There are theories about why Hippocrates, the father of medicine, named a cluster of abnormal cells karkinos (Greek for crab). Was it because the tumour felt hard as a rock, reminding him of the crab’s shell? Or, was it because of the stubborn nature of the disease, quite like how a crab doesn’t let go of you easily when it bites? Cancer continues to baffle and fascinate us, much like the origin of the word. But we surely have come a long way in understanding and treating it. Now, with artificial intelligence, there is new hope, says Dr Jame Abraham of Cleveland Clinic. As someone heading the department of hematology and medical oncology, he has seen both the human and clinical side of fighting cancer. In an interview with THE WEEK, Abraham, whose latest book―Cleveland Notes―traces his journey as a cancer physician, talks about how new therapies are changing cancer care.
Q CAR T-cell therapy has revolutionised cancer care. Most drugs today work on activating the immune system to attack cancer cells. How big a difference has the therapy made in treating different kinds of cancer?
A Training our immune system to attack cancer cells without causing damage to normal cells is one of the most important advances in cancer therapy in the past 10 years. Various immunotherapy approaches including monoclonal antibodies, such as pembrolizumab, and CAR T-cell therapy are currently saving patients’lives. Immunotherapy has improved survival in advanced melanoma and lung cancer―two of the most lethal cancer diagnosis. In August 2015, former US president Jimmy Carter was diagnosed with metastatic melanoma that had spread to his brain. He was treated with pembrolizumab (immunotherapy) and has been in remission for the past eight years, which is a remarkable achievement. Similarly, CAR T-cell therapy is offering long-term remission in advanced myeloma and lymphoma diagnosis.
Q How is AI helping with cancer diagnosis and treatment?
A The impact of artificial intelligence (AI) on our daily lives, medicine or cancer care will be more far-reaching than the internet’s or computer’s. Many specialties in medicine use pattern recognition to make diagnosis, such as pathologists or radiologists. A pathologist when she/he looks under the microscope is looking for patterns of normal versus abnormal cells to make a diagnosis of cancer. Similarly, a radiologist looks at the MRI of the brain or CAT scan of the lung for abnormal patterns to make a diagnosis of a brain tumour or lung cancer.
If we train AI, it can pick up abnormal from normal much faster than a pathologist or a radiologist. Scientists have developed deep learning tools and algorithms that can detect cancer better than the human brain. Another area where AI can help will be sorting through the large amount of genomic data to help clinicians diagnose and select treatment. In addition, AI will play a major role in drug discovery and development.
Q Covid-19 slowed down cancer diagnosis and treatment. Have we been able to catch up? How has Covid-19 changed cancer care?
A Covid-19 has caused significant delay in cancer screening and diagnosis in many cancers, such as breast cancer, colon cancer and lung cancer. In addition, Covid-19 has exposed the innate vulnerabilities and inequities that exist within health care systems across the world. We are still working to sort that out. Another impact of Covid-19 is on workforce. High burnout among health care providers has caused many of them to leave patient care completely. Hospitals in the west, especially the US, are still trying to cope with workforce shortage due to this great resignation. But many things have changed since Covid-19. Telemedicine programme has gained acceptance in mainstream. Scientific breakthroughs such as mRNA vaccine technologies, which were used in Covid vaccine, are already being used in developing new treatments for cancer. This can potentially be a game-changer.
Q Immunotherapy, precision oncology, DNA sequencing and such technologies are already changing how we look at and treat cancer. What is going to be the next big thing in cancer care?
A Due to economic development, the life expectancy in India and around the world will continue to improve. As we age, as a society and individuals, we will be dealing with cancer, heart disease, neurodegenerative diseases (like Alzheimer’s) and metabolic disorders (like diabetes). Health care systems around the world should be preparing to deal with the tsunami of these four diagnoses.
