What inspires you to work as a medical oncologist?
I’ve been treating lung cancer, researching and doing clinical trials in lung cancer since 1994. I went into the field because I was interested in the biology and the multimodality care of patients with the disease. When I was a Fellow at Dana Farber Cancer Institute in Boston, it was a disease with really no options for patients with advanced lung cancer. All we had was chemotherapy, which was very ineffective. In the early stages of the disease, we did okay but, still, most patients didn’t do well after radiation and therapy.
I then moved to the MD Anderson Cancer Center in Houston, where we developed what we call targeted therapy for specific mutations of this disease. I came to Yale 10 years ago and we’ve been working on immunotherapy. We’ve learned how the cancer grows, determined the factors, either in the tumor or in the host immune system, and then targeted the cancer. We’ve taken surgery, radiation, compassionate care and tailored care and moved it all together – and we’re seeing benefits. Are we where we need to be? No, but we’re making progress. I’m inspired every day by how our team at Yale comes together to combat this disease.
How do you collaborate with other specialties at Smilow Cancer Hospital to care for your patients?
I am the disease team leader, so I coordinate well with Dan Boffa (MD), chief of Thoracic Surgery, Henry Park (MD, MPH) who’s leading the radiation oncology group, and Sarah Goldberg (MD, MPH), who leads the medical oncology group. We work closely with Lynn Tanoue (MD, MBA) and the pulmonary group, and with social work and nursing – it takes a team to care for our patients. Cancer is such a tremendous adversary so we must work together to treat patients in the most effective way. We have a seminar series each week and we have a meeting where we discuss clinical trials, as well as a tumor board. We’ve added some new research meetings. We have a SPORE – Specialized Program of Research Excellence in Lung Cancer. (Dr. Herbst leads that grant with Katerina Politi, PhD.) Our team has come together to make the best inroads from the lab to the clinic and back again – because we learn from the lab and bring advances to the clinic. As good as our drugs are, some patients develop resistance, and we must go back to the lab again to improve our outcomes.
What advances have made the biggest impact in the treatment of patients with lung cancer over the last five years, and what is the outlook for lung cancer in the next five years?
In the last five years, it’s been all about immunotherapy, including immunotherapy and targeted therapy in the early stages of the disease. Much of this work is based on the studies of Leiping Chen (MD, PhD) here at Yale. We can take an immunotherapy checkpoint inhibitor, give it to a patient with lung cancer and see the tumor shrink because you’ve reactivated the immune system. Much of that preliminary work was done here at Yale. Now we’re seeing that we can bring these results, with worldwide collaboration, and use immunotherapy before surgery or after surgery with benefit. The other amazing thing is this works even in patients who have been smokers and have more aggressive tumors. That’s a great advance. The second advance is what we call targeted therapy. I was fortunate to do some of the earliest trials with EFGR inhibitors in 1997. In the last two years, I’ve led a worldwide trial with my Yale colleagues where we now take these drugs – and we don’t use them in the most advanced setting – but we use them right after surgery in relevant patients and we’re seeing tremendous results. There is also the early drug development at Yale, so we are seeing great advances that are just the tip of the iceberg.
Mentorship is an important part of laboratory research – how do you encourage collaboration and keep your team engaged?
Of all the things I’ve done, I’m most proud of the team I’ve built here at Yale. I have five people in the medical oncology group who could all lead a lung team anyplace in the country and they’ve been here since the earliest stages of their careers – our scientists have grown up with us. We have career development programs, and development programs for projects to add to our SPORE. We work very closely with medical students and fellows. Many of our fellows now want to focus on lung cancer. That wasn’t always the case. There are so many opportunities. You can work in a Basic Science Lab, work on clinical trials with translational in-points – meaning obtaining tissue and understanding sensitivity and resistance – and you focus on access and diversity. We go to churches and on radio shows here in New Haven to talk to people about nicotine addiction and smoking cessation and primary prevention. We’re working hard – with Dr. Tanoue, Dr. Boffa and their teams – on lung cancer screening.
How do you connect with clinicians treating patients with lung cancer to bridge laboratory research to clinical care?
We do Smilow Shares, outreach programs, and CME events. You have to do good work and provide access – then you must communicate to two groups: the patients and their families, and the providers. Yale has clinical trials; we’re raising the bar. We can offer you something potentially that a smaller place can’t because we have the university and we have the medical center. We’re learning and we’re implementing as quickly as possible. We do programs for our physicians. We write papers. We present at national conferences and symposiums. We publish, we speak, we collaborate. Around the world, there is a group that focuses on lung cancer and we are part of it.
Lung cancer screening is a critical part of early diagnosis. How do you encourage a long-time smoker who may be fearful to consider participating in a screening?
It has to come from their primary caregiver. It comes from building trust. That’s why we’re doing a lot of work in the community – to build trust. We’re doing work with investigators to teach them how to develop trust in the community. It’s hard for some people who have to take a bus to get here or pay to park. But we’re working hard in the community to build that trust. We can save lives if we can find lung cancers earlier. Let’s screen people who are over 50 who have smoked for 15 or more pack years. When they come in, we also try to work with them on tobacco control.
What are some of the biggest challenges you face in caring for patients with lung cancer?
The biggest challenge is drug resistance. These targeted therapies are amazing. I saw it in 1996 and 1997. Tumors melt away in people who would have had no chance. I made friends with my patients. I got very attached – I always get attached – (as) people lived (after diagnosis and treatment) for three, four, five years. But the problem is, as good as these drugs are that we use for specific alterations, resistance will ultimately develop. So, we’ve got to figure out what to do. It’s like it’s a nine-inning game and we need relief pitchers now; we’ve got to figure out how to win that game with new drugs and we’re working on that. We’ve got the best lab in immunotherapy in the world, and we still have 50% of patients who are primary resistant so it doesn’t work in lung cancer, and then another 30% will become resistant. It’s good but we need more science, more research.