Last year, local hospitals treated more than 53,000 patients for cancer. From prostate and breast cancers to melanoma and pediatric lymphoma, these numbers show no signs of abating. In 2003, the American Cancer Society estimates, cancer will strike 32,800 more Virginians. The State-wide death toll this year is estimated at 13,700.
It’s hard to obtain firm figures for the dollar value represented by that much disease and death. But this much is known: Treatment numbers for cancer care have nearly doubled in the past decade. Clearly millions of dollars are changing hands locally in the pursuit of cance research, treatment and, ultimately, a cure. But the wave of cancer money does not crest only at the UVA Cancer Center and Martha Jefferson Hospital where primary diagnosis and treatment take place. Five miles north of the Downtown and Corner areas, at UVA’s North Fork Research Park, is PRA International, a clinical research organization that specializes in oncology. Inside the 80,000 square-foot facility, PRA provides drug development services—that is, drug trials—on a contract basis to pharmaceutical and biotechnology companies. Founded in Charlottesville in 1976, PRA has since spread to six continents and 60 countries. It employs more than 2,000 employees in total.
Where other local employers have announced cutbacks in response to hard economic times, in 2002 PRA reported 25 percent workforce growth, hiring 75 additional employees to a local staff now topping out at more than 300. Indeed, at $140 million, PRA’s revenue beat out the $115 million generated by the UVA Cancer Center’s clinical care.
Unquestionably, cancer is big business in Charlottesville.
And as is usually the case when plenty of money is flowing, a competitive market has sprung up. There’s a contest for cancer warriors being waged behind the scenes. Fueled by steady growth, leadership opportunities and the comparatively stress-free work environment that it offers area physicians, nurses and research experts, PRA may well be winning this hidden battle for the sharp minds and unfaltering dedication needed to build a strong army against the disease.
Bob Fritz is a case in point. Now a medical director with PRA, Fritz closed the doors of his family practice more than a decade ago. His career had been marked by devotion to his patients, but with the changes in medical care, he simply couldn’t afford, mentally or financially, to keep his practice afloat.
He gave up the ghost in 1996 and joined PRA to monitor and support drug and vaccine trials.
“I grew to truly dislike the direction of modern American medicine,” says Fritz. “I simply couldn’t do it anymore.”
UVA and Martha Jefferson hospitals each treat cancer patients, but in terms of sheer girth there is virtually no comparison. Recently rated among the nation’s top centers by U.S. News & World Report, the UVA Cancer Center offers 34 doctors in direct care, and many dozens of specialists on staff.
UVA attracts more than 2,100 new in-patients and 50,000 outpatients annually. Two-thirds of patients come from an 80-mile radius while 24 percent travel from other parts of Virginia. And 10 percent fly in to be treated from around the world.
“During one of my appointments I was sitting beside people who had traveled hours to come to the UVA center,” says Mary Kay Ohaneson, a 54-year-old two-time cancer survivor, who was treated in both cases at UVA. “I felt so fortunate. I had traveled about 15 minutes.”
Martha Jefferson’s cancer center saw 801 cases in 2001, the most recent year for which data is available. With its new Martha Jefferson Outpatient Care Center inside a 14-acre, 94,000 square-foot facility at Peter Jefferson Place on Route 250E, Martha Jefferson plans to ramp up its cancer care, especially in the area of medical imaging when doors open in mid-September.
The $28 million building will be updated with state-of-the-art machinery such as a new PET scanner, which detects changes in the body at the cellular level. Martha Jefferson will also be offering the only open MRI machine in town.
But with a smaller workforce than UVA, only 56 Martha Jefferson medical staff are involved in or specialize in cancer diagnosis and treatment, 32 of them nurses with cancer specialization. In reality though, all physicians at Martha Jefferson and UVA are directly or indirectly involved with cancer care.
“A good family physician should be the conductor of the orchestra as far as all cancer treatment goes,” says Fritz. “The family doctor doesn’t have to be the one turning the switch of the chemo machine, but someone has to be the cornerstone and coordinator of the treatment.”
