RCY: We began a systematic process two years ago and asked, What are we going to need to look like in 2015 to continue to be a preeminent cancer center? We looked at what we were going to have to provide in terms of patient care in order to continue to do what we’re doing. We have had a tremendous and progressive increase in patient volume over the last 30 years. In 1980 we took care of about 750 new patients and this year we will take care of 6,500 new patients. In 2015 we’re likely to be caring for something in the range of 9,000 to 12,000 new patients a year. We’re bursting at the seams now, clinically. We don’t have enough outpatient or inpatient space to handle much more than the volume we’re handling now, and no way to handle that kind of a volume increase. We also took a look at how we would need to respond to the changing environment of science. One of the things that’s crystal clear to everyone is that the complexity of science is increasing and that requires two things: interactions of different scientific disciplines and substantial amounts of shared facilities, that is, state-of-the-art equipment that is available in a centralized facility that individuals can use periodically when they need it to enhance their science, but not duplicate these kinds of facilities in everybody’s lab. We’re going to have to have on the research side about a 50 percent increase in the size of the institution, and on the clinical care and research side about 100 percent increase in our current capacity and space.

RCY: We did what we call a "visioning effort," taking clinicians and scientists, laboratory investigators and administrators, and middle level folks, and asking, "Why don’t we take a look at this from the vantage point of the people who will be leading the organization in 2015 and focus on what they think the science of 2015 is going to be like?" We had about half of our board participating in and observing these processes. Certainly, the senior leadership of the institution participated, but they were not the primary generators of ideas and concepts. The clinical volume increases were pretty easy to come by because we’ve got a 15-year history of the trajectory of increasing volumes and we stepped back and asked, "What is the evidence that the incidence of breast cancer, or prostate cancer, or colon cancer is going to decline in the next 10 or 15 years?" Given the demographics of our community, the evidence is that it’s not. So, we felt very secure in our estimates that the volume of people needing that kind of care was likely to increase rather than decrease and we don’t see anybody replacing our patient referral patterns, given the present circumstances.

RCY: We have laid out a four-phase strategy which is going to take place over 20 or 25 years, while the exact time frame of those phases can be relatively flexible, depending upon how fast the need increases, and how fast we can get financial support to do this expansion. The first step, which we’re already fairly deeply into, is the building of a 100,000-square-foot cancer research pavilion to expand our outpatient facilities, our radiation therapy and high risk clinic activities. The top three floors will have laboratory bench science capacity. We have a $10 million grant from the Commonwealth of Pennsylvania to assist in that construction. The next step will involve on-location parking and a 200-bed hospital. We currently have a 100-bed hospital; we can convert that hospital easily into other functions, and we plan to do that. The next two steps will be a progressive expansion of the clinical research and clinical care capacity in lock-step with an expansion of our research capacity.

RCY: The biggest discussion now is with the Fairmount Park Commission, the City of Philadelphia and the Commonwealth of Pennsylvania, as well as with our neighbors. We believe strongly that, wherever we are, we need to be on one localized campus because, if you create a clinical facility on one end of the city and a research facility on the other end of the city, then the kind of interaction that is heart and soul of a comprehensive cancer center in terms of its research and treatment mission is lost. The kind of personal interaction between physician investigators and basic scientists is what we want to achieve, so we’ve got to be on the same campus. The only way we can do that and stay in our present location – which we’ve been in since 1949 and our patient population is served better by us remaining in this spot than going somewhere else – is to utilize a portion of an adjacent park land space, and that’s what we’re currently in discussions about. Part of the park is already leased for commercial purposes as a driving range. What we are proposing to the park, city and state is that we be permitted to swap park land in some other locale for this park land space and, instead of having a driving range on it, we would have a world class cancer center.

