug can be stopped 

sooner, without the additional expense of further trials. 

aCTNoW. NCI is using ARRA resources to fund 

37 new Phase I and Phase II cancer treatment 

trials to test the effectiveness of molecularlytargeted cancer therapies. The program, Accelerating Clinical Trials of Novel Oncologic Pathways (ACTNOW) has a goal of shortening the 

time it takes to move new cancer therapies from 

discovery, to development, to approval and safe 

use by adult and pediatric cancer patients. 

The program has dedicated $31 million for 

early phase trials, plus $5 million for support 

contracts, including those to assist investigators with data monitoring and statistical analysis. This is money that is paying compound 

dividends in health care and jobs for physicianscientists, oncology nurses, clinical research coordinators, statisticians, medical assistants, and 

other staff members who are helping administer ACTNOW trials at institutions all over the 

country. 

Importantly, all of the ACTNOW studies are 

designed to integrate the latest imaging technologies and correlative laboratory research studies 

to help us understand the underlying biological 

mechanisms of action. 

ACTNOW awards are also contingent on a 

very strict, accelerated timeline. Study investigators were required to finalize institutional 

review board approval and begin enrolling patients within 90 days, and enrollment must be 

completed within the two-year ARRA timeline. 

Investigators are also required to submit quarterly metrics related to the economic impact of 

their project throughout the funding period. 

DruG DeveloPMeNT: The BoTToM liNe. As activities 

and initiatives across NCI’s drug development 

pipeline mature and become more successful, 

the need for modern, efficient clinical trials to 

test those new agents will increase proportionally. The success of the ACTNOW program under 

ARRA — in terms of greatly accelerating the process of trial initiation and significantly increasing 

the number of new drugs that could be tested in 

patients — has moved NCI to plan to award a similar number of ACTNOW trials in FY 2011. Adequately supporting NCI’s early phase drug testing 

and development efforts designed to shorten the 

time from discovery to patient use would require 

an additional $69 million in the 2011 fiscal year. 

NCi-designated Cancer Centers. The National 

Cancer Act of 1971 brought strong change to 

the operations of NCI, designating it as the 

leader of the National Cancer Program, making its director a Presidential appointee, and establishing the National Cancer Advisory Board 

and the President’s Cancer Panel, with members 

of both bodies also appointed by the President. 

The cancer act also provided NCI other important special authorities, including the NCI director’s capacity to “provide for the establishment 

of fifteen new centers for clinical research, training, and demonstration of advanced diagnostic 

and treatment methods relating to cancer.” 

Today, those centers number 65, and they can 

be found in 33 states plus the District of Columbia. These are places of great research, home 

to the majority of the individual investigators 

20 T h e N a T i o N a l C a N C e r i N s T i T u T e | 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NCI supports. One would have a difficult time 

finding any major NCI initiative — from TCGA to 

the Chemical Biology Consortium to ACTNOW trials — that does not involve Cancer Centers and their 

faculty members. They are places sought by cancer 

patients for the latest advances in treatment and by 

young scientists and clinician-scientists dedicated to 

solving the mysteries of cancer; they are places that 

provide the best cancer care anywhere, that train the 

next generation. Cancer Centers, located at the country’s major academic health centers, are also strong 

forces in their communities, providing care to underserved patients, providing leadership in the healthcare 

field, educating the community, and providing many 

health care, technical, or other support staff jobs. 

Through ARRA, NCI-designated Cancer Centers received $63 million to supplement their core 

grants. Additional ARRA funding was awarded to 

specific research investigators within Cancer Centers through other mechanisms at NCI and NIH, 

including Challenge Grants, Grand Opportunity 

Grants, comparative effectiveness research funds, 

and others. ARRA funding has allowed the Centers to hire and retain faculty and staff, purchase 

equipment for new and existing labs, increase their 

investment in information technology, and initiate developmental projects focused on clinical trials, personalized medicine, and health disparities, 

among other areas. 