Three units at UVA are solely for cancer patients, with 35 beds in total. Out of the 106 cancer nurses at UVA, 33 are certified oncology nurses, the highest level of training attainable by nurses in the field of cancer care. UVA has the largest concentration of oncology nurses in the Commonwealth.
But beyond greater numbers of certified doctors, nurses and specialists, UVA has the deeper pockets.
As one of 60 clinical cancer centers designated by the National Cancer Institute, UVA receives more than $60 million each year to support some 200 cancer researchers. In conjunction with PRA and other research companies, UVA has more than 250 patients enrolled in clinical trials, reflecting the industry-wide bias for research.
“I would absolutely make the argument that clearly the way to eliminate cancer is through research,” says Michael Schwartzberg, media advocacy manager for the American Cancer Society.
Just this year, UVA received about $3.5 million in additional research grants from the American Cancer Society.
UVA doctor Michael Smith is getting about $623,000 of those funds for his research project. By studying the hepatocyte growth factor, or HGF, which, when it grows uncontrollably defines cancer’s basic manifestation, Smith hopes to block the activity of the HGF receptor. His work, if successful, could help uncover a treatment for gastric cancer, the second-leading cause of cancer deaths worldwide.
On the direct-care side of things, UVA’s cancer center was recently named a “designated” cancer center by the National Cancer Institute—one of 13 in the United States—all of which adds up to a top-notch cancer facility at UVA.
“Patient satisfaction is the main outcome you want in any care situation, period,” says Janice Fabbri-Fritz, a public health nurse who previously worked at Martha Jefferson, “especially where cancer is concerned.
“We’ve finally discovered that we can no longer be the all-powerful doctor telling the little patient, ‘You’ll be fine.’”
Even as new bedside ethics put patients first, some doctors and nurses find themselves wanting to do more.
“I was a frontline oncologist for more than 20 years,” says Bruce Silver, a physician who oversees medical and safety management of numerous clinical trials for PRA. “Yes, it’s extremely ennobling work. But all my work, and all my efforts, would have been futile if I had no drugs to use.”
Indeed, what PRA seems to have going for it in the contest for doctors and research experts is the chance to mingle with other thought-leaders in pursuit of cutting edge oncological discoveries. Additionally, PRA’s draw is simply the escape from what some physicians call the “pressure cooker” of modern medical practice. For a patient-oriented doctor like Fritz, for instance, PRA offers a space where he no longer has to worry that his productivity is scored by the number of patients he moves through the mill.
“I have finally found a platform to preach about patient advocacy and the important relationship between doctor and patient,” says Fritz. “I’ve been looking for it for a very long time.”
Joy Stockton, a senior clinical safety associate with PRA, is a former UVA neurosurgical nurse. After seven years in the intensive care unit as a “weekend warrior” (the crew that works ‘round the clock on weekends) Stockton was looking for a reprieve. Sure, she wanted better hours and no pressure to work holidays or nights. But beyond that, she wanted to avoid burnout.
“When I first started at UVA, the nurse-to-patient ratio was one nurse to every two patients,” she says, adding that there was also a charge nurse on duty, who had no patients of her own and covered for people when they took breaks.
“By the time I left, I would be the charge nurse for the shift, and I myself would have two patients,” says Stockton.
Ideal staffing, according to Stockton, would be seven nurses to every 12 beds. But in reality, the numbers were more akin to four or five nurses for every 12 beds. Although Stockton left her direct-care position five years ago, her friends remaining in various nursing departments say the shortage, the stress and the bureaucratic red tape is only getting worse, making drug development firms such as PRA more attractive than ever before.
That being said, these corporate firms aren’t for everyone. Dr. Peyton T. Taylor, a specialist in gynecological oncology and the deputy director of the UVA Cancer Center, says he, like others, could never be the people person he is in the world of PRA.
“It’s a very different world,” says Taylor. “There you look at data, and a low white blood cell count is simply an event rather than a friend of yours who has cancer.” Although Taylor, also a proponent of clinical trials (he has completed several himself), describes his daily activities as “very painful” emotionally, he believes that for hands-on, patient-oriented oncologists such as himself, there would be no place for him at PRA.
“Without throwing stones, I think that detachment is the appeal at PRA,” he says. “When you cannot invest emotionally in each individual patient, you invest in the research.
