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Cancer Center Puts Patients First

Exterior rendering of the new National Center Institute of Brazil
Designers of the new National Center Institute of Brazil solved stringent open space requirements by fronting the hospital complex with a generous courtyard that opens onto the street, providing public space in a congested part of the city. Drawing by Cannon Design

A new center for cancer research and treatment in Rio de Janeiro focuses on making the patient experience easier and more uplifting.

March 12, 2013—Amidst the hustle and bustle of Rio de Janeiro, Brazil, one of the largest cancer patient care facilities in Latin America is finally taking shape. The $600-million hospital and research center for the Instituto Nacional de Câncer (INCA)

will be the hub of cancer care and research in the country. The 500-bed hospital will treat the most acute cancer patients, and the building should help boost funding for cancer research in Brazil.

The 1.5 million sq ft building will include about 1.1 million sq ft of new construction and the renovation of a 400,000 sq ft hospital that dates to the 1950s. The new structure is near a series of dilapidated buildings that are being demolished in a part of downtown that is undergoing redevelopment. It will also consolidate the operations of several older hospitals around Rio.

The winning bid for the project was submitted by a team comprising the Sāo Paulo–based engineering firm MHA, the Rio-based architecture firm RAF Arquitetura, and the St. Louis–based architecture and engineering firm Cannon Design. Salim Lamha Neto, MHA’s principal engineer on the project, says Cannon Design has designed numerous cancer hospitals in the United States. “We invited Cannon as a consultant because of their expertise in oncology,” Neto says. 

 Exterior rendering of the building, featuring the facility's cancer research wing which forms a bridge over the planned public courtyard

The facility’s cancer research wing forms a bridge over the planned
public courtyard. Dubbed the bridge of hope, patients will enter
under this structure, which can be clearly viewed from the interior.
Drawing by Cannon Design

Open space requirements near the crowded center of Rio are stringent. According to Michael Pukszta, AIA, a principal and the health care practice leader of Cannon Design, one consultant on the project advised that if the team followed all of the codes, it would need to leave roughly 40 percent of the site open and design the building with a maximum height of five floors. “Essentially, he said, the only solution here is to build a doughnut—go up five floors all the way [and] leave a hole in the center,” Pukszta says. “There’s your forty percent. From an urban standpoint, that would have been an awful solution.”

Cannon Design completed a few sketches of the idea anyway but quickly realized it wouldn’t work functionally or aesthetically. The challenge, especially given the purpose, was to “put a lot of real estate on a relatively small piece of property and make it relatively humane,” Pukszta says.

So Pukszta and George Nikolajevich, FAIA, a design principal of Cannon Design, decided to bend the rules by creating a courtyard that would open on the street and create a civic amenity. Nikolajevich says the architects began to wonder, “What if we create a public park in the middle, with functions below the grade, left, right, and above, never interrupted—yet the park is there, both for enjoyment of the people living around, as well as for nurses, doctors, and patients?”

This was the solution, and the designers decided to accent the park with a bridge that would float above the street level at the open side of the structure. The bridge will contain research labs and link the old and new portions of the hospital; just as important, it will link researchers and patients. The structure is being referred to as the bridge of hope, a symbol to patients that the development of better treatments for cancer will be taking place directly over their heads.

 Another exterior rendering, featuring the structure's curving facade

The structure’s curving facade is meant to soften the building’s
appearance and provide a link to the country’s heritage of sensual
modernist architecture. Drawing by Cannon Design

“We were able to tell a story about the importance of that, and if we did that we would have to increase the height of the building from four or five floors up to eight or nine,” Pukszta says. Fortunately, the city’s mayor favored the concept and was able to push through a zoning change. “Something that in the States would have taken years to pull off, in Rio it actually was a line item by the mayor,” he says. “We thought it was going to be a grind. We were surprised how easy it was.”

