Interview: Alexander Eggermont – Director-General, Gustave Roussy Institute, France

UntitledThe Director-General of the Gustave Roussy Institute, a top cancer institute in Europe, talks about the revamping of their clinical research infrastructure to adapt to the rising new field of translational research and his ambitious plans for the next five years, in particular, his vision for Cancer Core Europe, positioned to be a virtual European Cancer Institute.

You have served five years as the Director General of Gustave Roussy Institute, one of the largest cancer institutes in Europe. What have been the key achievements for the institute over this period?

Gustave Roussy is a comprehensive cancer center, which means we work in the three areas of care, research, and education. We are the largest cancer institute in Europe by volume of activity; seeing up to 12,000 newly diagnosed patients a year. We can be seen as the European counterpart of the Memorial Sloan Kettering cancer center in the US. I attribute this success to the major changes we have implemented during the past five years. Our most significant milestone has been the overhaul of our infrastructure to better reflect and adapt to the paradigm shift that is occurring in clinical research. Previously, the fields of basic and commercial research were fairly separate, but a rising new field called ‘translational research’ is transforming the landscape, with new developments like molecular diagnostics and immunotherapeutics. Previously in clinical research, phase I trials were used to identify dosage-toxicity relationship, phase II to determine response rates and phase III to evaluate the efficacy of the drug in randomized controlled trials. Now, phase I studies are complex biomedical programs that can only be executed if the research environment and laboratory infrastructure provide all the necessary resources required.

When I joined Gustave Roussy five years ago, we took the important decision to fully embrace this new area. We sought to fully integrate our clinical research domain into our clinical domain, in order to advance our mission of accelerating access to innovation. As a result, we went from having 200 patients a year in phase I trials five years ago to 450 in 2015, plus another 450 patients who received molecular portrait driven treatments, in what is now the biggest early clinical trial  programme in Europe.

How attractive is the French clinical research environment and what role does Gustave Roussy play in improving it?

The most important factor researchers look at is the quality of the research environment. At Gustave Roussy, we have made a concerted effort to attract both French and international researchers of the highest calibre, both through improving our infrastructure and targeted programs. Firstly, we have a very advanced operational structure and culture, with a fully integrated clinical research and treatment process. This is very appealing to many researchers. Secondly, we have also launched a postdoctoral program for young but established postdocs. We have attracted top candidates from institutes like Harvard, Stanford and Memorial Sloan Kettering. That Gustave Roussy is in Paris is a bonus, but researchers will not come just for Paris. They will come for Gustave Roussy.

The French healthcare system has always been celebrated for its commitment to free, universal access. What is the biggest challenge facing the French healthcare system today?

The French healthcare system does stand as a model of achievement: that a country as expansive as France can create a top-notch healthcare system with free, universal and equal access is truly impressive and cannot be overestimated.

As a point of comparison, take the Netherlands and France. The Netherlands is such a densely populated country that one cannot physically live more than an hour away from a university medical center. Compare this with France, where a third of the population lives in Île de France, and there are significant swaths of relatively unpopulated, rural areas: Le Massif Central, le Grand-Est, le Grand Nord. It is a major achievement that such comprehensive healthcare infrastructure has been built nationally.

However, given the increasingly untenable burden healthcare expenditures are placing on the government budget, there is a need to re-evaluate and transform our existing system. Our healthcare system desperately needs to be consolidated. Our current system is built on the convenience model, which is acceptable if one lives within the Île de France region, but nationally, it is no longer feasible. You cannot expect this network of medical institutions and infrastructure to accommodate all sorts of elective medicine or specialty care for serious chronic diseases like cancers. It is unrealistic to provide every service in every hospital, if the quality is to be maintained.

This challenge is exacerbated by political complexity. The problems with our existing healthcare system are established, but there are serious political difficulties surrounding any attempt to overhaul the system. Hospitals are often presided over by town mayors themselves, which makes it extremely politically unattractive for mayors to push for consolidation when such measures would entail the closing down of hospitals by mergers into bigger regional hospitals.

How can this challenge be tackled?

The key is to transform society’s mentality regarding this issue. Currently, there is the understandable expectation on the part of the population that there will be comprehensive medical facilities within easy access, entrenched by decades of dependence on the existing system. The French people have yet to fully grasp the severity of the fiscal burden the healthcare system represents, so this will have to be fully articulated.

