Jack Beecher - Dec 6, 2019

Hidden Gems in Clinical Trials: A Gem by Yellowstone

In TrialScout’s Clinical Trials Landscape Project, we reviewed the top 21 cities in the country for overall clinical trial output. Despite the high performance of these cities, they account for less than half of the country’s trials; the reality is that clinical trials are not solely restricted to major metropolitan areas. Other cities that are not typically known as hubs for clinical trials make relatively significant contributions to the clinical trials landscape, as outlined in the “Hidden Gems” analysis of the project’s review paper. In the Hidden Gems Series, we focus our attention on these areas and take a deeper look at what accounts for their performances.

Coming in at #10 in our list of the country’s Hidden Gems for clinical trials is Billings, Montana. Despite a modest population of just over 170,000, a total of 1,958 clinical trials have been conducted in the city; this yields an index value of 11.4 clinical trials per 1,000 residents1,8. 719 (36.7%) of Billings’ trials are currently active, while 236 (12.1%) are recruiting for participation1.

As per the U.S. Office of Management and Budget’s (OMB) 2018 delineation of the statistical areas in the country7, the Billings MSA houses Carbon, Stillwater, and Yellowstone counties in southern Montana. The greater area thus extends as far eastern as Custer, westward to include Nye and Reed Point, and south to the Wyoming border. Located on the Yellowstone River and a few hours from Yellowstone National Park, Billings is the largest city in the state of Montana, with specialties including retail, trade, transportation, energy, and healthcare2,9. The Billings MSA as a whole holds a similar industry pattern, with a noticeably high concentration of “Educational services, and health care and social assistance” across its three counties according to the official state website6. It is plausible, then, that Billings’ relative overperformance in the clinical trial industry is linked to its focus on the healthcare industry.

The historical active trial performances of health systems in the Billings MSA is shown in the chart below1:

Active Clinical Trials in Billings, MT MSA

Copyright © 2019 TrialScout™

As seen, the Billings area is primarily served in the clinical trial industry by the Billings Clinic and SCL Health; about 42.2% of all clinical trials conducted in the MSA were by the Billings Clinic, while another 26.7% is accounted for by SCL Health. Both of these health systems accelerated notably from 2008 to 2010, for the most part grew steadily from 2010 to 2016, and have seen more growth since. The declines of the Northern Rockies Radiation Oncology Center and the Hematology-Oncology Centers of the Northern Rockies are attributable to their closing. In particular, the former was a partnership between the Billings Clinic and St. Vincent Healthcare (now a division of SCL Health) that closed in 2010 after the Billings Clinic pulled out to focus their services on their new cancer center. Remaining services were transferred to St. Vincent’s Frontier Cancer Center, likely including those of the affiliated Hematology-Oncology Centers of the Northern Rockies5.

Active Clinical Trials in Billings, MT MSA

Copyright © 2019 TrialScout

The chart above displays the active trials per year of the more significant clinical trial locations in the Billings MSA. While the Billings Clinic’s Cancer Center generally saw steady growth from 2010 onwards, it did not appear to be a major beneficiary from the closing of these two facilities, nor did the Frontier Cancer Center. The biggest beneficiary appears to be St. Vincent Healthcare, which saw the most rapid growth of all locations in Billings post-2010. At a top level, locations in the Billings MSA generally have steadied or declined in active trial output, and this is reflected in the totals for the entire area: in 2008, there were 908 active trials in the Billings MSA, compared to 884 in 2018. Looking back at the health systems in Billings, the concentration of active trials has shifted to the Billings Clinic and SCL Health over time. The Billings Clinic accounted for 38.1% of active trials in the MSA in 2008 and 48.2% of them in 2018, while SCL Health increased from accounting for 21.4% of active trials in the MSA in 2008 to 35.6% in 20181.

