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Promise and Progress - Leading The Way

Leading the Way Fall 2009 Winter 2010

Leading The Way

Date: December 1, 2009

Over the last decade the Johns Hopkins cancer program has undergone major growth.  It went from occupying one building, incorporating clincial care and research, to having the largest footprint on the medical campus with three buildings- a new clinical facility and two cancer research buildings. Now, it has a new leader. William Nelson, 51, was chosen after a national search to be director of the  Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins. He shared his thoughts on the cancer problem in the United States, what he brings to the job, and his vision for the Cancer Center.

Q. Why do you want to be director of the Kimmel Cancer Center?
If it were any other cancer center, I probably wouldn’t want the job. This place is special. This is a challenging position, but I’m committed to doing the best that I can. I’ve been a
researcher trying to invent new treatments and take them into the clinic. I’ve been a clinician working directly with people with cancer. I understand the promise and imitations
before us. I think the time is right to really take some major shots at the cancer problem.

Q. What made you decide to become an oncologist?
I was a chemistry major at Yale, but I had no plans to go into medicine. I went there to play soccer. St. Louis, where I was raised, was to soccer that Baltimore is to lacrosse, and the Ivy League was the premier league of college soccer teams in the country. I
thought I would eventually become a lawyer. One summer I worked in the laboratory of a cell biologist looking for molecular biomarkers of a rare skin disorder called ichthyosis. There were clinical trials of some new drugs, and so I was in contact with many of the participants. I was struck by how well they understood their disease and their reason for
joining the trial. They knew it was an experimental therapy that may not help them but could help others. That’s when I decided this is what I wanted to do.

Q. What is your background, and how does it help you as director of the Center?
I have focused almost entirely on prostate cancer in my research and in the clinic. Prostate cancer is a great story for all of the common cancers. When I started in oncology, men
were commonly diagnosed at an advanced stage. We had some limited success with treatments, but death rates were far too high. Since that time, we’ve gotten PSA (prostate
specific antigen), a blood test that made it possible to diagnose men far earlier, so they could benefit from surgery and radiation therapy. We’ve also developed new treatments. This whole system of surgeons, medical oncologists, pathologists, and radiation oncologists, all working together, is a modern paradigm that has allowed us to cut prostate cancer death rates almost in half in the last 15 years. This is the type of progress
we need to make in all cancers.

Q. You are one of Johns Hopkins’ home grown faculty members.Does this help you as director?
I am home grown—more home grown than usual. I went to medical school here, was a graduate student, a resident, a fellow, and my whole faculty life has been here. I have
never delivered any health care of any kind as anything other than a Johns Hopkins physician. My daughters were born in the hospital. I can’t be anymore home grown than I am. By being around the institution for so long I’ve ended up a professor in six departments, which helps me bring people together across the institution. I know everyone here and have a good sense of how great we can be when we work together across departments. The challenge is not to think about medical oncology in
isolation but rather how medical oncologists, pathologists, radiologists, surgeons, and radiation oncologists can work together across disciplines to take on a cancer.

Q. These are tough economic times. How do you maintain progress with limited resources?
Since 2003, federal funding has been flat, and in some years when inflation is taken into consideration, it has decreased. Getting funding can be a terrible stress on researchers undertaking a career in cancer research, particularly our young researchers. The challenge for us is to focus on the right problems that lead to deliverables that can be recognized in the population at large, so that people will appreciate the value of cancer research and want to invest.

We need to look for new opportunities and be smarter about the way we use limited resources. The development of more cancer therapies being administered in pill form has brought large pharmaceutical companies into the development of cancer
treatments in a way they really had not been before. For them, the problem is that, in cancer, they are developing drugs for very specific and smaller fractions of the population
than they typically would. They estimate it costs them about $1 billion to discover, develop and get a cancer drug FDA approved. These costs are passed on to people with the disease in the form of high costs for treatments. We worry that, in the future, there will be patients that could benefit from a drug but cannot afford it; and this is an unacceptable premise to all Americans and will be a significant stress on our overall health care
system. I think our Cancer Center can be a part of the solution. We have the discovery engine that can help pick the winners from the losers before large sums of money are spent.

There were 750 cancer drugs in clinical trials in 2008 with a 95 percent failure rate, and most of the time, we don’t find out until late in the trial that they don’t work. We need to use science to provide sound evidence so that we don’t invest a billion dollars into a drug that doesn’t work. I think pharmaceutical companies will see better payoffs with this approach, and when they do, they will be more willing to invest.

Q. The Kimmel Cancer Center is known as a leader in genetic discoveries. How has this improved cancer diagnosis and treatment?
There are two ways these discoveries have made a difference. We know that people carry genetic vulnerabilities that they inherit from their parents; and many cancers, about 15 percent  of all cancers, occur in people who seem to have these genetic  redispositions.

It doesn’t mean they are fated to get cancer just that they are more susceptible to getting a cancer. What is newer are tests for some of these genes that predict increased risk for a cancer so that we can use early detection and screening strategies to intervene and diagnose people at the very earliest stage. It also means that we can tell who is not as likely to develop cancer and economize our use of these tests, and leave those people
alone a little bit.

In terms of therapy, gene alterations in cancers may predict which treatments will be successful and which will not. In this current era, the newest kind of drugs hit specific
targets that are the products of cancer- related genes. For example, if a breast cancer makes the HER2 protein, the drug Herceptin is most likely to be effective. Testing for these genes allows us to get the right treatments to the right people.

Q. What role does prevention play?

There are about 1.4 million new cases of cancer each year, and this number is expected to increase as our population ages. Cancer is a major health concern, not just in the United States, but worldwide. So, I think an ounce of prevention is worth a pound of cure is going to be true in cancer medicine. If we can prevent people altogether from having some of these devastating diseases, we won’t be so much concerned about how expensive it is to treat them when they have them.

Look at screening and early detection that we already do—Pap smear, mammography,
colonoscopy, PSA. Their use led not only to improvements in survival but to treatments that are far less deforming and have fewer side effects. I think we have some exciting
things we are working on in the laboratory, like new epigenetic drugs, which will hopefully be able to both prevent and treat cancer. We also need to address behaviors and underlying causes of cancer like chronic inflammation and infection.

Q. Why should someone with cancer come to Johns Hopkins for their treatment?
The major difference at a place like the Kimmel Cancer Center is that the
 tate-of-the-art is just the starting point of what we can offer. That kind of treatment opportunity, the latest plus some, is what we have and always will deliver. Our mission, our brand, if you will, is to have better than the state-of-the-art cancer therapy.

Q. What is your vision for the Cancer Center?
The challenge the field of cancer medicine is facing is embraced in the term translational research. It is the idea of more efficiently taking what we learn in the lab—which everyone will tell you is very exciting with great promise and opportunity—but getting it from the lab to the clinical setting faster. Not just lackadaisically faster, but moving therapies to the clinic more efficiently and economically.

We believe that the tools being developed in the lab can help us perform this way. We can figure out whom to treat, how to treat them, and do it much more rapidly. If a treatment is not effective, let’s abandon it, and if a treatment is effective, lets develop
it further, but let’s figure it out far earlier on in the development process, before $1 billion is spent.

There is so much we have accomplished here already, but there is much more we can do. We have the perfect discovery engine here and tremendous opportunities. This is a great place to be and the right time to be here.