day 8 the research-driven part of "multi-disciplinary research-driven care"

The other key component of the care delivered at MD Anderson is that it is research driven. To me that means two things.

First, it means that our physicians are all academic, and strongly connected with the latest research. The vast majority are themselves engaged in research and education, splitting their time between the patient and academics. They make original contributions to knowledge about the cancer they focus on, and how it is prevented and treated, and learn of the advances of others through journals, conferences and by visiting other cancer centers. Through this work they are steeped in the latest advances, and are often driving them. It is hard to overstate the value of this, and the effort it takes for our faculty to remain current. Biomedical science has been accelerating faster than most human endeavors and has unleashed a flood of information and technological advances. Extracting true knowledge from this flood is not straight forward.

Some indicators of the pace of biomedicine include:

• the number of papers published in biomedicine, estimated two year ago to be more than one a minute (http://duncan.hull.name/2010/07/15/fifty-million/)
• the rapidly accelerating number of clinical studies in the US (http://clinicaltrials.gov/ct2/resources/trends)
• the rapidly plummeting cost of sequencing a human genome which is accelerating the entry of sequence information into clinical practice and far outstrips Moore’s law (see graphic)

This is tremendously exciting and the gain in knowledge is opening up huge possibilities. But it also needs to be assimilated and ultimately integrated into practice to be useful to the patient. 

I remember when I was a PhD student that you could get a handle on a reasonable field by reading perhaps the top 200 papers from the prior decade. Today a search on the term “breast cancer” yields over 250,000 citations in PubMed, and over 1.5 million hits in Google Scholar. There are over 60,000 papers on just one gene, the p53 tumor suppressor, which is admittedly one of the most intensively studied genes so far. Even the breast cancer gene Her2, which could be considered a niche gene in cancer, gets close to 10,000 papers. This flood of information is both empowering, and daunting. Add a full day of clinic, OR or other patient care activity, educational and administrative responsibilities and you can see what it takes to be an academic doctor.

Second, it means being able to participate in research yourself, as a patient. That means that your care may itself be part research, if you participate in a therapeutic or surgical trial, or you can support research if you participate in a registry or tissue trial. The benefits are potentially powerfully direct: you may gain access to treatments that are so new they are only available through a research protocol. Or they may be more indirect: your participation will help fight cancer by supporting research, and though it may not impact you, it will help those that follow. 

I have joined two biomarker registry trials – that means that my tissue will be analyzed in a variety of ways for molecular patterns which may well not affect my care. More on the details of the trials another day, but for now, I feel a little shift in my relationship to my disease. I feel that no matter how small my own contribution, the fact that we will learn something from these studies is a way to be a part of the answer. A tiny cog in the rockets we are launching to tackle breast cancer, if you pardon the weak analogy (do rockets have cogs?).

As a result of joining these trials, I went back to the biopsy clinic, and in a moment of deja vu another set of punch biopsies were taken. This time instead of them being processed for pathology and diagnosis by formalin fixation, they were collected for research in a way that keeps their nucleic acids, DNA and RNA, optimally preserved. One of our pathologist joined us to take charge of the tissue, QC it and initiate its processing. He showed me the touch preps he made from the biopsies which are used to check that they contain tumor. You literally touch the piece of tissue to a glass microscope slide, and look at what sticks to the glass, after staining it. We saw lots of tumor cells, and my colleague remarked that they didn’t look super aggressive to him – that was nice to hear! I’ve spent some good time looking down a microscope in my day, but of course had never seen something so intensely personal before. It looked like clumps of blue cells with big fat nuclei (for an example on the web look here). They weren’t revealing their secrets to me, so bring on the molecular studies that will give us clues as to how my cancer grows out of control, and so lead us to understand why, the key to better treatment and ultimately prevention.