The trends over time for these two health systems in the Billings MSA are virtually identical, and there are several potential explanatory factors. First is the fact that the two systems previously were affiliated (see above)5, so it is possible that the trials that were active at the Northern Rockies Oncology Center may have been distributed between them. Another interesting link is the correlation between the increase in active trials in Billings from 2016 onwards and the timing of the Cancer Moonshot Summit. This was a set of three conferences held in Kalispell, Bozeman, and Billings, Montana in 2016 by order of then-Vice President Joe Biden that aimed to address problems in cancer care in the state such as access, new treatment, preventative efforts, and optimization of data. Some of the main suggestions to come out of these conferences related to clinical trials, such as improved coverage, funding, and implementation of a community-based approach3,4. Interestingly, Kalispell and Bozeman are also performing well in the clinical trial industry relative to their sizes; Kalispell boasts about 9.5 clinical trials conducted per 1,000 residents while Bozeman comes in at just under five1.

Evidence for this potential link is mixed, however. The Billings Clinic’s Cancer Center has not grown significantly since 2016, but the St. Vincent Healthcare Frontier Cancer Center saw a very similar uptick in clinical trial activity to that seen by the Billings Clinic and SCL Health as a whole from 2016 onward. In addition, 2016 marked a rebound year for the Frontier Cancer Center, as it had been declining in active trial total each year since 20121.

As for clinical trials in Billings that are currently active, the distribution by location and status can be seen below1.

Currently Active Clinical Trials in Billings, MT MSA

Copyright © 2019 TrialScout™

As seen, there is generally a larger portion of active trials that are not recruiting for participation than those that are at clinical trial locations in the greater Billings area1.

The distribution of active clinical trials at locations in the Billings MSA is again displayed below, this time on the basis of phase1. The distributions for the Billings MSA as a whole, as well as the entire country, are also included for comparison. This analysis is based on a normalized scale rather than raw count of clinical trials.

Phase of Currently Active Trials in Billings, MT MSA

Copyright © 2019 TrialScout™

In general, clinical trial locations in the Billings MSA are focusing mostly on Phase 3 trials. The Billings Clinic Cancer Center, St. Vincent Healthcare, and the Frontier Cancer Center have phase distributions that are very representative of Billings as a whole, although these locations have little to no Phase 1 and 4 trials. When compared to the entire country, clinical trial locations in Billings have greater relative focus on Phase 2 and 3 trials than the national average, and less on trials that are Phase 1, 4, or “Other.” The Billings Clinic Hospital is slightly skewed from the averages and other distributions due to having a smaller amount of active trials1.

The following graph displays the percentages of currently active trials being conducted by the two major health systems in Billings that are accounted for by different intervention types1. It is important to note that a single clinical trial can be designated with multiple intervention types, explaining why the percentages for each entity explored exceed 100% when added.

Intervention Type of Currently Active Clinical Trials in Billings, MT MSA

Copyright © 2019 TrialScout™

The intervention distributions of the major health systems in Billings reveal a general focus on trials with drug and biological interventions. Both the Billings Clinic and SCL Health have greater concentrations of drug, biological, radiation, procedure, and “other” trials than the national average, but trail significantly behind the national average for device and behavioral trials. These trends are consistent when looking at all currently active trials in Billings and not just those of its two major health systems, suggesting potential oversight of Billings for these types of trials and perhaps a need for them. Notably, the concentration of biological trials in Billings is nearly double the national average, while the area has concentrations of “other” and radiation trials that are nearly 150% times the national average. On the other hand, Billings has a concentration of device trials nearly five times smaller the national average as well as a concentration of behavioral trials more than five times smaller than the national average1.

For a final graphic, the distribution of the currently active clinical trials in Billings by location and lead sponsor is shown below1.

Lead Sponsor of Currently Active Trials in Billings, MT MSA

Copyright © 2019 TrialScout™

The majority of the active trials in the Billings MSA are accounted for by a virtually even split between subsidiaries of the National Institutes of Health (NIH) and sponsors labeled as “Other” (usually referring physician, health system, or research group/foundation initiation. The National Cancer Institute (NCI) is the NIH branch that most frequently sponsors clinical trials; in fact, all of the currently active trials in Billings that are NIH-sponsored are sponsored by the NCI. Further, the “Industry” category usually refers to trials sponsored by pharmaceutical companies.

