I often start talks I give on cancer research with a discussion of the war on cancer. To be honest, I have a very mixed relationship with this metaphor.
The concept of the war on cancer was first popularized in 1971 by President Richard Nixon and used in a more nuanced manner more recently by Vice President Biden. This metaphor emphasizes how working together against a formidable foe will improve our lives and those of future generations. It speaks to the need for immense dedication, focus, sacrifice and persistence to achieve a noble goal. The war on cancer implies a need for teamwork by multiple sectors of society, including civilly minded citizens, government, academia and the private sector. It also implies there is an identifiable enemy, and that total victory is possible. This last point is where the metaphor of the war on cancer starts to break down. In 1971 our knowledge of cancer was quite primitive. We thought of cancer as a single disease where a single approach to victory was possible. We now know that cancer is not a single disease but multiple diseases. Indeed, every cancer is unique and personalized approaches are required for success. In other words, in the war on cancer, there is no single and simple way to target and defeat the enemy.
I heard a talk on leadership during a commencement address many years ago that has stuck with me. The esteemed speaker, a nationally known, highly successful businessman, spoke about what it took to be a successful leader. One theme of his talk was that successful leaders should not hesitate to switch jobs. His approach throughout his own successful career was to “build it for 3 years, run it for 3 years, then move on.”
A key role of the Holden Comprehensive Cancer Center is to collect and provide information about cancer that our researchers can use to find better ways of reducing the burden of cancer. This includes information on underlying genetics and lifestyle of patients. It includes analysis of cancers removed from patients so we can evaluate the genetic, molecular and cellular makeup of the cancer. Finally, it includes information on the response to cancer therapy including clinical response, side effects of therapy and quality of life. Given the complexity of cancer, robust information from a large number of patients is needed so we can conduct research that helps us determine what is best for each individual patient. Doing such research requires a partnership between researchers and patients who are willing to fill out surveys, provide blood samples and give us permission to use their cancer tissue and clinical information in research .
Last week, I had the pleasure of giving a talk on cancer at the University of Iowa Carver College of Medicine Mini-Medical School, a series of presentations provided to the lay public to introduce them to a topic in medicine. Every time I give a talk to a lay audience, I think back to a wonderful woman I had as a patient when I was doing my oncology training in the 1980s. She was a retired English teacher who took pleasure in gently ribbing me about the words I selected when I spoke with her (once a teacher, always a teacher). I recall one time when I suggested we consider putting her “on trial.” Her response – “Put me on trial? What a strange phrase. I certainly wish getting cancer was against the law! Why do you want to put me on trial?” That lead to an animated conversation about not only that phrase, but how doctors use expressions when talking to each other that are interpreted differently by patients. While I don’t recall which additional specific phrases we discussed back then, that conversation had a long lasting effect on me, and the phrases I use when I speak to patients, families and the public.
It is difficult for all of us to identify and address, on our own, those areas where we should and can do a better job. Sometimes dealing with day to day challenges limits our ability to step back and look at the big picture. Sometimes we might see an issue that needs to be addressed but hesitate to do so because of concerns about unintended consequences we know or suspect might result from implementing a solution. Sometimes we might not realize there is a better way. Sometimes we might see a better way, but are simply unable to implement the needed change on our own. This certainly is true for a complex organization such as a comprehensive cancer center where we are working to reduce the burden of cancer across the spectrum of clinical care, research and education – where opportunities and challenges are ever present and ever changing.
Achieving our potential requires we ask ourselves whether we are we doing our best to…
Identify and support the most promising cancer research.
Recruit and retain the best faculty, staff, students and volunteers.
Bring advances from the research lab to where they help patients as quickly as possible.
Provide state-of-the-art, personalized clinical care and service to every patient.
Educate the next generation of cancer researchers and caregivers.
Work within our community and across the state to disseminate advances so they help as many people as possible.
Collaborate optimally with other units within our own institution (departments, colleges, the hospital, etc).
Collaborate optimally with outside institutions (referring physicians and medical centers, other cancer centers, the National Cancer Institute, etc).
