His oncologist was out of ideas, and Duane Wait was low on hope.
So the South Carolinian looked 240 miles north, where the Duke Comprehensive Cancer Center, and a new clinical trial, beckoned.
Now, Wait drives more than four hours to Durham once a month for prostate cancer treatment and testing.
"I've had good treatment here [in Greenville, S.C.], but they just can't compete with Duke," said Wait, a 71-year-old retired Procter & Gamble manager. "It's critical for someone with cancer to have a positive attitude and think there is something hopeful. Going to Duke helps me stay positive and look at the future and not just say, well, you know, life is done."
Wait zeroed in on a place where cancer treatment is expanding. North Carolina's three largest academic medical centers, at Duke, UNC-Chapel Hill and Wake Forest University, are investing a collective $700 million to upgrade cancer facilities.
The latest: Duke Medicine's plan for a $261 million expansion to its cancer center, a seven-floor project that will bring all its clinical services into one place.
It follows the recent opening of UNC-CH's $207 million cancer hospital and comes as Wake Forest University, 100 miles west of Raleigh in Winston-Salem, is in the middle of a $152 million, five-story expansion of its cancer center.
But does North Carolina really need all this cancer care?
Experts say there's more than enough disease to go around. State health officials project a 14 percent increase in new cancer cases in North Carolina from 2006 to 2011 and a 21 percent jump in new cancer cases in the Triangle during that same time. Nationally, cancer cases across the nation are expected to grow 45 percent from 2010 to 2030, in large part because people are living longer.
"The medical care infrastructure in North Carolina has always been trying to catch up with demand," said Tom Ricketts, editor of the N.C. Medical Journal and a professor of health policy and management at UNC-CH.
If you've got cancer, North Carolina is a good place to look for help. It is one of just four states - California, New York and Pennsylvania are the others - with at least three "comprehensive cancer centers," a label the National Cancer Institute gives to cancer hospitals where research, treatment and clinical trials meet. These centers draw top medical talent and tend to offer the broadest treatments.
The next closest is Johns Hopkins in Baltimore. There are none in Virginia or South Carolina.
The existence of three such centers is a result of North Carolina's historic emphasis on higher education, a growing and diverse population, and a traditional political willingness to fund cancer initiatives, cancer experts say.
The state's population is a particularly valuable tool for cancer researchers conducting clinical trials. The state's smokers have long provided a study group for lung-cancer researchers; as have African-Americans, who traditionally have shouldered a disproportionate share of North Carolina's cancer cases, according to a 2008 report, "Cancer in North Carolina," produced by the N.C. Cancer Partnership, a consortium of medical providers across the state.
"There's been a fertile environment for people to support community-based cancer studies and fairly arcane laboratory work," Ricketts said. If you're going to have clinical trials, you need the proper populations. North Carolina has a fairly diverse population, which allows people to be involved."
Translation: The people of North Carolina are a working laboratory for cancer research.
That's fine with Wait, the South Carolina man. Without further treatment, he might be dead in a year or two; with Duke's clinical trial, he hopes to extend his life a few more years.
Still, he struggles with the knowledge that the end will come.
"What concerns me is the actual process of dying of prostate cancer," he said. "I know it's an anguishing last few months and I hate the thought of going through that, though at some point I suppose I will."
Competition is natural
In expanding their facilities, staffs and reach, these academic medical centers hope to raise their profiles and to compete nationally and internationally for patients and the best doctors. Duke's cancer expansion is just one piece of a $700 million facilities explosion on that campus that will include a new bed tower. It may seem like a lot of money, but across the country other health centers are doing the same.
Experts say competition is natural.
"It's a pretty typical scenario for an academic medical center," said Debbie Draper, a former hospital administrator and a senior fellow with the Center for Studying Health System Change, a Washington D.C.-based health policy research organization . "They tend to draw nationally or internationally. We're seeing this across the country, hospitals expanding to try to protect their market share." They're looking at trying to remain competitive with other academic medical centers across the country."
Cancer care is a boon to a hospital's bottom line. It has grown more complex and patient-specific, which is both more costly and more effective, said Walter Shepherd, who directs the N.C. Comprehensive Cancer Program, a strategic planning initiative within the state's Department of Health and Human Services.
An example: A decade or two ago, 10 breast cancer patients would likely receive the same treatment; today, they might get 10 different treatment plans, each tailored to the woman's age, condition, tumor size and location and other factors.
"It's more personalized treatment," Shepherd said. "And more expensive."
UNC and Duke officials each say the two cancer centers have complementary missions and don't need to compete for patients because there's plenty of business to go around. And each has specialty areas.
Duke's brain tumor center, where U.S. Sen. Ted Kennedy received treatment before his death in August, has an international profile thanks in large part to the work of its lead surgeon, Allan Friedman. And at UNC, gastrointestinal cancer specialist Richard Goldberg has built such a well-regarded program that more than half his patients fly to North Carolina for treatment, he said.
"For many years, our ambition was to serve the state," said Goldberg, the physician-in-chief of the N.C. Cancer Hospital at UNC. "[Now] we want to serve the state very well, as well as serve the entire country. We aspire to be right up there."
One way is to broaden their reach beyond campus. Rex Healthcare, which is owned by UNC, recently announced plans to build a $54 million cancer hospital in Raleigh, a facility that would be closely linked with the new UNC cancer hospital in Chapel Hill. And Duke is also planning to expand cancer services at Duke Raleigh Hospital.
Patients, doctors drawn
The state's investment in cancer care, and the presence of the three comprehensive cancer centers, makes North Carolina an attractive destination for both patients and doctors, said Chris Viehbacher, CEO of sanofi-aventis , a Paris-based drug manufacturer with a U.S. headquarters in New Jersey.
Viehbacher's firm, which recently donated $2 million to UNC-CH's new cancer hospital, said as medicine becomes more personalized and specific, private industry will need to partner even more with academic medical centers.
"Research and development is very sophisticated," he said. "Everybody brings certain strengths to the party."
Shepherd, who directs the N.C. Comprehensive Cancer Program, said the state's three comprehensive cancer centers have forged relationships with smaller hospitals and clinics to bring quality care to the state's farthest reaches.
"It's great to have all the bells and whistles of UNC or Duke," he said. "But it's another thing if you live somewhere rural and can go five miles to a hospital with virtually the same level of care."
In expanding their cancer centers, all three universities are shifting a long-held paradigm. For decades, cancer centers - and hospitals in general - have been vast, confusing and intimidating.
Frank Torti, director of the cancer center at Wake Forest, paints this scenario: Traditionally, a breast cancer patient at Wake Forest sees a surgeon, gets a mammogram and a biopsy, meets a radiation specialist, a chemotherapy specialist, and perhaps a plastic surgeon and genetic counselor. Think all those specialists are in the same building? No chance. Often they're nowhere near each other, forcing an ill patient to navigate parking lots, buildings, hallways and waiting rooms.
"By that time, the patient is either ready to shoot us, or is in tears," Torti said. "That has been the traditional, doctor-centric way of doing things."
It's not just about convenience, said Daniel George, a prostate cancer specialist at Duke. When those services are scattered around the medical campus there is a great chance of errors - in billing, blood testing, drug dosing or in other ways, George said.
"It changes the culture for us as clinicians because we'll be elbow to elbow," he said. "If you don't come together physically, it's hard to develop an understanding of disease."
At UNC-CH, the new hospital, gleaming and massive, is a quantum leap from the former facility, which was originally a tuberculosis sanitarium.
"The first thing that struck me was that this hospital was designed by patients," said Shepherd, the cancer program director. "That's the way it should be."
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