States find creative ways to finance cancer programs

Abstract

Facing cutbacks in state and federal funding for cancer research, prevention, and treatment, various states and advocacy organizations have collaborated to develop other mechanisms to support these initiatives. Texas Governor Rick Perry (front) signing the Cancer Prevention and Research Institute of Texas bill into law on June 13, 2007. Also pictured (left to right) are Texas State Representative Jim Keffer; Gabriel Hortobagyi, MD; Lance Armstrong; and Texas State Senator Jane Nelson. Perhaps the largest and most successful effort to date is that of Texas, which created the Cancer Prevention and Research Institute of Texas (CPRIT) through voter approval of Proposition 15 in 2007. The constitutional amendment authorized $3 billion in bonds to be issued over 10 years to create the agency in an effort to support cancer research and prevention services in Texas. “Texas loves to be first, and we do feel like we're innovative,” says Bill Gimson, CPRIT executive director. “We're very lucky to have Susan G. Komen for the Cure, LIVESTRONG, and a very strong American Cancer Society presence here.” A small group of prominent Texans—including the late former governor Ann Richards, former state comptroller John Sharp, and cancer survivor and LIVESTRONG founder Lance Armstrong—helped launch the movement that led to CPRIT, which also received strong support from the Texas legislature. “The stars aligned,” Gimson says, adding that CPRIT received its first year of financing in 2009 and will remain in existence for 10 years. Every research grant and company that receives funding through CPRIT must have a return-on-investment clause ensuring that a percentage of revenues generated will come back to the state to help fund cancer programs or retire the debt service. To date, the agency has received approximately 3000 grant proposals in cancer research and prevention and has awarded 364 grants, totaling approximately $600 million. All applications undergo a peer review process by experts from outside Texas in an effort to avoid conflicts of interest. CPRIT is required to spend up to 10% of its budget on prevention activities, and the agency has awarded roughly $30 million to screening programs for breast, cervical, and colorectal cancers in underserved populations. “We screen 70,000 Texans, and almost 30,000 of them have never been screened before,” Gimson notes. “We're finding precursors and early stage cancers, and no doubt we're diagnosing these cancers much earlier.” CPRIT also spearheaded the creation of a statewide clinical trials network with a single Institutional Review Board that coordinates studies throughout the state. Not only does the network simplify the entire process, it also enables greater participation in trials by people across Texas. Network leaders also are working to develop a biorepository of tissue samples on which to perform molecular diagnostics and advance the personalized medicine field. Another major initiative is CPRIT Scholar in Cancer Research program. Its goal is to help medical research institutions in Texas recruit leading and promising scientists from across the country. Thus far, the agency has funded approximately 34 scholars. The agency provides significant funds to help these investigators establish their laboratories, while the research institutions must commit to providing long-term support. The return-on-investment clause in their contracts requires that a percentage of the revenue from any drugs, devices, or diagnostics they develop is returned to the state. CPRIT also focuses on bringing biotechnology companies to Texas. These companies must undergo a rigorous application process to ensure their science, management, and business plans are very solid—of 200 applications, the agency has funded 9 companies. “We're always looking at big ideas,” Gimson says. “In 10 years, we want to look back and say that we really made a difference.” Cancer advocacy groups in California are helping their state to follow in Texas's footsteps with the California Cancer Research Act (CCRA), a campaign that is being cochaired by Lance Armstrong. The CCRA qualified for the next statewide ballot after its supporting coalition, led by major health advocacy organizations including the American Cancer Society (ACS) and cancer survivors, submitted 634,722 voter signatures to the California secretary of state. Voters will decide on the initiative in the next statewide election, which is scheduled for June 2012. The initiative proposes a $1-per-pack tax on cigarettes that is expected to deliver more than $855 million per year to pursue potential cures of cancers and other tobacco-attributed diseases, including heart disease; drive down smoking rates by investing in proven smoking cessation and tobacco control efforts; and assist tobacco law enforcement. Other states across the country do not have such extensive funding mechanisms, but they are finding creative ways to support cancer programs on a smaller scale. A study published in the September–October 2011 issue of Public Health Reports found that state donations collected by check boxes on state