The majority of Centers receiving ARRA funds 

were able to hire or retain between one and five 

new faculty, scientists, research coordinators, radiologists, research physicians, nurses, statisticians, 

post doctoral students, and laboratory technicians. 

Additional funding in FY 2010 is contributing to 

the hiring and retention of new faculty and other 

workers to support existing and new research opportunities. Through ARRA funds, Cancer Centers 

will also enhance current research facilities by purchasing additional large equipment, replacing older 

equipment, and, in some instances, constructing 

new facilities and renovating existing space. 

The BoTToM liNe. Cancer Centers are key 

participants — the linchpin, some might say — 

across virtually every NCI initiative. Their support needs will certainly never diminish, and 

there is a list of strong contenders that have 

been actively planning, with the strong backing of their universities, to prepare to apply 

for their Cancer Center Support Grant. Sustaining ARRA momentum at Cancer Centers 

and adding two new Centers would require an 

additional $50 million in the 2011 fiscal year. 

The NCi Community Cancer Centers 

Program. The NCCCP originated from a 

simple statistic: Approximately 85 percent 

of cancer patients in the United States receive 

their cancer care in the community where 

they live. For the complex, multispecialty care 

of cancer patients required today, community 

health systems and private practice cancer 

physicians have made great strides. Cancers, 

however, are not all common forms, and in 

some cases, simply diagnosing the correct disease can be a daunting process. In such cases, 

the NCI-designated Cancer Centers have long 

been the places patients seek out. For many, 

however, that is simply not possible. These 

patients may lack the strength, financial resources, insurance, language capacity, education, or family support system to seek out a 

large university health care system or NCIdesignated Cancer Center. 

With those reasons — and those patients — 

in mind, NCI created the NCCCP pilot to test 

the concept of a national network of community cancer centers to expand cancer research and deliver the latest, most advanced 

cancer care to a greater number of Americans in the communities in which they live. 

The principle was to give every cancer patient in the United States access to NCI — its 

science, its technology, and the latest guides 

to care. The NCCCP, through its current 16 

sites, extends the reach of NCI research into 

T h e N a T i o N a l C a N C e r i N s T i T u T e 21 | 
 

 

Mark Krasna, M.D., Cancer institute at st. Joseph Medical Center
�

Best practices. Those are the two words 

that the director of the NCI Community 

Cancer Centers Program’s (NCCCP) 

facility in Towson, Md., constantly espouses. 

“On an almost daily basis we assemble a team 

of physicians and other specialists from our 

facility and get them together with private 

practice doctors in the area and discuss everyone’s most challenging patient caseloads. We 

arrive at a solution that takes into account a far 

wider range of opinion than we could ever hope 

to assemble on our own,” said Mark Krasna, 

M.D., medical director of the Cancer Institute 

at St. Joseph Medical Center in Towson. “By 

assembling such a broad range of community 

expertise, patients essentially get a second and 

third opinion instantaneously, and for free.” 

As an NCI community cancer center, Dr. Krasna’s team is often able to offer a more personalized sense of care than some larger facilities. 

St. Joseph’s 6 percent clinical trials accrual rate, 

which he hopes to get to 10 percent by the end 

of 2010, is a testament to Krasna’s efforts, as 

the average adult accrual rate to cancer clinical 

trials is about 3 percent. Additionally, Krasna 

notes, what had been a three month course of 

treatment for many advanced cancers now only 

takes about two weeks, on average. “Most of our 

achievements have been based on the trust factor 

— we bring outsiders to us to see how we manage 

patients and offer them the opportunity to share 

their successes and failures with us, and by dint of 

that sharing, we’re all able to learn and benefit.” 

As an NCI community cancer center, St. Joseph’s 

doesn’t try to do what Krasna feels NCI-designated, 

university-based cancer centers already do extremely well, and that is discovery and early phase 

research. Rather, they tend to deal with later phase 

trials and more advanced disease and are eager to 

rapidly incorporate the important research findings 

developed by academic centers into their trials and 

patient care. 