Structure our own efforts to be as efficient and effective as possible to facilitate our ability to do all of these things well.
In addition to self-reflection and internal discussion, it helps to ask outsiders to take a fresh look and advise us on how to improve. One of the most forward-thinking aspects of the National Cancer Institute (NCI) Cancer Centers Program is the requirement that every cancer center have a yearly visit from an External Advisory Board (EAB) composed of experts from other cancer centers. Making optimal use of an EAB requires the hosting cancer center be totally open. We do not try to hide or paper over our major challenges when our EAB visits. Instead, we put them front and center. For the EAB to do its job and help us improve, it needs to be highly critical. As Oscar Wilde said “true friends stab you in the front.” Having an EAB say “keep it up, you are doing an excellent job,” just doesn’t cut it. We need the EAB to tell us how we can do better. Our EAB will be visiting next month and our presentations to them will include a discussion of what we are doing with a particular focus on where we feel we can improve. We will put down our armor, show them our soft underbelly, and say “hit me with your best shot.”
I have the privilege of serving on the EABs of nine other NCI-designated cancer centers and chairing five of them. I have no doubt participating on these boards helps me do my job at Holden more effectively. I get to see how other cancer centers handle particularly difficult issues. Sometimes I return home with a new idea of how we can address a gnarly challenge. Just as commonly, I return home after seeing a cancer center’s approach to dealing with a problem, grateful for the team we have at Iowa and the solution we have found to a problem that another center is struggling to address.
Sometimes it feels a bit awkward being on an EAB when I beat up on my colleagues and friends, and am rewarded for doing so by a nice meal and a sincere “thank you.” When our EAB visits next month, I am sure they will return the favor. I will say “hit me with your best shot,” and when they happily (and hopefully ruthlessly) comply, I will feed them and express my deepest appreciation.
Incredible advances in cancer genetics have revolutionized how we think about cancer. These advances are now being applied to patient care. A brief response to the question “how is our growing knowledge of cancer genetics impacting on cancer research and cancer medicine?” is to say “it’s complicated – and exciting!” That is not a very helpful answer. Here, I will summarize the big picture with the understanding that this brief summary will not even touch on some of the rapidly evolving, nuanced, yet very exciting concepts in cancer genetics.
Let’s start out with a review and discussion of why the genetics revolution in cancer is so important.
When I give a talk about cancer research, I like to highlight both the diversity of cancer research and that it is a continuum. One way to do this is by showing a scale that, going from smallest to largest, includes cancer research focused at the level of molecules, cells, tissues, organs, patients, clinical trials, cohorts, and communities. Much cancer research spans various points on this scale. I can take any two points on this scale, and talk about an important research project at Holden based on those two points. For example, molecular epidemiology involves taking samples from a large number of individuals in a group of cancer patients and evaluating them at the molecular level in order to improve our ability to predict how specific changes in genes might impact an outcome. Identifying new cancer drugs requires we screen large numbers of compounds to see which have the most promising effects on cancer cells, then after appropriate testing in the laboratory, assess the effects of these new drugs on patients in a clinical trial. Continue reading →
In Slaughterhouse-Five, the masterpiece by Kurt Vonnegut (from our own Iowa Writer’s Workshop), the protagonist Billy Pilgrim used the phrase, “So it goes,” repeatedly when considering various traumas including the incredible horrors of war. Much has been written about what Billy, and hence Mr. Vonnegut, really meant by this phrase. I will not weigh in on this debate, but instead reflect on what this phrase means to me. Continue reading →
I can think of nothing better than Yogi Berra quotes to organize a brief discussion of how molecular oncology is impacting cancer medicine.
“It’s tough to make predictions, especially about the future.”
When I was growing up in New York, if you had asked me which was more likely – for me to spend my career as a cancer center director in Iowa, or to own a flying car, I most definitely would have predicted the flying car. So much for predicting the future. Continue reading →
Popular psychology describes the left side of the brain as logical/analytic and the right side as emotional /creative. This dichotomy in anatomy and function is not supported by modern neuroscience, but I can’t resist using it since I want to talk about how my left brain and right brain have been going at each other this week. Continue reading →