Because the INCA complex will be both a hospital and a research facility, the design worked on integrating the two functions as part of a philosophy referred to as translational medicine, the virtuous loop through which research breakthroughs are quickly brought to patients and then feedback from treatment is quickly returned to researchers. “So the whole future of research drove the basic [plan] for the building,” Pukszta says.

“This client surprisingly had no real program when we walked in,” he adds. “They were looking to us as the international health care and cancer experts to suggest to them what a cancer hospital of the future would look like.”

So the design and engineering team embarked on a tour of hospital and research centers in Lisbon, London, and Paris and also visited the National Institutes of Health’s National Cancer Institute, in Bethesda, Maryland.  

Cancer patients typically access care 100 times a year, Pukszta says, so the patient experience dictated the design. Related functions—for example, phlebotomy and infusion labs—are located close together, so patients can have their white blood cell count taken as soon as they arrive. Furthermore, the designers organized the building so that every patient would enter through the garden and would be able to quickly grasp where he or she was in progressing through the building. The public circulation and waiting areas face the courtyard, that is, “back toward hope and light—and the garden,” says Pukszta. “It would be hard for a patient to get lost in the building.”

 Aerial view rendering of the new center shown in downtown Rio de Janeiro

The new center will be located close to downtown Rio de Janeiro,
in an area that’s been neglected for years but is beginning to see
renewed development. Drawing by Cannon Design

The new design is also meant to reflect the notion that cancer treatment is moving toward more personalized medicine. “In . . . yesterday’s world of cancer care, we used to have drugs that worked on most patients,” says Pukszta. “If you had a particular type of cancer, they would say drug X is the one you should take. Now we’re getting to the point where we understand the patient’s DNA and we’re actually able to customize the drug.”

What is more, cancer facilities of the future will be far more geared toward outpatient treatment, requiring fewer hospital stays. Pukszta notes that in Brazil the “current model, no matter who walks in the door, [is] they admit you as an inpatient and begin treating you.” INCA, however, is trying to shift to becoming a robust outpatient center. “The vast majority of building is designed for ambulatory patients.”

Neto notes that geotechnical surveys led the engineers to rearrange the level of the ground floor to save money by not having to excavate too deep into rock. There were other challenges on the tight urban site, including the need for both large water tanks and emergency diesel generators, as well as the need to place radiation equipment within heavy concrete bunkers 1.5 m thick. Most hospitals would use 1 or 2 such bunkers; the INCA project will employ 10.

These requirements added complexity, Neto says. “The weight of this and the foundation that we need—all these considerations—that was a huge challenge.”

The hospital will have 400 parking spaces for staff members, along with plenty of space for ambulances, which in some cases will be transporting patients from other cities or even other states. But otherwise the designers tried to minimize parking opportunities to encourage people not to come by car. “We don’t have many places to park downtown, and the streets are narrow and tight,” says Flávio Kelner, an architect with RAF. “That’s why we don’t ask for a lot of car spaces in this area.”

Construction of the new hospital and research space is slated to take three years; after that workers will refurbish the existing hospital building, which should take another year.

Nikolajevich says he was keen to engage the country’s great tradition of modern architecture, noting that the legendary modernist Oscar Niemeyer, the designer of Brasília, lived nearby. (Niemeyer died late last year at age 104.) “It’s a land of poured-in-place concrete—a wonderful material, a plastic material,” Nikolajevich says.

“We used some of the inspiration of the modern architecture of Brazil, our icons of Brazil,” Kelner says. Designers were also keen to harmonize with the 1950s hospital building. “We tried to connect one design to the other design, not to cut the history.” This gave rise to the curves on the north facade and to the open terraces that take advantage of the city’s tropical climate.

As Rio gears up for the 2016 Summer Olympics, redevelopment is slowly restoring some of the luster that the so-called Wonderful City has lost in the decades since Brasília became the capital. “They forgot this part for fifty years,” says Kelner, speaking of the neighborhood around INCA. “Now they’re coming back, and all the area is going to have new [construction]. You can see the life changing, with restaurants, nightlife, [and] places for people to meet and work.”



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