St. Joseph’s is also part of the Catholic Health 

Initiative (CHI) chain of 70 hospitals and care 

facilities nationwide. Dr. Krasna notes that CHI is a 

microcosm of health care in America as it represents all ethnicities, geographies, and age ranges, 

and as a bonus to NCI and the NCCCP, many of its 

hospitals are in locations without NCCCP or NCIdesignated Cancer Centers. 

“NCI is certainly getting a good bang for its buck, 

because the best practices in cancer care being 

developed at St. Joseph’s and other such facilities are being rapidly disseminated to other CHI 

Mark Krasna, M.D., 

Cancer Institute at 

St. Joseph Medical 

Center 

more U.S. states, cities, and towns, including rural areas and inner cities. 

The NCCCP sites are working to draw 

more patients into clinical trials in community-based settings, reduce cancer health 

disparities, prepare sites for standardized 

collection and storage of biological specimens for cancer research under caHUB, 

and link all of the information gathered at 

these sites together with the national computer networks and electronic cancer health 

records made possible through caBIG. 

In just a little over two years, NCCCP sites 

have increased outreach staff and forged 

new community partnerships. They have 

instituted cancer screening initiatives, new 

survivorship programs and, importantly, 

have dedicated resources to reducing 

22 T h e N a T i o N a l C a N C e r i N s T i T u T e | 
 

hospitals in addition to NCCCP sites,” said Krasna. 

As a prime example, he noted that 90 percent of 

breast, lung and colorectal cancer patients are 

now getting multi-modality care, with routine prospective case presentation, which a center such 

as St. Joseph’s or other CHI hospitals can now 

easily handle. “This is a huge paradigm shift from 

just three years ago.” 

inequalities of care. Close to half of the 

NCCCP sites have also developed relationships with academic medical institutions. 

NCI, with the use of ARRA funds, plans to 

add approximately 14 competitively chosen 

NCCCP sites. We are also allocating funds 

to current NCCCP hospitals for two years, 

again competitively awarded, for 18 specific 

projects encompassing clinical trials, disparities, community outreach, biospecimen 

collection, electronic health records, quality 

of care, partnerships with state cancer plans, 

communications, survivorship, and palliative 

care. 

The BoTToM liNe. Sustaining NCCCP as a 

community project, as it moves to the end 

of its pilot phase and becomes a permanent 

NCI program, would require $56 million in the 

2011 fiscal year. 

areas of intensified scientific 

investigation 

ne important subtext to everything Odiscussed in this document is the fact 

that science thrives on ideas. It is 

often said that every truly successful experiment leads to 10 new questions to be studied. Thus, we face the obligation to look just 

over the horizon, to consider important new 

concepts at their earliest stages of intellectual 

development. Science most often can benefit 

from utterly unique viewpoints — from the 

unanticipated, and from creating opportunities for research at the crossroads of scientific 

disciplines. 

Physical science-oncology Centers. In 

early 2008, NCI commenced a series of meetings designed to elicit views of cancer from 

scientific disciplines that have traditionally 

not been involved in its study: physics, physical chemistry, engineering, and theoretical 

mathematics. The physicists, in particular, 

brought to the table a list of concepts more 

foreign to cancer biologists, including the influences on cells of heat, pressure, time, and 

evolution. Out of this series of three workshops came the realization and confirmation 

that the germ of an idea was a good one, and 

T h e N a T i o N a l C a N C e r i N s T i T u T e 23 | 
 

Franziska Michor, Ph.D., Memorial 

sloan-Kettering Cancer Center
�

T

he mental image of a cancer researcher is more 

likely to involve a lab coat than an equation. Yet, 

because of NCI’s Physical Science-Oncology Centers initiative, the picture is changing. 

“I’m trying to use techniques from applied math and 

statistics to answer questions in cancer research,” said 

Franziska Michor, Ph.D., principal investigator of the 

PS-OC at New York’s Memorial Sloan-Kettering Cancer 

Center. “We try to come up with a mathematical representation of a particular situation in cancer and then 

use mathematical techniques to solve it and make some 

useful predictions.” 