Some of the technological advances in the future that will help us deal with cancer are
* Cancer interception approaches: Individualised risk-based screening, incorporating personal behaviour (smoking/alcohol), family history (history of breast cancer), genomic information and ctDNA (circulating tumour DNA) may allow us to detect cancers before it really happens in an individual. There are a number of studies looking at this.
* Every patient and patient encounter are filled with thousands of data points―when we add genomic information from the patient and the tumour, it can increase exponentially. But all these data points can give us valuable information to provide highly personalised care for that person. Emerging AI tools will help doctors to filter these data points and tailor treatment.
* Evolution of novel approaches such as mRNA-based vaccines, CRISPR technologies for gene editing, cellular therapies, bispecific antibodies, oncolytic viral therapies and novel antibody drug conjugates will continue to transform cancer treatments. They will offer novel options for cancer prevention and prolonged cure.
* Novel technologies such as holograms, virtual reality and AI may further revolutionise telemedicine globally, allowing patients to see a doctor anywhere in the world.
Q In your latest book, Cleveland Notes, you poignantly bring out what it means to fight cancer through your patients' experience. Could you share your experience about putting that on paper?
A There are three main reasons for me to write this book.
First, I would like to tell the story of my journey. It is a story of luck, chances, God’s grace, failures, disappointments, eternal optimism, hard work and perseverance. I am very grateful to the free public education I received, which gave me a passport for social upward mobility. I hope my journey from a small village with limited means to a leadership position at one of the best hospitals in the world will inspire another young girl or boy to dream big.
Second, taking care of patients with cancer on a daily basis is truly inspiring. You will have the privilege of witnessing the strength of human spirit when they are facing the worst crisis in their life. It is amazing to watch ordinary people rising up to the occasion and living with hope, kindness and compassion for themselves and others.
Third, as a cancer doctor, I experience many moments of joy and gratitude. But that cannot diminish the impact of dealing with pain and suffering on a daily basis. Writing is therapeutic for me and it allows me to express my feelings on paper. This work is a compilation of articles over the past many years.
Q You have also written about how doctors do cry, perhaps not in front of patients. Over the years, has dealing with loss changed?
A I chose oncology because I deeply care about patients with cancer and because of my passion to find a better treatment for cancer. That hasn’t changed. I hope I will not develop compassion fatigue, and the day I do, I shall stop seeing patients. As an oncologist, I learned to celebrate small and large victories and milestones. It has given me a strong sense of perspective and purpose. But as any caring individual or a doctor, each loss or suffering takes a bite out of your heart. It will hurt you deeply. As I mentioned in the book, “the size of the cemetery we carry in our heart will continue to expand.”
I will never forget the words by Amber, one of my patients: “I know that I always said that you have the worst job in the world! But I am thankful to you. You were my doctor and my friend. When you get to heaven, I along with so many others will be there to greet you and welcome you to paradise. You are truly amazing and I cannot thank you enough for all you have done.” Three months after Amber died, her husband handed over this letter to me. These words will continue to inspire me to work even harder.
Q You have traced your journey as a cancer doctor in your book. How do you think it will help readers, including patients and medical students who aspire to be where you are?
A Three takeaways from this book:
* Never take yourself too seriously and never forget your roots. That is why I explored my journey from a small village to Delhi, New York, Washington, DC and Cleveland and my identity crisis in a funny manner. Dream big and work hard, but at the same time be prepared to pay the price for big dreams. You will fail and fall down. But your journey will be defined by your courage to persevere.
* Patient stories in my book are filled with hope and resilience. All of us need to practise compassion in our daily lives. As a cancer doctor, I am reminded of the momentariness of life on a daily basis. Those patient stories will inspire anyone, not just someone in the medical field.
* Finding a purpose in your life is important. My purpose is to lessen the pain and suffering from cancer. That is a tough task. As a cancer doctor and researcher with the privilege to work at some of the best research centres and hospitals in the world, my journey is still a work in progress. Whatever your purpose in life, with intense focus and hard work, you will be able to do that, too.