However, this must be framed in the context of improving quality. For me, institutionally, quality accreditation programmes are the most – if not only – feasible means by which the French system can be reorganized. They function similarly to a quota system, where hospitals or departments failing to meet relevant criteria (quality- and/or volume-based) are shut down. The actual process is more complex but essentially, hospitals are consolidated by highlighting their areas of strengths and eliminating the domains in which they are weaker. It is not merely a cost-cutting measure; if a department does fewer than a set number of procedures, it also implies that the staff do not have the necessary experience required to be familiar with all the potential complications that may arise from these procedures, which is problematic.

The current convenience model does not improve quality, but places a huge burden on France’s fiscal budget and is unsustainable. The only solution that is politically palatable, financially feasible and quality-improving is consolidation through quality accreditation programmes.

Ultimately, the French people are the final decision-makers, but once they understand the situation, I believe they will accept the compromise: for higher quality treatment, they will have to travel a little further to the nearest facility.

Is France’s Cancer Plan 2014-2019 a step in the right direction?

Definitely. Part of the plan is to have a regional parcours, or a network of hospitals, as part of a push towards consolidation. Gustave Roussy has already taken the initiative to form partnerships with other healthcare and medical institutions, in order to build and improve the regional network. The most important thing is to not try and do everything ourselves, but to partner with excellent partners in order to produce excellent programmes. Choose your priority programs and concentrate on them, and then partner with other institutes that are excellent in complementary areas. We have created an Institute of Thoracic Oncology with Marie Lannelongue Surgical Center. We treat patients on both sites and we work on various therapies, but they do the actual thoracic surgeries, because we simply do not have the capacity to accommodate them. This is a mutually beneficial arrangement. Ultimately, this problem needs to be solved regionally, through regional cooperation with various hospitals, all with complementary strengths. Individual hospitals like Gustave Roussy may initiate these programs and they are effective for participating countries, but they alone cannot improve the overall system. Rather, we hope to serve as a model that will both encourage and facilitate other hospitals’ adaptation to the consolidation of the system.

You have just been re-appointed as the Director-General of Gustave Roussy for the next five years. What projects are you most excited about?

In my last term, we consolidated and integrated our research infrastructure, but there is much more work to do on that front. We have bigger ambitions. We have just released our 2015-2020 plan, where we detail our development of a Cancer Campus. The first step is to build the biggest pre-clinical research infrastructure dedicated to oncology in France. The building shall be delivered in the first quarter of 2018. Ultimately, our goal is to build a fully-fledged biopark, with heavy integration of biotechs and other private institutions. I am very excited about this project. We will have our own metro station right in front of our front door, and the station will be called Gustave Roussy.

What about your internationalization programmes?

A major initiative we have launched is Cancer Core Europe, which is a virtual hospital/research institute that we are positioning to be the premier Cancer Institute of Europe, like the National Cancer Institute in the US. We have partnered with six other institutes, all of which are experts in their own fields: Cambridge Cancer Centre in the UK, Karolinska Institutet in Sweden, the Netherlands Cancer Institute in the Netherlands, the Vall d’Hebron Institute of Oncology in Spain and the German Cancer Research Center. Unlike many other consortia that have been formed in Europe, we are investing in this as a long-term sustainable project to create a permanent structure and are in the process of making it a legal entity. In fact, we have also made this a private investment to eliminate any external pressures that will jeopardize the success of this venture. We will also be fully integrated – each of us will have access to patient databases and records, for instance, and we can improve patient search facilities.

This will also be significant in terms of improving clinical research in this area. Retrospective data mining in oncology is very difficult: fully clinically annotated data is needed for outcome research, but obtaining it retrospectively produces very incomplete data, because of the extreme complexities surrounding cancer treatment. The pathology is very complex, especially if there is molecular diagnostics involved. There are post-surgery interventions and then there could be remissions and relapses, so there are a lot of variables to consider, and if data is not comprehensively collected from the start, it is very difficult to retrospectively obtain anything useful. With Cancer Core Europe, we will be able to do prospective data mining, which is crucial.

Furthermore, as a leader in cancer in Europe, Gustave Roussy occupies a prominent place internationally because of our innovative model of comprehensive care, the excellence of our research and the quality of the training we provide to health-care professionals in the field of oncology. We are developing a programme through our subsidiary Gustave Roussy International, to promote our model of care abroad. We have for example developed projects in Kazakhstan and Kuwait which are guided by the principles of creating lasting infrastuctures and long term relationships regarding developing cancer care programs and education programs as the needs in many countries or paramount in these domains. These programs will also help us to finance our very ambitious investment plans to complete the infrastructural demands of Gustave Roussy in France.

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