One of the projects Michor’s group is pursuing is the 

identification of the sequence in which genetic alterations arise on the road to cancer. “If you look at the cancer genome of a patient, you see hundreds to thousands 

of mutations. The question is, which of those mutations 

are necessary and sufficient to cause cancer and which 

are just bystanders? And also, what’s the order, the temporal sequence, in which they arise?” It could be, Michor 

says, that there is no sequence — that cancer development simply involves the accumulation of a critical mass 

of mutations in any order — but she suspects otherwise. 

“This is such an important question because if we know 

what the sequence of mutations is, we can better design 

treatments. Those mutations that come up early during 

tumorigenesis are more likely to be homogeneous in the 

tumor. Whatever comes up late can probably be found in 

only a small subset of the cancer cells.” Michor’s PS-OC is 

working to develop mathematical and statistical techniques that parse out the temporal sequence of mutations. 

Michor is quick to point out that mathematics, physical 

sciences, and biological sciences depend on each other, 

and that the interactions will benefit all of the disciplines. Her mathematical models, for example, may be 

validated or modified by biological studies. 

Bringing disciplines together in the pursuit of cancer 

also requires a degree of cultural acclimation. “If you 

meet a researcher trained in pure mathematics who 

wants to collaborate, it’s actually very difficult, because 

their language is different from that of biologists,” says 

Michor. “Biology is intrinsically very complex. It’s not clear 

that if you’ve shown something in one situation it’s going 

to be true in all situations, like it is in math. There are a 

lot of conceptual differences between these disciplines, 

and also differences in expectation. That’s why the PS-OC 

initiative is such a great idea. It’s a strong incentive to 

bring people of different disciplines together.” 

The Memorial Sloan-Kettering PS-OC is also working to 

identify the cell of origin of tumors, which may be “stemlike” cells, progenitor cells, or more differentiated cells. 

Additionally, Michor’s group is working on mathematical models for optimally dosing chemotherapeutics, to 

avoid — or at least postpone — the emergence of drug 

resistance. 

24 T h e N a T i o N a l C a N C e r i N s T i T u T e | 
 

 

 

 

 

 

 

Franziska Michor, Ph.D., Memorial Sloan-Kettering 

Comprehensive Cancer Center 

One intriguing question is why a mathematician would want to 

participate in cancer research. The chance to impact a devastating disease, Michor says, is never far from her mind. So, too, is 

an intriguing intellectual quandary. “As an evolutionary theorist, 

it’s a very interesting case. Cancer is something that goes wrong, 

even though there are no external causes, such as an infection, 

in many cases. It’s an evolutionary system that goes wrong even 

though it’s designed to prevent exactly that case.” 

this idea became reality with the funding 

of 12 Physical Science-Oncology Centers 

and a five-year initiative to better understand the laws and principles that shape 

and govern the emergence and behavior of 

cancer. 

Given the complexity of cancer, it is becoming increasingly clear that external 

forces and physical laws have profound 

influences on cancer initiation and progression, and upon the behavior of the 

host as it deals with the abnormal growth 

process. The Physical Science-Oncology 

Centers will probe those forces, through 

understanding the physics of cancer by 

studying how energy flows, gradients, mechanics, and thermodynamics affect cancer cells versus normal cells and contribute 

to the complexity of cancer; exploring and 

understanding evolutionary theory and 

evolutionary processes of cancer from a 

physics perspective; and understanding the 

coding, decoding, and transfer of information in cancer at the molecular and submolecular levels, particularly in the tumor 

microenvironment. 

The BoTToM liNe. NCI established the 

Physical Science-Oncology Centers as a 

five-year initiative. Through funding of 

an additional $9 million in the 2011 fiscal year, NCI could expand the centers’ 

areas of investigation. 

infectious agents and cancer prevention. Current evidence indicates that 

as many as one in five cancers have an 

infectious cause. With an increased effort, 

research addressing how viruses or bacteria can impact cancer causation may continue to give us significant opportunities to 

reduce incidence and mortality. 

