David J. Sugarbaker, M.D., professor and chief of the division of thoracic surgery in the Michael E. DeBakey Department of Surgery, and director of the Lung Institute of Baylor College of Medicine, sat down with Texas Medical Center Executive Vice President and Chief Strategy and Operating Officer William F. McKeon to discuss the upbringing that inspired his exceptional career, and how a “team sport” approach to medicine can improve the quality of patient care.
Q | Can you tell us about your formative years?
A | I grew up in Jefferson City, Missouri, located on the Missouri River, midway between St. Louis and Kansas City. My father was a busy cancer surgeon who trained out east at The Memorial Hospital in New York City. I grew up as the eighth of ten children. Along with six sisters and one younger brother, I had two older brothers— they were numbers one and two in the family. They both became surgeons; both went to Cornell Medical School and then went on to Boston to train in surgery. So I had a pretty well worn pathway in front of me. My father and two brothers were excellent role models for me. Medicine had a very strong influence on my early life. I spent a lot of my early years in high school and college helping my father in his operating room, at the hospital, often driving with him to see patients outside of our hometown as well. Everybody in our family was very much involved in his surgical practice. So from this exposure, I knew from a very early age I wanted to be a surgeon.
Q | What led you to thoracic surgery?
A | I did my research in esophageal physiology at the Harvard-Thorndyke laboratory in Boston in the laboratory of Dr. Raj Goyal. I really became interested in the esophagus and decided to pursue thoracic surgery because some of the prominent esophageal surgeons at the time were thoracic surgeons. Dr. Ronald Belsey and Dr. F G Pearson are two individuals amongst many that inspired me to go into general thoracic surgery.
Q | What, in your mind, makes a truly exceptional surgeon?
A | There are two attributes or two components that are the essence of excellence that I have seen in surgeons such as Joe Murray, who was one of my surgical mentors. Dr. Murray won the 1990 Nobel Prize for performing the first successful human organ transplant, a kidney transplant, at the Peter Bent Brigham Hospital in 1954. The first of these two components is that, like Dr. Murray, they have certain clarity of purpose. They know exactly why they are in a certain position or place. They treat their patients with a clear sense of purpose in mind. They know why they are there and they know what their purpose is there at that moment. Secondly, they are able to focus and sustain their attention on that purpose and on each step along the way required for its completion. So they have the understanding of their purpose and they have the ability to focus their efforts on the task at hand. Those two attributes, when put together, in my experience, define the essence of excellence in a surgeon.
Q | What, surgically, is available to a patient today that may not have been available to them at the time you started your career?
A | So, let’s take a well-known but somewhat rare tumor known as mesothelioma, caused by asbestos, as our example. We’ve all seen the ads, ‘Do you have mesothelioma?’ So starting out at the Brigham, right out of my training, and seeing a patient with mesothelioma, I found that there was no accepted operative approach. There was really no accepted concept of cyto-reduction followed by a secondary treatment of micro-metastatic disease. Essentially, everyone died three to seven months after diagnosis. Nothing seemed to work. Let’s fast-forward 25 years. After working with colleges from all over, we have defined a series of surgical procedures that will reduce the number of cancer cells in the patient and achieve what we call a macroscopic complete resection, so that no visible cells are left in the patient at the end of the surgical procedure. The initial operation is called an extra-pleural pnuemonectomy. In 1988 it carried a prohibitive mortality rate in most centers and had been discarded as an operative procedure by many surgeons. So we redesigned it and at the present time, we can perform that operation with an acceptable mortality, in the range of other similar major thoracic procedures. Depending upon the stage of the patient, we can achieve up to a 36-52 month median survival in certain subgroups of patients. So there has been a substantial improvement in survival in mesothelioma for many patients. I think that arises from a strong surgical presence within the disease treatment community, which is able to do one very important thing: to completely cyto-reduce the patient’s tumor to the point where there are no visible cells left in the patient. This may make the task of the additional treatments somewhat more achievable, as they have less tumor cells to deal with. After 20 years of understanding how the tumor would come back after the surgery, we learned it does not come back through the bloodstream as in other solid tumors, but it recurs just where it was taken out. We couldn’t figure that out until we could extend survival. So the first step was to perform the operation consistently across a larger group of patients, such that they could enjoy extended survival. We then learned where it came back, and we’ve now devised different local and regional treatment strategies to attempt to try and prevent it from coming back. One of the strategies we are working on here at Baylor is what we call HITEC, or a hyperthermic, intraoperative, intrathoracic chemotherapy. During the surgery, we remove the tumor and then have a type of pump that delivers heated high-flow lavage of chemotherapy agents directly to the at-risk area. We do it for one hour in the middle of the operation.
