July 27, 2020

Diseases

#121 – Azra Raza, M.D.: Why we’re losing the war on cancer

"We are living in an era of the most sophisticated technological advances possible, and yet the treatment of cancer is paleolithic." — Azra Raza

Read Time 21 minutes

Azra Raza is a physician, scientist, author, and outspoken advocate for reconfiguring the current model of research in cancer. In this episode, Azra discusses the content of her book, The First Cell, which takes a critical look at the outdated models being used to study cancer resulting in a lack of progress in survival rates for cancer patients. Azra offers a solution which focuses on early detection and prevention, and she concludes with an optimistic outlook for the future of cancer research.

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We discuss:

  • Azra’s upbringing, interest in oncology, and the basis for writing her book [3:30];
  • The lack of progress in cancer treatment over the decades [18:45];
  • What is holding the oncology field back? [33:15];
  • Do the purported advances in oncology reflect the billions of dollars spent on cancer research? [40:00];
  • Economics of new cancer drugs—how small increases in survival come with staggering financial burdens [47:00];
  • How good intentions can still lead to misaligned incentives and a broken system [1:03:00];
  • Why 95% of new cancer drugs fail—a critical review of the cancer research model [1:11:15];
  • Early detection and prevention—a potential solution to the cancer problem [1:22:30];
  • Coping with the loss of her husband to cancer [1:46:00]; 
  • Azra’s optimistic view of the future [1:49:30]; and
  • More.

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Azra’s upbringing, interest in oncology, and the basis for writing her book [3:30]

  • Azra had no intention of ever writing a book
  • In fact, she always explicitly said that she is NOT a writer
  • However, she certainly had the credentials to write a book about cancer:
    • First, she has spent 30 years studying oncology
    • Secondly, she’s had a very active basic science laboratory throughout that time
    • Third, she is a cancer widow—lost her husband to cancer in 2002
  • But even that wasn’t enough to motivate her to write the book
  • The final push to write the book happened when her daughter’s best friend, at age 22, developed a glioblastoma multiforme—one of the most malignant tumors known to mankind

“It slapped me in the face physically that, on the one hand, the ferociousness and violence of his tumor, and on the other hand, the utter helplessness of all of us, his oncologists, to do anything about it. Our complete failure in front of Andrew. How is it possible that we are so spectacularly failing a 22 year old boy? That’s what forced me to write the book.”

What drove Azra to oncology?

  • Growing up in Pakistan, she was very interested in the nature world around her
  • She like embryology
  • She loved evolution and was a fan of Darwin’s work
  • If it were an option for her in Pakistan, she claims she was have likely studied myrmecology—the scientific study of ants

A couple things happened to her that set her course into oncology:

  1 | In his third year of medical school, she saw her first patient—

  • That patient was a young woman with acute myeloid leukemia presenting with a very large spleen
  • “I realized from that moment on that all of my life would be devoted to somehow use the best that science has to offer to reduce human suffering.”

 2 | Witnessing the violent nature of cancer

  • Karachi, Pakistan is very impoverished and when a person would get cancer they would travel long distances by donkey and on foot
  • By the time they arrived for care, they would have end stage malignancies sprouting through breasts or huge lumps breaking out of people’s heads and arms 

The combined factors of i) the violence of the disease, and ii) the intellectual challenge of understanding cancer pushed her into oncology

“It was the malevolence of the tumor, the violence of the disease, on the one hand. On the other hand, the intellectual challenge of trying to figure out how this whole thing began in a single cell and how that cell goes rogue, what journeys has it undertaken to reach this level of malignancy? It was the dual emotional as well as intellectual grip that basically caught me at a young age.”

The commonality of being moved by a med student’s “first patient”:

  • Peter tells a similar story of how moved he was after seeing his first patient as a med student—someone with stage four colorectal cancer who Peter became very close with until he died 2 years later
  • Steve Rosenberg’s first patient—
    • The patient had metastatic gastric cancer to the liver, which should have killed the patient, but somehow his tumor was eradicated 
    • This led Steve to conclude the only way that was possible was if his immune system eradicated it — and Steve has since pioneered effective immunotherapies for cancer
  • Azra says she is very mindful of this experience for first year med student

Azra quotes Emily Dickinson, “Tell all the truth but tell it slant. Success in circuit lies. Too bright for our infirm delight, the truth superb surprise. As lightning to the children eased, with explanation kind, the truth must dazzle gradually or every man be blind.

