“My interest in cancer began at Northwestern University,” said Robert Maki, MD, PhD, chief scientific officer for the Northwell Health Cancer Institute. “I joined the Integrated Science Program, which forced us to study many sciences simultaneously -- biochemistry, mathematics and particle physics, for example. It was life-changing for many of us, and led me to apply for an MD/PhD program and a start in medicine.”
A medical oncologist, Dr. Maki specializes in treating sarcomas (tumors of connective tissue). He conducts clinical trials for sarcomas and related tumors, such as desmoid tumors, and collaborates in translational research with the Cold Spring Harbor Laboratory. He spoke at length about the direction of cancer research and how it improves care.
Nancy Nahmias [senior administrative director] and I are responsible for CNCT [pronounced “connect”], the Center for Novel Cancer Therapeutics, which is the consolidation of cancer clinical trial efforts across Northwell. For the foreseeable future, our overarching goal is to build an efficient cancer clinical research structure for the health system’s outpatient centers and hospitals that treat cancer.
As an organization, if you’re not offering clinical trials, then patients are falling behind the newest medications and treatments. That’s because other institutions are engaged in clinical trials, now more than ever. There have been over 40 new approvals this year alone by the FDA (US Food and Drug Administration) of new medications for specific cancers. So, by extension, at least some patients who participate in cancer clinical trials will get new medication(s) that would otherwise only be available months or years later, after FDA approval. On the other hand, if you’re only offering standard-of-care, FDA-approved medicines, then you’re not offering what may be the treatments with greatest hope of benefit, fewer side effects, or perhaps both.
People who are treated on clinical trials have better outcomes than those who are not, because the research studies guarantee carefully monitored follow-up.
It’s certainly interesting work. This kind of test may help in terms of primary care doctors being able to screen for cancer non-selectively. Some of the techniques are quite elegant. One test uses different physical characteristics of the cancer cell’s DNA floating around in the blood stream, compared to the normal DNA we all have floating around in our blood. If a rapid and simple blood test, like the one being proposed, can tell me that there’s abnormal DNA in the blood, then you have a powerful technique to diagnose cancer and also track how people are doing as they go on treatment.
For example, a blood test a few weeks after colon cancer surgery and may show signs of cancer DNA in the blood stream. That’s a good indication that there’s may be cancer cells in the body we cannot detect otherwise. One of the remarkable things about DNA is that it is stable to allow these sorts of analyses. The whole issue will be “how low can you go?” in terms of the measurement’s sensitivity and what such tests can tell us.
In addition to cancer treatment clinical trials, the DNA test I previously mentioned examines cancer diagnosis, but there are other types as well. For example, adherence to guidelines can be one type of cancer research – you take a look at outcomes in a population and what you can do to intervene and then apply that to a larger population. You can study if people are getting their colonoscopies or mammograms and other epidemiological questions, and analyze how doing these tests or not impacts outcomes.
Translational research is also very important. It involves looking at cancer tissue and making some observations, and then use those results as “tea leaves” to see what is going on with the therapy and whether it may be useful or not.
Through the Northwell Health Cancer Institute, we look to take translational cancer research to the next level. Our initiatives have been strengthened significantly by a relationship with Cold Spring Harbor Laboratory [CSHL] to conduct this more biological type of cancer research. [See infograph for types of cancer research.]
Northwell Health treats a large number of patients. CSHL has laboratories studying how cancer cells develop and thrive. So we’re looking at achieving a greater depth of knowledge and understanding of cancer through our partnership in basic and translational cancer research.
Of the 50 or so laboratories at Cold Spring Harbor, 25 to 30 are cancer-oriented. We’re trying to link their work, which focuses on how cancer cells grow, live and survive, and tie it back to the actual clinical practice here at Northwell through collaborative cancer clinical trials.
In addition, there is increasing pressure from national authorities -- the National Cancer Institute, for example -- to make basic science more clinically relevant faster. So a priority for CSHL and the director of its cancer center, David Tuveson, is to increase ties to clinical medicine and clinical oncology.
CSHL is a serious research center that many people on Long Island don’t even know about. The work at CSHL is first rate; no fewer than eight Nobel Prize winners in physiology or medicine have worked there.
CSHL is not only recognized for everything they’ve done in cancer research, but also in a wide variety of other areas, including neurosciences, big data and even plant biology. Some of their work is already leading to other relationships with Northwell researchers, for example in the Feinstein Institute for Medical Research.
We recognize just how wily and difficult an enemy cancer is – how heterogeneous cancer is – both from one patient to the next, and even within the same tumor.
One of the biggest advances in science to impact cancer research is the first sequencing of the human genome, with its three billion bits of information that every person has in every cell in their body.
It took multiple billions of dollars to achieve that first blueprint for normal cells, which we’ve now been able to apply to cancer cells. Now that we have a template, it’s very easy to use that template and match information to that template. When we didn’t have that, making progress was much more scattershot.
We had known that cancer is a genetic disease. Now, there is a genetic map to help guide selection of treatments and to assess how DNA is turned on and off between normal cells and cancer cells. The genetic map will impact how we treat people with cancer in the future.
To me, that has been the single greatest advance, and we’re still just beginning to take advantage of it. The map of the human genome is such fundamental work, that it will allow us to reap dividends in any number of diseases. It is significantly important in terms of any and all future research that we do.
The one-to-one interaction I have as a doctor with another person in the clinic. That relationship is still fundamental the core of what we do, and our research has to remain pointing toward improving lives. Even if you enjoy research, you become a physician to try and make other people better. There is a famous paper from Dr. Francis Peabody from 1927 that simply and clearly says that the care of a patient involves actually caring for the patient. So despite the paperwork and other distractions that pull us from that one-to-one relationship, we have to maintain focus. Inasmuch as our research can help us maintain that focus on improving patient care, one cannot help but be successful.
Keyboarding and related tasks such as insurance pre-authorizations that slow down our practice of medicine. We regularly spend two-plus hours with a computer for every hour we spend with a patient. There is also lots of administrative work to do in order to get new therapies to patients more efficiently and safely… Many of these steps are necessary, and many people are working hard to make that happen faster, but I wish that we could translate information from the laboratory to our own patients more rapidly. That is beginning to happen, but I am impatient to not just treat someone with cancer but to also know better why something is working or not, so I can treat the next patient better.
I have a simple message to those who may be reading this: Be aware of your own body and if there is something that has changed. Go ahead and ask what it is. Find out what is causing that problem. Many times, we’ll see a cancer that is very advanced but the patient has had symptoms for six months, a year or two years. If you notice a change in you or a loved one, it is worth an evaluation, because there is increasing expertise to help with any number of medical issues. While I have focused on cancer in this conversation, the same applies to other diagnoses too. Of course, we all have any number of reasons not to see the doctor. But being aware of things sooner undoubtedly yields positive dividends, and sometimes can be the difference between life and death--be it cancer, heart disease, stroke or other conditions. Don’t ignore that change, do something about it!