income tax forms, fees from specialty license plates, and revenue from state lottery tickets have raised millions of dollars for breast cancer research and prevention programs nationwide.1 The study was led by Amy Eyler, PhD, research associate professor at the Brown School of Social Work and Prevention Research Center at Washington University in St. Louis, Missouri. Dr. Eyler and her colleagues found that between 2001 and 2009, 18 states had programs that allowed taxpayers to check a box on state income tax forms to donate part of their refund to breast cancer programs. Average yearly revenue ranged from $10,000 in Delaware to $935,500 in California. The median annual state revenue collected through income tax check-off boxes was $115,000. Meanwhile, 26 states had breast cancer license plates that had generated a total of more than $4.1 million in revenues as of 2009. In most cases, specialty license plates are more expensive than regular plates (ranging from $20 to $75), and the revenue from the plates comes from a percentage of the extra fee. For both the specialty plates and income check-off boxes, the amount of revenue collected varied according to population, the number of other plates/check-off boxes offered, and the pressures of economic difficulties. “What surprised me was the variation in the number of specialty plates,” Dr. Eyler said. “Some states only have 1 or 2, while Massachusetts has 500 different plates. That's a lot of competition for very limited dollars.” While the income tax check-off provides an easier and steadier source of income than the plates, it does require legislation to have it placed on the state income tax form, she adds. Illinois has yet another way of generating funds. In 2005, its legislature approved the “Ticket for a Cure” scratchoff lottery ticket, which raises money for a breast cancer awareness and education fund. As of 2009, the lottery had collected more than $7.4 million for the cause. Dr. Eyler and her colleagues found that states sharing geographic borders were more likely to have the specialty plates. They also discovered that states with medium or high breast cancer mortality rates were 2.5 times more likely to offer the plates. Georgia's specialty breast cancer license plate has raised approximately $4 million for indigent care, including screening, prevention, and treatment. The recipient organizations for the proceeds from these fundraising efforts varied, but the top 3 were research universities, Susan G. Komen for the Cure, and state health departments. In Georgia, the recipient organization is the Georgia Cancer Coalition, a previously independent nonprofit that initially was funded by tobacco settlement dollars. (It is now an initiative of the Georgia Research Alliance.) The income tax check-off (which, as of 2009, became a fund for all types of cancer) has generated approximately $3 million and enabled the funding of 71 seed grants for researchers in breast, prostate, and ovarian cancers. “Those researchers have, in turn, brought in nearly $12 million in external funding because the grants allow them to be more competitive for larger federal or ACS awards,” says Amy Moore, PhD, the Coalition's director of research programs. “We're seeing a pretty good return on investment.” Georgia's specialty breast cancer license plate has raised approximately $4 million for indigent care, including screening, prevention, and treatment. Funds are allotted to the state health department, which generally has selected the Coalition to award the grants. Of the $80 fee for each plate, $22 will go toward the fund. Tobacco settlement dollars have helped fund the Coalition's Distinguished Clinicians and Scientists Program, initially created because Georgia was one of the largest states east of the Mississippi to lack an National Cancer Institute–designated cancer center. The program's goal was to encourage scientists to come to Georgia to help the state build up its research infrastructure. To date, the Coalition has made 174 awards to research institutions across the state, totaling nearly $400 million. They also have awarded grants to investigators at 9 community cancer centers. The tobacco funding has varied over the 10 years since the Coalition was founded. Originally, the Coalition was created with the goal of investing $1 billion in cancer research—drawing on $400 million from tobacco funds, $500 million in federal funds, and $100 million from private sources. “We're close to achieving that vision,” says Angie Patterson, director of patient navigation and survivorship. Because the Coalition was an independent nonprofit, it has been able to focus on a broader agenda than just implementing the state's Centers for Disease Control and Prevention–funded comprehensive cancer control plan. Many other states have coalitions, but their sole focus is on implementing these plans, Patterson notes. Among the Coalition's initiatives are: Georgia Care, which focuses on clinical trial coordination; Cancer Patient Navigators of Georgia, which works on best practices; and the Biorepository Alliance of Georgia for Oncology, which coordinates the collection of research specimens.