T h e N a T i o N a l C a N C e r i N s T i T u T e 25 | 
 

 

 

 

 

Researchers are still learning how a cell 

that is infected with a virus becomes a 

cancer cell. Hepatitis B and C have been 

linked to liver cancer conclusively and 

there are several cancers, including cervical 

cancer, as well as a subtype of upper-airways 

cancer, that are associated with the human 

papillomavirus (HPV). 

Additionally, the bacteria, Helicobacter 

pylori, has been linked to stomach cancer and several viruses have been associated with leukemia, lymphoma, and 

Kaposi sarcoma. Scientists are currently 

examining potential connections between 

some viruses and brain, colon, breast, and 

prostate cancers, although no definitive 

associations have been established yet for 

these diseases. 

Identifying, treating, and even possibly preventing cancers caused by infectious agents 

such as retroviruses are ongoing challenges, 

because each agent causes cancer through 

a different process and some cause cancer 

indirectly. Each day we are gaining a better 

understanding of the relationship between 

infection, immunity, and genetics. With 

this new understanding, we are beginning 

to develop new therapies and novel vaccines that target these agents, which could 

help to significantly prevent the number of 

cancers that are associated with infections. 

The BoTToM liNe. These efforts received $20 

million in ARRA funds to study possible viral 

genomic fingerprints associated with cancer. 

Expanding the infectious agents and cancer 

prevention effort would require an additional $30 million in the 2011 fiscal year. 

Cancer stem cells. A growing body of evidence suggests that some tumors are driven 

by a small number of cells that have properties similar to those of embryonic stem cells. 

The cancer stem cell hypothesis suggests 

that these rare cells are the only cells within 

a tumor that can self-renew and give rise to 

diverse progeny. It is also theorized that in 

cancer, stem cells or their near descendants, 

with their longevity and proliferative ability, must be the cells co-opted by the genetic alterations associated with the disease 

in order to lead to malignancy. These cells 

are known, therefore, as cancer stem cells 

or tumor-initiating cells. Unlike the bulk of 

tumor cells, tumor-initiating cells may be 

able to endure hostile environments by entering a state of dormancy. This hypothesis, 

if confirmed, could help explain why many 

patients with cancer unfortunately relapse 

after apparently successful treatments. 

This area of study, while still relatively new, 

is growing at a tremendous rate. The study 

of stem cells can yield enormous gains in 

treatment of diseases where the replacement of these damaged cells would be effective. In addition, insights into cell proliferation and differentiation can be gained 

from studying the exact means of control 

utilized by stem cells. Such insights would 

prove invaluable in the development of 

therapies for cancer, in which differentiation and proliferation are often deranged. 

The BoTToM liNe. NCI is taking steps to build 

a nationally recognized cancer stem cell 

biology program. It will provide scientific 

discoveries in understanding cellular development and proliferation in support of 

strategic approaches in early drug development, and serve as an important focal point 

for cancer-related research. Expanding that 

effort would require an additional $40 

million in the 2011 fiscal year. 

26 T h e N a T i o N a l C a N C e r i N s T i T u T e | 
 

Cathy Backinger, Ph.D., NCi
�

Despite significant progress in reducing smoking in the U.S., nearly 20 percent of Americans smoke, and tobacco use remains the leading 

preventable cause of death in the United States. A new 

era is at hand, however, now that the U.S. Food and Drug 

Administration has the authority to regulate tobacco 

products. “NCI-supported science will be crucial to 

informing FDA as it moves forward to implement its new 

authority,” said Cathy L. Backinger, Ph.D., chief of NCI’s 

Tobacco Control Research Branch. “We are committed 

to working with FDA to ensure that scientific research 

continues to help advance tobacco control policies and 

interventions.” 