“That way, you still feel as if you’re helping people, just indirectly.”
For those unlike Taylor who are willing to make the leap, PRA has open arms for them. “Nurses and doctors are a very high commodity for us because the thrust of our work is interacting with physicians and hospitals,” says Silver. “We need former doctors and nurses who can communicate most efficiently, especially when it comes to medical and procedural questions, documenting and reporting adverse side effects of trials to the Food and Drug Administration.”
With cancer-related research such a large component of PRA’s work (46 percent of PRA’s overall contracts are in oncology), Charlottesville’s hospitals provide a fine pond in which PRA can fish. “Oncology nurses, with their expertise, are critical to our success,” says Bruce Teplitzky, senior vice president of worldwide business development for PRA.
While PRA offers a less frustrating venue for some medical practitioners, it also offers a higher rate of compensation. UVA oncology nurses’ entry-level salaries generally begin at $34,000, and can go up to $73,000 for the most experienced nurses. While she wouldn’t reveal how much PRA pays, Stockton says that the company generally beats those figures.
“It’s the value of the salary that’s more important,” says Stockton. “What you have to do to earn it is better.”
PRA is the world’s largest privately held contract research organization. And with an impressive acquisition track record of five other CROs since 1997, the company is now one of the top five drug development organizations in the world. Growth has not been trouble-free, however.
In the United States, only 2 percent of cancer patients are enrolled in the company’s tests. Some physicians blame this phenomenon on the growing number of aging baby-boomers being diagnosed with the disease. Older generations, some believe, are far more likely to be skeptical about clinical trials, while others hear the diagnosis, and immediately anticipate the worst. “Why bother?” they think.
Furthermore, according to Silver, only 3 percent of all physicians participate in the administering of the tests. PRA employees worry the reluctance to participate lies in not only physicians’ indifference, but also in a misapprehension of clinical trials generally. This, in turn, puts the clinical trials themselves at risk to suffer.
But patient and doctor anxieties are misplaced, says Fritz, adhering to the company line, and pointing out that physicians administer various drugs regularly without strict guidelines or oversight. “These are no longer guinea pig trials anymore,” he says. “This, in fact, is the best form of cancer care for a lot of people.”
In trials, cancer patients get constant attention, screenings they might not have been able to afford before, and strictly FDA-regulated care.
On the other hand, even if all physicians nationwide wanted to participate in studies, PRA wouldn’t want them. PRA maintains a clinical-trials blacklist, of sorts, full of the names of physicians the company shuns. In trials, individual physicians are paid a per-patient stipend, which apparently motivates some to hide adverse side effects in the trial patients to whom they’re administering drugs. When PRA discovers this, the doctor is cut off.
“There are sites that are money mills,” says Fritz, “but then again, wherever you have money, you will have greed and fraud.”
For Virginians, out of the 13,700 forecasted to die of cancer this year, 3,900 deaths will be from lung cancer—the most prevalent form of cancer in the State. The UVA Cancer Center reports that the number of general cancer patients it sees grew 6 percent annually between 1996 and 2000, and Martha Jefferson’s center saw a 15 percent rise in 2001 from 2000. Even more staggering, over the past decade, Martha Jefferson’s annual total of cases diagnosed and treated rose 67 percent to 801. Due to the aging population of area residents and local population growth—more than 28,469 people in the last decade—cancer growth numbers in Charlottesville are soaring.
All of which means there will, unfortunately, be plenty of business for expanding cancer programs including UVA’s new $1.9 million Breast Cancer Center. Set to open in July, it will house 7,500 square-feet of consolidated breast cancer services, equipped with valet parking in front. Martha Jefferson hopes to acquire even more acreage at its new Peter Jefferson Place as soon as the Board of County Supervisors approves rezoning plans.
“The oncology field is never ending,” says Fritz, “not until cancer is either cured, or at the least, kept under control.”
But even the glitz of new digs and greater renown can’t win back the hearts of some doctors and nurses who have seen the ugly side of health care in the age of managed care.
“We’ve done some bad things in the medical profession—we’ve empowered lawyers and insurance companies,” says Fritz. “I’m proud of what I do, but I’m not proud of what my profession does.”