We’ve talked to members of the City Council and state Legislature who represent our area and pointed out that there are huge economic benefits to this expansion, both for the state and for the city. We currently are one of the biggest employers in the northeast part of Philadelphia with 2,200 employees. We’re talking about an expansion which over a 20- to 30-year period would potentially add 4,000 more jobs to the city of Philadelphia. That has a huge economic impact to the city. Both the mayor and governor have been essentially championing the idea of using creative strategies to bring more people, more workers, more employees into the city, as opposed to driving them away. So, there is considerable enthusiasm, I think, on the part of the city and the state for something like this to happen. We have been meeting with neighborhood groups, who would prefer us to stay here – not very many people would like us to move – but they would like also not to have us utilize park land. But, we can’t find an alternative solution and they haven’t proposed an alternative solution that seems to work. So, we’re in that discussion phase. We care a lot about that park and one of the things we talked to the Fairmount Park Commission about is whether we can actually help maintain the park, keep it safe and keep it utilizable by the neighbors. We need to get a pretty clear idea of whether this is a go or no-go by our next board of directors meeting, which is in March.

RCY: The same way we’ve gotten all of our expansion. Since I’ve been here, we’ve built a building about every five years and we fund it through philanthropy, assumption of debt and through funded depreciation. We have a very low debt-to-equity ratio, so we’re pretty healthy in terms of our capacity to prudently take on debt. Our investigators have been very successful in competing, even in tough environments, for peer review funding. We have less than 300 investigators currently and, in December of this year, we will get our second Nobel Prize. For institutions our size, to have any Nobel Prize is quite an accomplishment. To have two is virtually unheard of. The clinical care facilities are a bigger challenge in some sense because they’re more extensive, and therefore more expensive, and the environment for reimbursement on the clinical side is certainly not robust. We have a positive operating margin in our hospital but it’s not extraordinary. Most hospitals don’t have a positive operating margin, but ours is two to three – to sometimes close to four percent, on an enterprise that’s about $150 million dollars a year. State-of-the-art hospitals in an environment with expanding need are of great interest to the community, to potential donors, and to both the city and the state, so we certainly are going to explore ways that those entities can help us accomplish our goals.

RCY: We estimate that, when we finish this entire expansion, we would probably triple the number of employees – to about 6,000 employees as opposed to the 2,200 that we have now. We would then be the largest employer in the northeast part of the City of Philadelphia and over that 20-year period we would probably be one of the very few institutions to expand the number of city-based employees to that degree. We foresee something in the range of 100 research investigators over that period of time and probably something in the range of 300 physicians or physician investigators.

RCY: We are not planning to duplicate anything that other people have, in the sense that our service area generally cares for patient populations that are not primarily cared for by either of the two other comprehensive cancer centers in the city, so this is not just a war between institutions. What we’ve seen in this region is a gravitation of more and more patients into specialty institutions where enormous amounts of experience exist, and less people with complex cancer problems are being treated initially in community hospitals. I think the quality of care is likely to advance as a result of that. I’ve been in this business my whole life and I’ve never looked at it as a profit-making business. I’ve seen too many people die to have that sort of orientation. I don’t look for this to dramatically change the income margins as a result. My hunch is, 25 years from now, hopefully we’ll be still sitting here looking at a two or three percent margin. It’ll be on a lot more money so it’ll be a bigger absolute number of dollars, but of course the institution will have a bigger absolute need for those dollars. We feel that the mission of a comprehensive cancer center is to make discoveries in the laboratory that can be translated into applications, into patient care, and to make cancer care better, not just for the patients who walk through our door but for patients everywhere in the country. Our board of directors absolutely buys that completely. The orientation is not primarily around a hospital as a business.

RCY: We have a substantial interest in prevention. In fact, the building that we completed most recently is called a Cancer Prevention Pavilion and in it is housed things like human genetics, genetic epidemiology, high risk clinics. We currently follow about 5,000 families and about 120,000 individuals who for reasons of their family history appear to be at increased risk for cancer. It’s something that we do because we believe that the science of cancer prevention is where the next century is going. We now, through the human genome project and other research efforts, have the capacity to begin to understand why people are at risk. I think the next wave of science is going to be heavily into the ways in which cells accomplish protein messaging and the ways in which one can intervene in order to alter disease states. If one can do that, one can then begin to make interventions in patients who are well so that they stay well. We’re also going into an era of targeted chemotherapy, where an understanding of the underlying genetics and protein messaging allows us to begin to craft cancer therapies that are directly related to these abnormalities. The hope is that these therapies will be more specific and less toxic than their predecessors. Of course we’re going to continue to see an improvement in the reduction of morbidity associated with curative cancer treatment. We’re seeing this on a continuous basis in surgery and in radiation therapy. We’re able to use more and more sophisticated forms of treatment to get the same or better success rate but to reduce the side effects of cancer treatment.