Backinger’s branch funds a broad spectrum of basic 

and applied tobacco control, prevention, and cessation 

research. The branch has recently co-sponsored several 

scientific meetings, including a workshop focused on the 

use of graphic images on cigarette package warning labels, and a conference examining the health implications 

of menthol in cigarettes. “These activities help build our 

research base and provide critical forums for scientific 

discussions,” she noted. 

Research related to light 

cigarettes is a particularly 

important example. NCI-supported research helped determine that light cigarettes 

are not less hazardous than 

other cigarettes, and have 

not contributed to reducing 

the enormous health risks 

of smoking. Backinger notes 

that “NCI helped provide the 

scientific evidence supporting FDA’s efforts to ban the 

use of misleading terms such 

as ‘light’ and ‘low,’ on cigarette 

packaging.” 

Then there is smokeless tobacco. “Traditionally our 

research portfolio focused primarily on smoked tobacco 

products. But, last year we issued a request for applications to jump-start research on smokeless tobacco 

products, including studying patterns of use and smokers’ perceptions about the products,” said Backinger. 

The results of this research should be of great help and 

interest to the FDA. 

Tobacco use by young people remains a particular 

concern for NCI. “We need to focus efforts to look at 

products like bidis, which are small hand-rolled cigarettes, and hookahs, both trendy products that appeal 

to adolescents and young adults. A recent NCI funded 

study found higher nicotine and carbon monoxide levels, 

and dramatically more smoke exposure, in hookah smokers compared to cigarette smokers. More research is 

required to get a better handle on these products,” said 

Backinger. 

Cathy Backinger, Ph.D., NCI 

T h e N a T i o N a l C a N C e r i N s T i T u T e |
�27 
 

 

 

 

 

 

supporting FDa regulation of tobacco 

products. The Family Smoking Prevention and Tobacco Control Act, signed into 

law June 22, 2009, gave the U.S. Food 

and Drug Administration new authority 

to regulate tobacco products. Already the 

FDA has banned candy-flavored and fruitflavored cigarettes; in the months ahead, it 

is slated to require brand-specific disclosure 

of ingredients; restrict marketing and sales 

to youth; and ban misleading descriptors, 

including “light,” “mild,” and “low tar.” 

In addition, the bill gives the FDA other 

authorities that will require resources from 

NCI. For example, FDA will be able to 

establish product standards, to remove 

or reduce harmful ingredients, and will 

be able to reduce — but not eliminate — 

nicotine. FDA will be able to require enlarged warning labels and graphic images 

on smokeless tobacco and cigarettes. It is 

clear, though, that research will be necessary to determine the impact of new warning labels; understand effects of changing 

marketing practices; develop methods and 

measures for determining the impact of 

product ingredient changes; monitor how 

exposures change over time, as a result of 

product changes, and determine long-term 

effects. NCI is preparing for what will most 

certainly be requests to help the FDA implement this sweeping public health law. 

The BoTToM liNe. NCI has issued administrative supplements to existing grants to expand the science base to more effectively 

inform FDA efforts to design and implement 

tobacco product standards, regulations, and 

criteria for product-related review. In the 

2011 fiscal year, an additional $20 million 

would be required to maintain and expand 

these efforts. 

Comparative effectiveness research. 

During the debate over health care reform, 

one oft-used phrase has been “comparative 

effectiveness,” sometimes referred to as research into “what works.” Comparative effectiveness research, or CER, is about using 

tools such as clinical trials; observational 

studies and population modeling; and secondary data analysis to compare the benefits and harms of different interventions and 

strategies in real world settings. Ultimately, 

CER is about improving patient outcomes 

by developing and disseminating evidencebased information. CER is not a new concept to NCI; however, ARRA funds have 

opened up new areas of investigation. 

Using CER dollars allocated under ARRA, 

NCI is conducting smoking cessation trials; 

studying risk behavior interventions in 

health care settings; comparing surgical 

treatment options for prostate cancer; and 

studying colon cancer screening methods, 

just to highlight a few examples. 

