Published by
Stanford Medicine


Cancer, In the News

“Cancer will always be in our midst:” A conversation with physician-writer Siddhartha Mukherjee

"Cancer will always be in our midst:" A conversation with physician-writer Siddhartha Mukherjee

MukherjeeTonight PBS television airs its new documentary Cancer: The Emperor of All Maladies. The six-hour feature (shown over three nights) is an in-depth look at the past, present and future of cancer, told primarily through the eyes of those dedicated to understanding and treating it.

The video preview promises the kind of data-rich and intensely dramatic storytelling we expect from acclaimed filmmaker Ken Burns, especially when he describes his acute awareness in early childhood that “something was desperately wrong with my mother.” That something was cancer, and his mother died before Burns was 12 years old.

As its title implies, the film is based on the Pulitzer Prize-winning work The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee, MD, PhD. Now an assistant professor of oncology at Columbia, Mukherjee earned his undergraduate degree from Stanford, and last year he returned for a guest lecture. During his visit he sat for an interview with the Stanford Cancer Institute. Here is an excerpt:

What motivated you to pursue medicine?

I became interested in natural biology while here at Stanford. I took my first biology class as an undergraduate and became fascinated by the natural world. Over time I began to understand that medicine is actually applied biology, in that there is a direct connection between understanding human physiology and translating that understanding to people who are ill.

Why cancer?

I started as a cell biologist working on immunology and virology, then become interested in viral cancers and ultimately human cancers. In a way, I sort of backed into medicine by becoming interested in human biology and virology research first, and then decided to pursue clinical medicine as well.

It seems the more we learn about cancer, the more complicated it becomes…

Just because something turns out to be more complex that we initially thought does not mean that we cannot simplify it. The complexity allows us to evaluate what the reality is, and our interventions depend on us teasing out which part of the complexity are relevant and which parts are not. Complexity is just a description of the physiology of cancer, and interventions can follow from that. We should not be daunted by the fact that cancer is complex, and scientists aren’t, because the complexity makes our understanding deeper and more real.

In fact, there is an argument that cancer’s complexity may be its weakness. The fact that cancer cells have to create such interconnected networks of behavior just to sustain growth may make cancer more vulnerable to disruptions in those networks. Just because a chain is longer does not necessarily make it stronger, and cancer’s chain may have profoundly weak links. We just have to continue to work to find what they are and how to exploit them.

You’ve written cancer’s biography; will its obituary ever be written?

Cancer will always be in our midst for one simple scientific reason: the very genes that allow us to grow and adapt, when mutated, lead to cancer. And these are not incidental genes – we are not talking about the periphery of human physiology – we are talking about the genes that function as the centerpieces of normal cellular growth and development.

So, I think cancer will always be with us, but we will continue to evolve our interaction with the different forms of cancer in the future. We will learn to prevent some forms, learn to treat some and learn to cure some. We will turn some cancers into chronic conditions. And this sort of cat and mouse game with cancer will go on for a long time. This will be a reiterative contest that we will have to play over and over again. And I believe that as soon as we declare victory over cancer, then that will be the beginning of our defeat.

Continue Reading »

Events, Medicine and Society, Patient Care, Stanford News

Author-physician Atul Gawande on dying and end-of-life care

Author-physician Atul Gawande on dying and end-of-life care

Dr Atul Gawande, MD, MPH, Professor, Department of Health Policy and Management Harvard School of Public Health Harvard Medical School, gives a lecture ?Being Mortal: Medicine and What Matters in the End? on Monday, March 2, 2015, at Cynthia and Alexander Tseng, Jr., MD, Memorial Lectureship at Berg Hall Li Ka Shing Learning and Knowledge Center at Stanford School of Medicine . ( Norbert von der Groeben/ Stanford School of Medicine )When Atul Gawande, MD, MPH, witnessed the untimely and inevitable passing of patients, friends and his father, the shortcomings of our medical system’s approach to dying were revealed to him. As the noted author and surgeon told an overflow crowd at Stanford’s medical school earlier this week, he became inspired to “pick up my journalist’s pen” and explore questions about life and mortality that his elite medical education hadn’t equipped him to remedy.

Headlining the eighth annual Cynthia and Alexander Tseng, Jr., MD, Memorial Lecture, the former Stanford undergrad introduced his talk on end-of-life issues with the observation that begins his New York Times #1 book, Being Mortal: “I learned about a lot of things in medical school, but mortality wasn’t one of them.”