As seen, the major clinical trial locations in Billings are also generally split between NIH- and “Other”-sponsored trials. However, the Frontier Cancer Center and Billings Clinic Hospital have higher relative concentrations of industry-sponsored trials than their peers. At a top level, Billings has a higher concentration of trials that have a NIH lead sponsor when compared to the national average, but a much smaller concentration of industry-sponsored trials. The NIH’s reach is beyond that seen above, however, as its subsidiaries are frequently listed as collaborating sponsors on trials that they are not the lead sponsors of both in Billings and across the nation1.

Given the nationwide focus on cancer research in addition to the Cancer Moonshot Summit, it comes as no surprise that the overwhelming majority of the currently active clinical trials in Billings are cancer-related. Across the greater Billings area, the five most studied conditions are Recurrent Breast Carcinoma, HER2/Neu Negative Cancer, Breast Cancer, Stage 3B Breast Cancer AJCC v7, and Stage 4 Breast Cancer AJCC v6 and v7. The top five conditions being studied at each location are shown in the table below1:

Billings Clinic Cancer Center St. Vincent Healthcare St. Vincent Healthcare Frontier Cancer Center Billings Clinic Hospital
Recurrent Squamous Cell Lung Carcinoma HER2/Neu Negative Cancer Breast Cancer HER2/Neu Negative Cancer
Recurrent Breast Carcinoma Recurrent Breast Carcinoma HER2/Neu Negative Cancer Recurrent Breast Carcinoma
HER2/Neu Negative Cancer Recurrent Squamous Cell Lung Carcinoma Lymphoma Stage 3B Breast Cancer AJCC v7
Stage 4 Squamous Cell Lung Carcinoma AJCC v7 Estrogen Receptor Negative Recurrent Breast Carcinoma Stage 4 Breast Cancer AJCC v6 and v7
(Five Tied) (Three Tied) Estrogen Receptor Negative (Three Tied)

  1. Approximate attributable data as per the TrialScout database collapse as of 10/21/2019. All data is derived from clinicaltrials.gov
  2. Billings Chamber of Commerce (n.d.). Visit Billings: About Us [Web Page]. Retrieved from https://www.visitbillings.com/about-us
  3. Cancer Support Community Montana (2016). In the News [Web Page]. Retrieved from https://cancersupportmontana.org/latest-news/in-the-news/
  4. Cancer Support Community Montana (2016). Moonshot Resource Ideas for Montana [PDF File]. Retrieved from https://cancersupportmontana.org/wp-content/uploads/2015/12/Moonshot-Ideas-from-Montana.pdf
  5. Cochran, Diane (2010). Oncology center to close after all. Billings Gazette. Retrieved from https://billingsgazette.com/news/local/oncology-center-to-close-after-all/article_f0237a3c-2c00-11df-8912-001cc4c002e0.html
  6. Montana.gov Official State Website (2012). Industry 2012 [Web Map]. Retrieved from https://mtdoc.maps.arcgis.com/apps/MinimalGallery/index.html?appid=3a4c8fa06cfd4409a4c89dfbf97b1248#viewer=3e817480d8674987be12ed77e8704fca&fullscreen=true
  7. OMB Bulletin No. 18-04: Revised Delineations of Metropolitan Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas, and Guidance on Uses of the Delineations of These Areas” (PDF File). United States Office of Management and Budget. September 14, 2018. Retrieved August 14, 2019.
  8. U.S. Census Bureau, Population Division. (2019). Annual estimates of the resident population: April 1, 2010 to July 1, 2018 – United States – Combined statistical area; and for Puerto Rico. Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk
  9. Yellowstone County, MT (n.d.). About Yellowstone County, Montana [Web Page]. Retrieved from http://www.co.yellowstone.mt.gov/cofacts.asp

Written by Jack Beecher

Jack Beecher is a data analyst at TrialScout. He primarily oversees and conducts the organization of clinical trial data at the company, and also contributes to various marketing campaigns. Upon graduating from the University at Buffalo with a degree in psychology, he began his data position at a local healthcare company, and will pursue further study as a Physician Assistant. His hobbies include playing hockey, listening to music, and spending time with family and friends.

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