NCI’s ongoing CER efforts cover numerous programs and initiatives, including 

the Cancer Intervention and Surveillance 

Modeling Network (CISNET) and HMO 

Cancer Research Network. 

The BoTToM liNe. A total of $40 million 

would be required to maintain and expand 

the CER effort in fiscal year 2011. 

28 T h e N a T i o N a l C a N C e r i N s T i T u T e | 
 

Muin Khoury, M.D., Ph.D., Centers for Disease Control and Prevention
�

Given the many recent advances in genomics 

and personalized medicine, do we currently 

have the evidence to prove that applying 

new genetic screening and testing modalities in 

clinical and public health practice will lead to better 

health outcomes than our current practice? “There is 

what I call an ‘evidence dilemma’ in genomic medicine,” said Muin Khoury, M.D., Ph.D., director of the 

Office of Public Health Genomics at the Centers for 

Disease Control and Prevention in Atlanta, and a 

senior consultant to the NCI. “There are many basic 

science discoveries that make biologic sense, but 

they haven’t really been explored in the real world 

to see, if you compare them to standard practice, 

whether they would lead to better outcomes and 

less harms.” 

Khoury is working with the NCI’s Division of Cancer 

Control and Population Sciences to develop a collaborative network to advance comparative effectiveness research in genomics, in order to develop a 

roadmap for genomics and personalized medicine for 

the 21st century. Comparative effectiveness research, 

including some of the projects being funded by 

ARRA, can help assess the utility of genome-based 

medical applications and facilitate the progress 

toward personalized medicine. 

Muin Khoury, M.D., Ph.D., Centers for Disease 

Control and Prevention 

ARRA funds are supporting seven institutions that 

will be part of this network, each studying a different 

aspect of the field. They will develop and apply methods to analyze and synthesize existing knowledge 

about genetics and cancer, gained from basic, clinical, 

and population sciences. This research will be genome 

based, but will study not only genes but also proteins, 

biomarkers and tissues, all of which present more 

complex scientific challenges that must be faced. 

The traditional clinical trials model used to study efficacy, Khoury says, needs to be adapted when trying 

to study the effectiveness of new personalized genomic tests, because clinical trials are costly and time 

consuming. “People often ask, ‘How much evidence 

is enough?’ I don’t think we know the answer to this 

question,” said Khoury. “It’s easy to be seduced by the 

allure of the technology, but when you start using it in 

people, sometimes you need clinical trials, other times 

you can start using it while you are conducting the 

research. This is why we need CER in this area.” 

CER can be utilized not only to compare new technologies to standard practice, but also as a means of 

comparing competing technologies currently accepted 

by the medical community. When looking at an area 

like colorectal cancer screening, where there are several 

different screening modalities available, CER can be 

used to determine which of the technologies is truly 

more effective. 

“Performance in the real world is a combination of the 

effectiveness of the intervention plus the uptake of 

the intervention. If you have something that is less 

effective with better uptake, you might be saving 

more lives. That is why CER as a form of translational 

research is so important,” said Khoury. 

T h e N a T i o N a l C a N C e r i N s T i T u T e 29 | 
 

 

 

 

 

 

 

Presidential recognition
�

n a warm autumn morning, Presi- Odent Obama stepped onto the 

stage in a crowded auditorium on 

the campus of the National Institutes of 

Health. He had come to Bethesda, Md., 

along with Health and Human Services 

Secretary Kathleen Sebelius to say thank 

you — and to recognize the work and long 

hours staff members at all of the NIH institutes and centers had put into implementation of the American Recovery and 

Reinvestment Act.“The work you do is 

not easy,” the President said. “It takes a 

great deal of patience and persistence. But 

it holds incredible promise for the health 

of our people and the future of our nation 

and our world. That’s why I’m here today.” 

President Obama went on to praise the 

work of The Cancer Genome Atlas, which, 

by that day, had been selected as one of seven 

ARRA Signature Projects of the NIH. 