In a highly personal, and at times moving, talk, Gawande went on to discuss how decades of modern medical advances have changed our attitudes about dying and death. As fewer diseases and injuries pose life-threatening risks due to vastly improved medications and therapies, people simply expect to live longer. Well-being has become synonymous with longer and more robust life, supported at every stage by effective medical interventions, including a growing market of “lifestyle” rather than life-saving treatments.

Gawande argued that while health and medicine advances are of course positive, one consequence is that we have “medicalized our mortality” to the point where even terminally ill patients and their families look to their doctors for life-saving answers.

“Well, I didn’t [have the answers],” Gawande said.

Gawande said that medicine’s typical approach is to trade time and quality of life in the short term for longer life in the future, but the trade-off isn’t always a good one. For example, aggressive cancer treatment can be debilitating and painful, and often fails to prolong life, merely making the end of life miserable for patients.

In contrast, the goal of palliative care is to create the best possible day for patients today, regardless of what it means for the future. Studies show that for terminally ill patients palliative care improves quality of life, including people’s sense of control and empowerment over their lives. While these positive attitudes may be expected, palliative care practices reduce unwanted medical procedures (as well as costs) and have been shown to actually increase life span – by 25 percent in one study of late-stage lung cancer patients.

“If palliative doctors were a drug, the FDA would approve them,” Gawande told the audience.

Continue Reading »

Cancer, Health and Fitness, Stanford News

The ride of his life: Local cyclist races across the country to benefit Stanford Cancer Institute

John Tarlton big

Menlo Park businessman John Tarlton is on the ride of his life, attempting to bike 3,000 miles across the country in 12 days. He’s competing in the Race Across America (RAAM), one of the world’s most extreme endurance events. RAAM originated in 1982 as four cyclists raced from the Santa Monica Pier to the Empire State Building.

“I have dreamed of competing in RAAM since childhood,” Tarlton told me by e-mail prior to the race. As of this post, he is more than halfway through, having biked more than 1,800 miles in about six and a half days.

Tarlton, 45, a lifetime cycling enthusiast, has been preparing for RAAM for several years. The RAAM course is nearly 50 percent longer than the Tour de France, though completed in about half the time. And unlike the Tour de France riders, who rest and refuel at their hotels each night, most RAAM riders can’t afford to sleep more than four hours a day, since every minute counts against the 12-day time limit. Eating presents an interesting challenge: Tarlton, a lean vegetarian, estimates he’ll need to consume 16,000 calories per day (and no, that’s not a typo!) during the race.

Like many RAAM riders and teams, Tarlton is using interest generated by this event to raise awareness and dollars for a cause – in this case, cancer, which has affected both his and his supports team’s families. Donations made in honor of Tarlton’s effort will support the Stanford Cancer Institute.

Since I mostly ride an indoor stationary bike with a TV screen affixed, I had a few questions for this ultra-driven athlete. Below are Tarlton’s answers provided by e-mail and lightly edited:

Describe your typical training day.

There really is no “typical” training day for me. Some days I only ride the bike for one hour, spend another hour weight training and then two hours doing recovery activities. Other days I will be on the bike for 14 hours straight.

What is the biggest challenge during the race?

It is hard to predict. Some years, there have been lightening storms that require riders to hide inside cars, while other years there are strong headwinds for extended periods of time. Our biggest challenge will be to adapt to whatever nature throws at us, in addition to any unexpected equipment failures, while sticking to our plan.

Besides finishing, what’s your goal for the race?

We hope to raise quite a bit of money for Stanford Cancer Institute. In all honesty, the goal of completing the race within the allotted 12 days is such an overarching goal, that any other athletic goals would pale in comparison.

Why did you choose to benefit the Stanford Cancer Institute (SCI)?

SCI is at the forefront of the cancer treatment effort, from cutting-edge primary research to new ways of focusing on the patient during recovery. My professional life revolves around buildings for life science research and commercialization. The partnership between Tarlton Properties and SCI seems a natural fit.

My family has been deeply affected by cancer and has strong ties to Stanford. My parents met in the Stanford Choir in 1954, and my father is a past president of Stanford Associates. My wife, Jenny Dearborn, graduated from the Stanford Teacher Education program; her father attended Stanford and her grandfather was a professor there.

Finally, Stanford doctors were central to the care of my mother and sister, as well as my crew chief’s wife, during their battles with cancer.

Continue Reading »

Cancer, In the News, Patient Care

Is cancer too complex for targeted therapies?