RCY: I think it will have generally a positive relationship. We’ve had a relationship with Temple for now almost 20 years, involved with training – particularly in medical oncology, surgical oncology and pathology. We’re doing some things jointly with them in bone marrow transplantation. We’re working on a potential collaborative program in neuro-oncology. The bigger we get, in a sense, the wider the array of opportunities for joint teaching and training that we have with Temple. In terms of our network, I don’t see any conflict. We have been successful with our network because we have tried to work out individual relationships with particular hospitals. Not every hospital needs everything we do, so many of these relationships are different depending upon the size and needs of the institution. I think the network hospitals have a fairly high comfort level with this relationship. We see patients that they want us to see and we send patients that to our network hospitals if they could get the same care close to home. I think that those relationships are pretty healthy and I don’t see anything in this that’s likely to change that. We are not going to attempt to extract patients from our network hospitals to fill or to respond to this expansion. In fact, quite the opposite.

RCY: There are 30.

RCY: Not necessarily. The basic reason for the network relationships are several-fold. One of the things we wanted to provide is access to Fox Chase’s national cooperative group clinical trials so that network physicians would have access to programs that they might not easily have access to without such a relationship. In many instances the individual institutions wanted to market their cancer programs in the community and wanted to utilize this relationship with Fox Chase to enhance that marketing effort. In some instances they wanted access to some programs that we have that it doesn’t make economic sense for them to create – the biggest example of that is our high risk clinics for families at high risk for a particular disease. What a community hospital can do is refer those families to us and allow us to evaluate whether or not there is truly a familial pattern of risk, to look at genetic predispositions and provide that information back to the physicians involved with their care. That’s worked very well. We grow network relationships when it makes sense for the hospital and for us to entertain such a relationship. I could see the number of network hospitals staying the same as it is now, increasing slightly, or increasing a lot. As we grow this research and treatment enterprise we have some unique things to offer. My hunch is that network hospitals and regional hospitals will be interested in it. If we don’t, they won’t be. Any of those outcomes would be fine for us. We don’t have a strategic plan which requires us to increase network hospital relationships in lock-step with this expansion.

RCY: We have an interesting relationship with both Jefferson and with the University of Pennsylvania cancer centers. We are competitors and collaborators with both of them. We are actually just submitting a breast cancer research program in collaboration with the University of Pennsylvania. We have an ovarian cancer research program that’s already funded by the National Cancer Institute in which investigators from both institutions participate. And we have training programs that are linked with Thomas Jefferson. We have a healthy scientific competition, but at the same time we have collaborations when there are opportunities for synergism between the institutions. I don’t see this as basically changing the dynamic, particularly since the expansion in patient populations that we see does not involve pulling patients away from either of those institutions. Certainly, the more we can produce a scientific and medical synergy in the institution, the more attractive it becomes for recruiting the best and brightest. Occasionally, we recruit people from other institutions in town and occasionally they recruit people from us, and of course that always produces a struggle. But if you look at the three comprehensive cancer centers, for the most part the lion’s share of the people they recruit comes from other parts of the state or, most commonly, outside of the state.

RCY: Sure, we attract people from all over the country, all over the world. But a substantial number of the patients of every cancer center in the country comes from the region immediately around the institution. That’s true of all the comprehensive cancer centers in this city. We believe we are uniquely located because we serve an area of the region that’s not really served actively by all the others. The lion’s share of our patients comes from throughout the northeast part of Philadelphia; from Bucks, Berks and Montgomery counties; and from central and southern New Jersey. Those are areas that are not traditionally serviced by either Penn or Jeff, so we don’t compete for patients very actively with those institutions. We serve a completely different area of the region than they do and, given the aging demographics of this state and this region, we anticipate that growth of cancer volume is going to continue.