 

The lack of progress in cancer treatment over the decades [18:45]

When Azra came into oncology, she says it was almost a “stigma” to have cancer

{end of show notes preview}

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Azra Raza, M.D.

Dr. Azra Raza is the Chan Soon-Shiong Professor of Medicine and Director of the MDS Center at Columbia University in New York. She is the author of The First Cell: And the human costs of pursuing cancer’s last published by Basic Books, October 2019. She is considered an international authority on pre-leukemia (MDS) and acute leukemia and is one of those rare physician-scientists who divide their time equally between caring for patients and supervising a state-of-the-art basic research lab which is well-funded by multiple large grants. Dr. Raza started collecting blood and marrow samples on her patients in 1984 and now her Tissue Bank, the largest and oldest in the country with >60,000 samples, is considered a unique national treasure. She’s the recipient of numerous awards including The Hope Award in Cancer Research 2012 (shared with the Nobel Laureate Dr. Elizabeth Blackburn). [Full bio at azraraza.com]

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  1. That was such a rich podcast. I love just listening to Azra’s voice as she recites prose and poetry. She tried to end on a positive note, but I just couldn’t help being pessimistic when it was all over. Obviously, prevention is important, but it isn’t 100%.

    Early detection should be promising. My best friend’s father had pancreatic cancer and died within a few months of diagnosis. I asked him if they could have done anything to detect it earlier and the answer is that this form of pancreatic cancer tends to go from undetectable to Stage 4 inside of 6 months. Apart from doing a PET scan every 6 months, which is infeasible, you can’t catch this thing before it kills you and by the time you are symptomatic, it is too late. Now this is what he told me… I’m not a doctor. Could be all wrong. But expanding our detection tool kit seems like an area ripe for investment that has the potential for a better ROI than doing what we have been doing.

    She did not pick up the story where the grad student was contemplating dropping her oncology research, but it is a valid question. Where there are smart people looking to make inroads against this disease, what are they to do? The entire system will not simply reinvent itself. I guess her answer would be to focus on early detection rather than a cure?

    This was a great albeit a depressing podcast.

  2. As an oncology research nurse who loves patient care and teaching, gets weird satisfaction from explaining mechanism of action, is the regular recipient of administrative nasty-grams for incorrectly documented research billing notes, and whose brilliant dad died from GBM in 2011, I thank you and Dr. Raza for this discussion.

  3. In an Era of global caos during this pandemic , busy careers , risky work environment in healthcare , we end up not having the time ..
    But How can a PODCAST makes me jump out my seat , scream “ yes “ she gets it ( the way I see things too ), and make me cry too ??
    Thank you so much for sharing this with all of us . This podcast is very special!
    It’s a great overview, learning tool and make me believe that I am not alone , there are physicians out there trying to end people’s suffering too . I am designing my own clinical training within this broke healthcare system of ours , every time people ask me “ why not oncology?” I keep saying that primary care is the only way to bring innovation to everyone!! I believe that personalised care should start with family doctor hand to hand with other specialties and research without perpetuating the old mistakes R&D / clinical trials using animal models . Primary is the missing link! I have decided to dedicate my life to it because we can’t afford to keep making the same mistakes and this podcast ( in my head at least ), helped understand that I am doing the right thing . Innovation can be lonely , this podcast made me feel that there are many of us out there . She is brilliant, wish I could give her a hug , with all my heart.
    #LeaveNoOneBehind
    Thank you Dr Attia and thank you Dr Azra.
    Greetings from London.
    Dr Erika Tajra.

  4. Peter-
    I Love how you stop the dialogue to clarify points and make it totally clear for the audience. You are amazing. Thank you.

  5. I hope Dr. Raza’s clarion call for oncology research reform finds purchase, (perhaps a 60 minutes episode). This was a wonderful discussion and sobering diversion from groupthink. Thank you, Dr. Attia for creating a platform for these talks. And thank you, Dr. Raza for your eloquent assessment of the state of oncology research. I hope you get the chance share your wisdom with a broader audience.

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