Cancer. It’s been called “The Big C,” but the more we study it, the more it resembles hundreds of little c’s, each with its own unique molecular makeup. The differentiation exists both among patients with cancers in the same site (the various sub-types of breast cancer, for example) as well as within a single patient. This latter phenomenon is referred to as “intra-patient tumor heterogeneity,” and it has profound implications for the future of cancer treatment, including the viability of so-called “targeted therapies” receiving so much attention and hope.

Many cancer tumors tend to be chaotic mixes of different cell types, some more aggressive – and therefore more dangerous – than others. Chemotherapy and the emerging category of more specific “targeted therapeutics” work by acting on a known characteristic of a particular cancer cell type, like accelerated replication rates or a specific genetic mutation.  But in a complex tumor, not all cells will exhibit that specific characteristic, or at least not do so at the same time. Also, it is possible for cancer cells to adapt and become resistant to a particular therapy, in a partially analogous way in which evolution works on a macroscopic scale.

A recent opinion piece published online in the journal The Scientist points out that intra-patient heterogeneity can also involve treatment-relevant difference between the primary tumor and metastases, as well as among metastases. Written by Stanford Cancer Institute Director Beverly Mitchell, MD; David Rubenson, associate director for administration and strategic planning; and Daniel S. Kapp, MD, professor emeritus of radiation oncology at Stanford, the article discusses these matters in detail and lays out many of the significant scientific and clinical questions surrounding the potential for treating cancers with targeted therapies. This fall, the Stanford Cancer Institute will convene an international symposium to discuss these questions and a range of related issues.

Information on the symposium, titled “Intra-patient Tumor Heterogeneity: Implications for Targeted Therapy,” will soon be available on the Stanford Cancer Institute website.

Previously: Director of the Stanford Cancer Institute discusses advances in cancer care and research

Events, Science, Stanford News

Hawkeye Pierce (i.e. Alan Alda) teaches scientists how to better communicate about their work

Hawkeye Pierce (i.e. Alan Alda) teaches scientists how to better communicate about their work

Alan_Alda_MASH_1972 - smallAs a teenager, I wanted to grow up to be Alan Alda. Actually, I wanted to be Hawkeye Pierce, the wise-cracking Army surgeon Alda played on the iconic television series M *A *S * H. I loved M*A*S*H, and Hawkeye was The Man. He was the funniest character, the best surgeon, and the biggest partier and, whenever the show got serious, he displayed the most passion for people and justice. (And since I was a gangly kid with red hair and acne, it probably didn’t hurt that Hawkeye got all the women, too.)

This came back to me when I attended Alda’s recent lecture on the importance of science communication held at Stanford’s Li Ka Shing Center for Learning and Knowledge. The talk was part of a two-day workshop conducted by the staff of the Alan Alda Center for Communicating Science at Stony Brook University to teach Stanford scientists how to more effectively speak and write about their work.

I couldn’t help but smile when he ambled out to greet the capacity crowd. It’s Hawkeye! He was a few decades older (aren’t we all) and had swapped olive drab fatigues for a natty gray suit, but his voice and smile were the same, as was his distinctive, infectious laugh.

For more than an hour Alda used personal anecdotes, video clips, audience participation and a lot of humor to argue that too many scientists are holding themselves back – as well as science itself – due to their inability to explain their work in clear, understandable language. Whether speaking to policy makers, the public through the media, potential funders, or even scientists from other disciplines, the meaningful exchange of ideas and information is too often lost in incomprehensible detail and specialized jargon. (Alda got a big laugh with a story of a multidisciplinary collaboration that dissolved due to an argument over the correct meaning of a “probe.”)

The consequences are serious, though, with government research budgets under constant pressure and large portions of the population blithely disregarding scientific consensus on issues like climate change and evolution. Alda challenged the scientific community to do a better job educating policy makers and the public, and his center provides some unique tools to do so.

Continue Reading »

Cancer, Stanford News

Saying thank you with art: Stanford undergrad pens one-woman play on cancer

Saying thank you with art: Stanford undergrad pens one-woman play on cancer

Camille face painting

These days, most people say “thank you” with a quick e-mail or text. If they’re really grateful they may (gasp!) hand write a note. Stanford senior Camille Brown wrote a one-woman play.

Brown is a science, technology and society major and has penned and performed “Seeing the Spectrum,” a series of intimate monologues telling the story of Camp Kesem at Stanford – a summer camp for the children of cancer patients – from the campers’ perspective. Brown has volunteered with the student-run camp for her entire college career, and during that time she has counseled, hugged, face-painted and sat quietly with countless children facing the reality of a parent with cancer.

