Regression to the Mean in
Oz

By

Leonard Zwelling

         This concept was first described in genetics by Sir Francis
Galton. The idea of the regression to the mean or to mediocrity is essentially
this. If a test is given to a population and the results of that test appear to
be a normal distribution and those in the top 10% are retested, the mean of their
retest scores would be closer to the mean of the entire first group than it
would be to their previous mean that of being in the top 10%. This concept is
used in statistics and economics as well. Its essential finding is that the
extremes of any group will not likely remain as extreme on repeat examination.

         Thus the first degree off-spring of a brilliant couple each with
an IQ in the 170s are not likely to all have IQs in the 170s but the collective
mean of their IQs would be lower, closer to 100, the mean of the general
population.

         Unfortunately, it is looking like it’s also true of academic
medical centers over time.

         MD Anderson was a one-of-a-kind place. Unlike most academic
centers, the patient was truly the most important determinant of all activities
at Anderson. Providing the best cancer care was everything to the faculty and
staff. Things like membership in elite research societies, acquisition of huge
grants and the award of prestigious prizes that focused on the individual were
far less important than the development of a new treatment by an entire group
of radiotherapists. Of course there were many famous Anderson faculty known for
their unique individual achievements, but they were far more likely to be
clinicians than biochemists.

There
were many faculty members who had developed real treatments for patients back
when we arrived in 1984, but usually did so in the context of a group effort.
The Department of Development Therapeutics had many stars. None outshone the
boss, Dr. Freiriech, yet all were expected to contribute.

         My, how times have changed.

         With the emphasis placed on laboratory-based science by the
past two Presidents and the removal of the spotlight from the clinic-based
investigator, MD Anderson chose to alter the focus of its competitive
activities so as to rival those of the traditional medical schools and academic
cancer centers on the coasts. In making this choice, MD Anderson gave up its
soul and regressed to the mean of American cancer medicine. Its clinical
research is now pretty much the same as that everywhere else. Even non-academic
places like the Cancer Treatment Centers of America seem to be touting the same
message of personalized cancer care as MD Anderson does, so why bother trekking
to Houston? The ads for the newer cancer treatment facilities look exactly the
same as those of Anderson and their outcome results are probably similar as
well.

What
is the competitive advantage of MD Anderson in such an environment once it
regresses to the mean?

I
saw this happen once before. I was fortunate to be among the last classes of
oncology fellows to participate in the post-Vietnam Era of the golden days of
the Medicine Branch of the National Cancer Institute in Bethesda, MD. During
the war years, under the guidance of the fathers of modern oncology starting
with Freireich and Frei and going on to DaVita, Chabner, Lippman and Young, the
intramural clinical program at the NCI produced advance after advance in the
treatment of advanced leukemia, lymphoma, breast and ovarian cancer. The Medicine Branch’s battles with the intramural department of radiotherapy over
the relative benefits of the various treatment modalities were legendary and
made the NCI the place to be in the late 60s and early 70s for young medical
oncologists and radiotherapists in training. It was in direct competition with
places like MD Anderson, Sloan Kettering and Roswell Park as the Lourdes of
cancer care.

Then
the war ended. The excellent young trainees were no longer forced to go to
Bethesda to avoid Saigon and those senior leaders capable of leading a clinical
service like the Medicine Branch left and were not replaced by those of similar
vision. The Medicine Branch regressed to the mean of any other oncology program
in the country. Surely it has been 30 years since a major advance in cancer
care has emanated from the intramural program of the NCI in Bethesda. Why
bother? Just add the money supporting the intramural program to the RO1 pool and close
the clinic doors of Building 10.

MD
Anderson is on the same trajectory. As those who led that revolution in cancer
care age, retire or simply leave for greener pastures (or are forced to do so),
the excellence that was once Anderson clinical care and clinical research is
giving way to a research Goliath bearing more resemblance to a drug company
than to an academic cancer center and that includes the corporate culture and
heavy handed leadership of corporate America. How unfortunate!

I
am just glad I was there to see the death of academic medicine in general and the
sunset of MD Anderson in particular knowing that I was lucky enough to
participate in something truly special the likes of which may never be seen
again.

 The sun has indeed set on R. Lee Clark’s MD
Anderson. No wonder its red marble is no longer visible covered with the new
structures of fixed cost excess and the loss of that magical Pink Palace at the
end of the yellow brick road that used to cover Holcombe Boulevard.

Don’t
look behind the curtains. You won’t be happy with what you see.

            

Leonard Zwelling