Despite the current health crisis, 2020 is a banner year! The National Comprehensive Cancer Network (NCCN) is celebrating its 25th anniversary. On this occasion, it is worthwhile to recall the origins of the organization and the vision of its leaders in those formative years. When NCCN celebrated its 20th anniversary, both Joseph Simone, MD (the first Chair of the NCCN Executive Committee, 1994–1996) and David Hohn, MD (Chair of the NCCN Board of Directors, 2004–2007) published their historical recollections about the history of NCCN.1,2 So as NCCN employee number one (Dr. Sevier) and a founding member of the NCCN Executive Committee (Dr. Balch), we wanted to add a dimension of NCCN history during those formative years from 1993 to 1996.
NCCN was conceptualized in 1992 and 1993, after several confidential phone calls to explore setting up a national managed care network between me, Charles M. Balch, MD, while at MD Anderson Cancer Center (MDACC), and James S. Quirk, who was Senior Vice President for Research Resources Management at Memorial Sloan Kettering Cancer Center (MSKCC). At that time, there was significant uncertainty about the impact of managed care on patient referrals, care, and reimbursement at our and other comprehensive cancer centers. We, and many other NCI-designated Cancer Center leaders, feared for our ability to continue conducting important clinical research and providing complex care in the potentially constrained environment. To maintain confidentiality, we couldn't meet at each other’s cancer center, so we arranged to have evening meetings in Philadelphia in the office of John Durant, MD, President of Fox Chase Cancer Center (FCCC), along with his Executive Vice President, F. Jay McKay.
The leadership group was expanded to include Joseph V. Simone, MD, of MSKCC and Robert C. Young, MD, of FCCC, as well as Michael D. Goldberg, MBA, who brought in Catherine D. Harvey, DrPH, as a consultant and the first paid staff member. NCCN was informally organized in 1993 with 5 comprehensive cancer centers (MSKCC, MDACC, FCCC, City of Hope, and the Fred Hutchinson Cancer Research Center [FHCC]). We commissioned Coopers & Lybrand to do an initial survey of national insurance carriers and large employers, which they presented in March 1993 and concluded that “both insurers and employers expressed interest in contracting with NCCN, in a relationship that advances high quality, cost-effective cancer care…to development and use of clinical guidelines...and risk-sharing (financial) arrangements.” We then commissioned Coopers & Lybrand to perform a detailed business plan, including a market analysis, financial arrangements, and plan administration of NCCN. As presented on September 20, 1993, NCCN’s defined goals were to: “(1) enhance and control the quality of cancer treatment through the combined efforts of the centers to develop standard treatment protocols; (2) place patients in the most appropriate settings, diagnosing and treating the initial stages of cancer properly so as to achieve efficient use of resources and improve outcomes; (3) enter into managed care contracts; (4) provide cancer services under a partial- or full-risk payment arrangement; and (5) develop products and services that can be adopted by self-insured employers or included in managed health plans marketed by commercial insurers.”
Further planning meetings were held in 1994. The leadership consisted of (in alphabetical order): Charles M. Balch, MD; Michael D. Goldberg, MBA (as CEO); Catherine Harvey, DrPH (as Executive Director); Stephen T. Rosen, MD; Joseph V. Simone, MD; and Robert C. Young, MD. Over the early months in 1994, NCCN reached out to 17 comprehensive cancer centers to meet at the ASCO Annual Meeting in Dallas in May 1994. Based on interest and a willingness to contribute to the organization, NCCN was expanded to a total of 13 cancer centers by adding the comprehensive cancer centers at Dana-Farber (DFCC), Johns Hopkins, Robert H. Lurie Cancer Center at Northwestern University, Ohio State University – Arthur James Cancer Hospital, St. Jude Children’s Research Hospital, University of Michigan, Stanford University, and University of Nebraska.
In July 1994, NCCN leadership held a major planning meeting and agreed to an interim operating plan, which included “(1) a meeting of center directors and administrators that will be held in October, 1994; (2) at that (October) meeting, a detailed budget and a contract for management services will be approved; (3) NCCN will be formally incorporated as a not-for-profit organization; (4) the Executive Director will complete initial visits to potential member institution; (5) a public announcement will be made about the formation of the Network at or subsequent to the October meeting; (6) Members must commit to the funding requirement by the October meeting ($120,000 a year for 3 years commencing January 1, 1995); and (7) Governance will be agreed upon at the October 1994 meeting.”
An institutional commitment to join NCCN was significant, especially when considering that the organization was willing to take significant financial risk and engage their leadership in a very novel but latent managed care business entity. Each institution had to commit to $120,000 dues per year for 3 years, 2 board members (1 medical and 1 administrative), and to internally fund their faculty participation in NCCN committees, including travel expenses. It was truly a time when individuals had to take a risk on a value proposition that was being created as NCCN evolved. But the risk of managed care was real enough that 13 cancer centers decided to find the money and donate their time and reputation to the effort.
A major organizational meeting was held in Chicago on September 13, 1994. Leadership from the 13 member organizations voted to approve the formation of NCCN and promulgate a “Statement of Principles” as “a national alliance of cancer center providers, organized to develop and institute standards, guidelines, and systems that assure high-quality cost-effective care.”
Thus, the creation of cancer treatment guidelines over a continuum of care was an initial core value of NCCN activities that has been sustained over its entire history. This principle was originally described in the 1994 NCCN Statement of Principles: “The rational delivery of complex medical therapy by a geographically diverse group of providers has a number of requirements, including establishing a common set of treatment guidelines. With input from recognized experts, the Network will develop consensus-based, peer-reviewed clinical guidelines. These guidelines will be used as the core of a quality assurance program with the objective of achieving equivalent outcomes among distinct providers…While the established guidelines will form the foundation upon which rational patient care decisions are based, the Network is committed to the expeditious and timely update of guidelines based on the most recent clinical and scientific findings. Unlike many payer-driven systems, cost effectiveness will be achieved by the most rational approach to care over the course of the disease…Employers and insurers seek high quality, cost-effective medical care and ways to better predict costs. Network members will meet these needs through contracts for the entire spectrum of cancer care. The Network will offer participants a platform to help shape the future on oncology (italics added).”
The formal announcement was made in New York City on January 31, 1995 (Figure 1). Later that year, Bruce Ross (retired from Bristol-Meyers Squibb Oncology) was appointed as Chief Executive Officer, Catherine Harvey was appointed as Chief Operating Officer, the NCCN office was established in Philadelphia, and 2 more member institutions were added, Roswell Park and University of Alabama at Birmingham, to constitute the 15 inaugural members of NCCN.
Major activities during 1995 included (1) establishing a governance mechanism and organizational structure, led by Joseph Simone, Catherine Harvey, and James Quirk of MSKCC; (2) developing clinical guidelines for management of commonly treated cancers and unique product opportunities, under the prodigious leadership of Rodger Winn, MD, of MDACC as Chair of the Guidelines Committee; (3) developing and implementing a 3-year strategy for measuring clinical outcomes, led by Jane Weeks, MD, MSc, of DFCC as Chair of the Outcomes Committee; (4) developing and implementing marketing and public relations strategies to target major employers, payers, and select consumers, led by Catherine Harvey, DrPH of NCCN; and (5) developing a strategy and mechanism for the negotiation and brokerage of managed care contracts, led by Peggy A. Means, MHA, of FHCC and Catherine Harvey.
The energy among the members during this time was palpable. We knew we were creating something that could impact the quality of care for people with cancer and would certainly set a high bar, using evidence-based methods for creating guidelines and measuring success with outcomes data. Everyone worked extremely hard. All of the member representatives had full-time responsibilities at their institutions, yet simultaneously put in many hours developing templates, structure, and tools for the work of the organization. They worked as volunteers, committed to safeguarding best practices beyond the walls of their own institutions.
Joseph Simone, the first Chair of the Executive Committee, provided extraordinary leadership of this fledgling organization, which he described as being composed of “academic organizations, (which) are inherently difficult to manage because of their nature to question and debate, sometimes endlessly…The challenge is to leverage this diversity and focus the intellectual independence to the advantage of all.” Catherine Harvey characterized it much less delicately as “herding cats”; yet she would go on to say they were the most committed group of professionals she’d ever seen. In a June 6, 1996 memo to NCCN leadership, Dr. Simone summarized the “State of the NCCN” 18 months after its formation. A notable quote from his memo stated, “Let me simply reiterate the 2 facets of our mission as I see it. First, to set national benchmarks for excellent cancer care, including practice guidelines, medical outcomes, and efficient resource utilization. Second, to promote the business success of member cancer centers so each may receive sufficient patients to carry out its academic mission and service the people of its region.” Dr. Simone then listed some of the strengths of NCCN: (1) excellence of the member cancer programs and their outstanding reputations, (2) the vision and perseverance of the cancer center leaders that kept them coming to meetings and collecting the annual dues, (3) outstanding work by Rodger Winn on the Guidelines Committee and the development of a potential big winner in the Outcomes Committee headed by Jane Weeks, and (4) a hugely successful guidelines meeting that had legitimized NCCN’s promise to deliver them and had drawn considerable interest around the country. Finally, he listed some opportunities: “Our structure provides an unequaled platform for influencing the standard of care more widely than in the past. It won’t be easy, but we are clearly capable of a huge and lasting impact…We must be open to new paradigms, novel business partnerships, and new opportunities that we hadn’t previously considered…I can’t say exactly where we are headed or what NCCN will look like in 2 or 3 years, but I am 100% certain that we will be a force for good if we persevere despite the inevitable bumpy road, keep our eye on the ball, and keep an open mind.” He summarized the state of NCCN that holds true today: “The NCCN has enviable strengths in its institutions and is capable of having a lasting impact on the cancer care agenda.” His prophetic message in 1996 materialized to a greater extent than any of us dreamed of at the beginnings. And Dr. Simone later concluded in 2016, “The NCCN has become the primary trusted source of treatment guidelines globally.”
As NCCN has evolved over the years, its original goal did not materialize in the marketplace for national managed care contracting using case rates or capitation. The leadership followed Dr. Simone’s advice and pivoted to provide comprehensive disease and stage-specific guidelines that are used worldwide, a Drugs & Biologics Compendium, Chemotherapy Order Templates, a highly attended annual meeting, and a highly cited national journal, JNCCN. David Hohn, MD, Chair of the NCCN Board of Directors from 2004 to 2007, listed many of the significant accomplishments of NCCN over its first 2 decades.2 He concluded with a message that holds true today as NCCN celebrates its 25th anniversary: “We owe a huge debt of gratitude to the visionaries who recognized the need for NCCN, the talented staff who built the framework for our many successful programs, and, above all, the many hundreds of faculty who wrote and upheld the guidelines and lead our educational programs.”2