It’s a reality Brown knows all too well. The day she graduated high school her family learned of her mother’s diagnosis with Stage 3 colon cancer. Brown’s entire Stanford experience has been colored by cancer and, remarkably, she’s focused on her gratitude. Not for the cancer, of course, but for her Camp Kesem community, from which she says she’s received far more than she’s given.

So, as she approaches her final year of camp (only undergrads can be counselors) she created “Seeing the Spectrum,” with support from a Spark! grant from the Stanford Arts Institute, as her unique and lasting expression of appreciation.

I sat down with Camille Brown on the morning before her first performance – a very special private show for Camp Kesem counselors, campers and families. Here is part of our conversation.

Tell me about your play.

“Seeing the Spectrum” is a collection of eight monologues based on interviews I conducted with 15 Camp Kesem campers about their experiences with their parent’s cancer and with camp. Each monologue is fictionalized to preserve anonymity, and some are composites of two or more interviews.

The idea is to help people outside the program understand the enormous impact that Camp Kesem has on the lives of the campers and their families. For these children it is very important that they have a week that is more than bereavement counseling, but rather is a week of friends, water fights and silliness, because they are going through situations that essentially don’t let them be kids anymore. And Kesem is more than just the week of camp; these kids gain a year-round community.

What inspired you to create it?

I work at the Stanford Humanities Center and they assigned me to write an article about Anna Deavere Smith’s 2012 guest lecture on grace. She explained her process of basing her monologues on interviews. She picks a topic and then talks to a number of people to get multiple perspectives. While working on the article it occurred to me that Camp Kesem would make a great subject.

What has working with Camp Kesem meant to you?

I was initially terrified to do it, because I worried that if I became involved as a counselor I would be projecting my feelings about cancer onto the campers, and it would be a horrible experience for everyone. But in fact, the more work I have done with camp, the more I have just been able to fall in love with the kids and feel that I am combating this frustrating force of cancer in my life by helping to give them a chance to handle it. I actually feel a little bit selfish because the kids are like my therapy. They are so resilient – some going through situations worse than my own – and I feel that I have been able to learn more about myself by trying to be selfless for them.

Continue Reading »

Cancer, Health and Fitness, Stanford News, Women's Health

Ironman of Stanford Women’s Cancer Center

Ironman of Stanford Women’s Cancer Center

ironmanOliver Dorigo, MD, PhD, loves training. The associate professor of obstetrics and gynecology has trained in medicine, surgery, gene therapy, molecular biology, laboratory research and clinical trials management. And that’s just for his day job(s), directing Stanford’s Division of Gynecologic Oncology and the gynecologic oncology program at the Stanford Women’s Cancer Center.

In his spare time Dorigo’s training has included enough running, biking and swimming to compete in 19 Ironman distance triathlons, the most recent being the 2013 Ironman World Championship, held in Kona, Hawaii in October. (For those keeping score, “Ironman distance” means a 2.4-mile swim, a 112-mile bicycle ride and a 26.2-mile run.)

Dorigo says the physical and psychological rigors of triathlon training have helped him professionally to overcome challenges and find solutions for success in difficult situations. And they are lessons he imparts to his patients. As he told me:

In every race, there is a moment when making another step forward seems almost impossible. However, with persistence and the right attitude, this step and all others necessary to reach the finish line will eventually happen. There’s just no giving up. And that’s exactly the attitude I convey to my cancer patients. Don’t give up; keep fighting! Otherwise, how does one ever know whether one could have reached the finish line?

Dorigo and his primary medical passion – ovarian cancer – are discussed in the latest edition (.pdf) of the Stanford Cancer Institute News.

Michael Claeys is the senior communications manager for the Stanford Cancer Institute.

Previously: Frontiers in the fight against ovarian cancer and Ovarian cancer biomarkers may enable personalized treatment, say Stanford scientists
Photo by Grayskullduggery

Cancer, Dermatology, Image of the Week, Public Health

Image of the Week: Ready for some football – and protected from the sun

Image of the Week: Ready for some football - and protected from the sun


Above is a shot of just a few of the Cardinal football fans who applied temporary tattoos – and plenty of sunscreen – from the SUNSPORT booth at the recent Stanford Football Open House. The Open House is an annual opportunity for fans to meet players and run through drills in Stanford Stadium, and SUNSPORT was there to help everyone play safely in the Palo Alto sun.

SUNSPORT, a collaboration of the Stanford Cancer Institute, the medical school’s Department of Dermatology, Stanford Athletics, and Stanford Hospital & Clinics, is Stanford’s first-in-the-nation program to provide sun-exposure education and protection strategies to outdoor athletes and fans. The program is profiled (.pdf) in the latest edition of Stanford Cancer Institute News.