Q | How has the strategy or timing of cancer surgeries changed from the use of radiation, chemotherapy, and surgery? Those strategies are changing, aren’t they?
A | The strategies are changing and one of the major influences producing that change is the whole genomics, genetic characterization of tumors, as well as their metastatic lesions. Part of that was the concept of better genomics and genetic characterization of thoracic cancers can lead to a predictive model to tell us what types of treatment strategies will work best for the individual patient. We are setting out to define each tumor’s profile of mutations. This could allow us to use specific cell pathway inhibitors to treat the patient’s cancer after surgery or even instead of surgery. We then can select which patient should have chemo first, followed by surgery and which patient should have surgical cyto-reduction followed by chemotherapy or other types of treatments based on this type of genomic characterization of the tumor itself.
Q | Now that you are at Baylor, what would you like to accomplish?
A | I think you could sum up all the primary goals in saying we want to establish a platform within the Baylor College of Medicine and Texas Medical Center that provides the best possible, most effective patient care. So the idea would be to work with our team of translational, basic, and clinical researchers as well as physicians and surgeons so that they work together, such that there is a seamless interface— as seamless as humanly possible across those disciplines—to treat patients with thoracic cancers. We will work together to set a team up with that kind of seamless communication and centralization of the therapeutic goal for each individual patient. People talk about getting a cure, and we will all work toward that goal. However, today it is about getting patients to survive longer with the treatments we have available now. We hope to develop the communication systems between team members in such a way that information flow is effortless. I believe that this is paramount to getting optimum results for our patients. If we can get this type of communication and collaboration, we will make tremendous progress.
Q | How do you help nurture that kind of collaboration?
A | Well, the patient becomes the real focal point of a team effort. If you want to liken it to football, you assemble a team and based on how the defense is lined up, you call a play. But that play has been communicated to the entire team before the snap. So when a patient comes through the door of the clinic, the ball gets snapped. But one has to have assembled the team that has the same overall game plan and knows the specific play so that when the patient comes in, we know exactly what the sequence of events will be in order to complete the right diagnosis, evaluate for stage, and treat the patient using each element of the offense available. The offense here is our growing number of novel treatment strategies. Each player of this team knows where and how they come into play for the treatment of that particular patient. People have to know what the game plan is. That means the constant improvement and constant communication of the plan for that patient. It requires the focus of each member of that team on the overall goal of the therapy in an individual patient. In addition, the patient and patient’s family and caregivers also know and understand their role in the treatment. Mesothelioma will have a team. Lung cancer will have a team. Esophageal cancer will have a team. Our approach here at Baylor is going to play our strengths—our strengths are the genomic evaluation of tumors, basic and translational research, and excellence in patient care. We look forward to collaborating with our Texas Medical Center partners, because the problem is bigger than all of us. It seems clear that all of us working together give our patients the best chance at a good outcome from treatment, and the approach will foster progress in the treatment of thoracic malignancies in the years to come.
Q | We often talk about the work being done by Richard Gibbs and his team, and it is truly an inspiring vision that they have for clinical genomics and a future Genomics Institute. It sounds like much of his work aligns with what you are talking about.
A | Several years ago I had the opportunity communicate with Dr. Gibbs, long before I would have ever conceived coming to Houston. We were working with a company in New Haven, 454 Technologies, to sequence mesothelioma tumors. We did the a high-throughput sequencing of the mesothelioma transcriptome and we found that every tumor that we looked at had a separate and distinct mutational profile, meaning that there were different genetic mutations involved in different tumors. We found that it wasn’t one specific genetic mutation causing the mesothelioma. I had been in the high-throughput sequencing field for only a short time and it was brand new technology. Dr. Gibbs gave our team very valuable advice. Today we take a tissue sample for biopsy in the OR during surgery and we take it to the pathology frozen section room where a piece of tissue is processed and placed under the microscope. The pathologist then tells us what it is and that tells us what we should do next in the surgery. One day, we are going to take a piece of tissue in the operating room and the pathologist will do a quick genomic analysis of it and that will tell us the genetic mutational profile, which will tell us more specifically what to do for our patient.
Q | It seems to be that when people think of personalized medicine, often they think of it to be five or ten years away. I hear about it happening on this campus and in your program every day. No one comes through the door with a generic cancer anymore. It’s unique and quite personal to them. How much more is available today for a person that walks through the door than two decades ago?
A | There are many advances today. A major advance in the treatment of lung cancer is the earlier detection of lung cancer through CAT scan screening programs. Medicare and other insurers are now funding CT screening for smokers and ex-smokers, so that’s a very practical advance. Because we know that if we find tumors early—whether it is breast cancer, colon cancer, or lung cancer—the cure rates are higher. The smaller the cancer is at the time of surgical removal the better the survival rate. Published data on lung cancer certainly supports this view. We have learned a lot using that two-step approach to cancer we talked about earlier with mesothelioma, and we have made progress in each of the two areas. As we said earlier, first step is to remove the entire tumor that can be seen by doing a surgical resection. Step number two is to treat the micro-metastatic disease. You can wait and treat it when it arises, or when you know where it’s going to arise you can treat it prophylactically before it shows up clinically. Sort of like putting the weed preventer down before the weeds sprout up.
Let’s look at the advances in the first step: remove the entire tumor that can be seen. We can do it with a growing variety of minimally invasive techniques, such that the actual injury done to the patient is substantially less than it used to be and the overall risk of the surgery has been significantly reduced. That’s been a major advance. The tumor in the lung or elsewhere in the chest can be removed with much less trauma to the patient.
Now, let’s look at the second part, which is treating micro-metastatic disease and preventing recurrence of the cancer. So we know by the genomic analysis of the tumors that have been removed that there are a number of markers that have been established that indicate that certain specific therapies will be effective in an individual patient’s residual tumor cells. EGFR is a genetic marker in lung cancer that is correlated with better survival when treated with drugs that are specific for that pathway. There are a growing number of these ‘markers’ that will allow better selection of effective chemotherapeutic and biologic agents for an individual patient. Now, that wasn’t available even ten years ago We have good data now that shows in certain settings, with certain tumors, it can be very helpful to give a certain type of chemotherapy after the surgical removal for that second step and in other situations it appears giving the chemotherapy first followed by surgery seems to give the best survival. This work continues all over the globe.
Q | What was your greatest motivation to pick up your life and move from arguably one of the top institutions in the world to come here?
A | I am very glad to have worked in one of the best hospitals in the world. My colleagues there were committed and dedicated to their patients as well as their academic mission. They inspired me everyday. When visiting the TMC, I saw the same type of commitment. In addition, it was the atmosphere of a ‘can-do’ attitude that inspired me. I made a couple of visits here, and I have to tell you, I was very intrigued and inspired by the big vision that I heard from a variety of different individuals at the Baylor College of Medicine and others in the TMC. There was a can-do approach that was infectious, and I’ve always ascribed it to visionaries who accomplish great things. So I thought, if I am going to do something here in Texas, in this atmosphere, it is going to be a lot of fun. The opportunity to build a program here at Baylor College of Medicine and the Texas Medical Center was very attractive to me. The winter weather in Houston was another definite plus!
Q | Any closing thoughts?
A | I would say that the Baylor College of Medicine and the Texas Medical Center do, I think, radiate a certain optimism that is infectious. There are so many focused, dedicated individuals here in this medical center and I’m very optimistic that in the future, as in the past, many great things are going to come out of the TMC. It is a real privilege for me to have the opportunity to be a part of it.