“In cancer, we’re beginning to see treatments based on our knowledge of genetic 

changes that cause the disease and the genetic predispositions that many of us carry 

that make us more susceptible to the disease. But we’ve only scratched the surface 

of these kinds of treatments, because we’ve 

only begun to understand the relationship 

between our environment and genetics in 

causing and promoting cancer.” 

As part of the President’s NIH visit, he and others got to see cancer 

cells close up under a microscope, as 

NIH Director Francis Collins, M.D., 

Ph.D., led the President and Secretary 

Sebelius on a tour of the laboratory of 

W. Marston Linehan, M.D., in NCI’s 

Urologic Oncology Branch, a component of its Center for Cancer Research. 

Indeed, we do have much left to accomplish. President Obama’s visit was an affirmation of the lifesaving work that is 

symbolized by TCGA but that is also realized in thousands of labs and clinics in 

Bethesda and across the United States. 

The work that we do at NCI is paying dividends. The Annual Report to 

the Nation released in December 2009, 

shows that the incidence and mortality 

rates for most cancers continue to decline. But that progress is not sufficient. 

The very word “cancer” still engenders 

fear. For too many of our fellow citizens, it elicits images of suffering and of 

death. NCI’s true cause for celebration 

will come when all cancer patients are 

free of those bonds, whether envisioned 

or experienced. None of us will rest 

until we get there. 

30 T h e N a T i o N a l C a N C e r i N s T i T u T e | 
 

Official White House Photo by Lawrence Jackson 

“The work you do is not easy,” the President said. 

“It takes a great deal of patience and persistence. 

But it holds incredible promise for the health of our 

people and the future of our nation and our world. 

That’s why I’m here today.”
�

T h e N a T i o N a l C a N C e r i N s T i T u T e 31 | 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The 2011 Professional Judgment Budget request
�

Documents like this one are, by 

nature, selective and not encyclopedic. The examples cited in 

the preceding pages discuss the 

progress begun with the unanticipated but needed funds from 

American Reinvestment and 

Recovery Act and how it could 

be financially sustained. ARRA 

allowed NCI to put into action 

most of the plans contained 

in last year’s Bypass Budget 

request. This year’s document 

request includes resources that 

would allow NCI to further cultivate and mature the initiatives 

originated with ARRA funding. 

There are, however, hundreds of 

NCI programs that remain extremely valuable, even though 

they have not been discussed 

in detail on these pages. From 

systems biology to efforts to reduce cancer risk for all patients, 

from NCI’s proud intramural science program to every effort 

to end inequities in cancer diagnosis and treatment, the Institute 

remains committed to every 

avenue of research, be it laboratory, clinical, or behavioral. The 

final three items in the new investments table reflect budgetary requests for some of these 

areas. 

The numbers that follow represent the NCI’s professional

judgment 

increases 

on potential budget 

that could hasten

our research progress against 

cancer, bringing new therapies,

earlier detection and better prevention techniques to all people.

National Cancer Institute 

New Investments 

(dollars in millions) 

Supporting Individual Investigators $ 310 

TCGA and TARGET $ 28 

caBIG $ 103 

caHUB $ 60 

Patient Characterization Center $ 12 

Chemical Biology Consortium $ 11 

Drug Development $ 69 

Cancer Centers $ 50 

NCI Community Cancer Centers Program $ 56 

Physical Science-Oncology Centers $ 9 

Infectious Agents and Cancer Prevention $ 30 

Cancer Stem Cells $ 40 

Support FDA Regulation of Tobacco Products $ 20 

Comparative Effectiveness Research $ 40 

Expand Training and Career Development $ 40

Invest in Intramural Research Program $ 75

Strengthen Scientific Infrastructure $ 145

Total Annual Increased Investment $ 1,098

32 T h e N a T i o N a l C a N C e r i N s T i T u T e | 

NIH Publication No. 10-7545
�

Printed February 2010