Michael Claeys is the senior communications manager for the Stanford Cancer Institute.

Previously: Working to protect athletes from sun dangers and Image of the Week: Stanford SUNSPORT

Cancer, Dermatology, In the News, Sports, Stanford News

Working to protect athletes from sun dangers

Working to protect athletes from sun dangers

sunsport2SUNSPORT, Stanford’s new program to educate student-athletes about the dangers of sun exposure, was featured in the health section of today’s San Francisco Chronicle.

The piece (subscription required) tells the story of Stanford distance runner Erik Olson, who was diagnosed with melanoma last summer at age 20. Following successful treatment, Olson has adopted healthy sun-protection habits and is working with SUNSPORT to encourage other outdoor athletes, and fans, to do the same.

SUNSPORT, a collaboration of the Stanford Cancer Institute, the medical school’s Department of Dermatology, Stanford Athletics, and Stanford Hospital & Clinics, provides student-athletes with information about their heightened risks for sun-related skin damage and works with the teams’ coaches and athletic trainers to reinforce skin-protection practices on a daily basis.

“Outdoor athletes are an at-risk group for skin cancer, and SUNSPORT offers structured prevention strategies as well as research into skin protection behaviors,” Beverly Mitchell, MD, director of the Stanford Cancer Institute, told me.

Susan Swetter, MD, director of Stanford’s Pigmented Lesion & Melanoma Program, is quoted in the article. Swetter, who recently published research showing that young white men have a 55 percent higher risk of death from melanoma than their female counterparts, is one of SUNSPORT’s founders.

More information on the program is available at SUNSPORT’s website.

Michael Claeys is the senior communications manager for the Stanford Cancer Institute.

Previously: As summer heats up take steps to protect your skin, Stanford study: Young men more likely to succumb to melanoma, How ultraviolet radiation changes the protective functions of human skin, Image of the Week: Stanford SUNSPORT and Working to prevent melanoma

Ask Stanford Med, Cancer, Men's Health, Stanford News

Six questions about prostate cancer screening

Prostate cancer is the second leading cause of cancer death among men, and it’s something of an enigma. Unlike cancer in most other sites, tumors aren’t surgically extracted from the prostate. Instead, the entire prostate is removed, leading to short- and long-term side effects in patients. Also, it may be the only type of cancer that is diagnosed via blind biopsy – the urologist never actually sees the tumor and must resort to taking multiple needle-stick samples from throughout the prostate. Even when the presence of cancer is confirmed, there’s still a great amount of inaccuracy in determining its stage (or relative aggressiveness).

Judging prostate cancer’s aggressiveness is very important because despite the number of men it kills, the vast majority of cases are not life threatening. Most affected men have very slow-growing tumors that they will die with rather than from. And because the side effects of treatment – including urinary and sexual dysfunction – can greatly affect men’s quality of life, the medical challenge is to correctly assess which men require treatment and which do not.

James Brooks, MD, is a professor of urology and a member of the Stanford Cancer Institute. He has been caring for prostate cancer patients and conducting laboratory and clinical research at Stanford for more than 16 years, and he recently answered some basic questions about prostate cancer screening for me.

What is the PSA test?

PSA stands for “prostate specific antigen,” referring to a protein made exclusively in the prostate. We measure the relative level of PSA as an indication that cancer might be present. To be clear, though, the PSA test is not a cancer test. Lots of different things can make PSA level go up, including infections, enlarging of the prostate – which happens as we age – and other things that have nothing to do with cancer.

Who should get a PSA test, and how often?

Recently released guidelines from the American Urological Association advise that for men at an average risk for prostate cancer, they should get a PSA test every other year beginning at age 55 and stop at age 69. If a man has a family history of prostate cancer, or is of African American descent, it is probably better to begin at age 40 or 45, and if their first score is very low he can wait up to five years to get another test.

What has been the impact of the PSA test?

I think it is pretty clear that screening has made a difference in survival rates. Prostate cancer death rates were slowly rising for many years. Then in the late 1980s we started screening with the PSA test. Deaths from prostate cancer peaked in 1994, and they are now 40 percent lower than they were at that peak. Two things changed since 1994: aggressive screening and aggressive treatment of prostate cancer.

All of this screening has in a sense changed prostate cancer. It used to be that men presented with more advanced prostate cancer. For example, in 1990, one in five men who walked into my office had prostate cancer that had already spread outside the prostate. Now only one in 25 men has metastatic disease.

Continue Reading »

Stanford Medicine Resources: