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Oncologists Break Old Rules With Precision Cancer Treatments


When two people catch the flu in the same flu season, odds are they've been infected by the same virus with nearly the same genetic mutations. And that's one reason it makes sense for millions of us to get the same flu shot. But when two women, say, have breast cancer, the genetic mutations present in one patient can be vastly different from those in the other. And that goes for other kinds of cancer, too.

The oncologist, Siddhartha Mukherjee, writes in this Sunday's New York Times Magazine about a trend in fighting cancer that's based on that fact, precisely targeted treatment that breaks some old rules. Siddhartha Mukherjee who wrote the Pulitzer Prize-winning book the "Emperor of All Maladies: A Biography of Cancer," joins us now. Welcome to the program.


SIEGEL: How do these advances change the way that you deal with your patients?

MUKHERJEE: They've changed my interactions with patients dramatically. Ten years ago, there was something formulaic about treating cancer patients. You know, you'd have a patient with lymphoma and we treat them with, you know, a classical culmination chemotherapy.

These days, I take a very different look. I think to myself, well, OK, here's a patient with cancer, how much information can I glean from this individual patient's tumor? Can I understand something about its biology? Can I understand something about its particular behavior, its gene mutations? And now can I cleverly tailor some therapy? It's far, far from where we want to be because I have only a few tools, but I try to use them in the most effective manner possible.

SIEGEL: You acknowledge that when therapies are in fact tailored to the individual patient and to, say, medications are used in novel ways or off-label ways, we're talking about not only extremely expensive medicine but medicine that might not be reimbursed by insurers because it is novel and it's not standard.

MUKHERJEE: Absolutely, this has become a new battle. You know, it's we - on one hand, doctors are battling cancer, but on the other hand, they're also battling a relatively old system of reimbursement and understanding disease, which is not personalized. And there are costs associated.

I'll give you a very concrete example. There's a patient of mine who I was convinced would respond to immunological therapy, new immunological therapy, except - this was several months ago - it was not still indicated for that particular cancer. And ultimately, this resulted in a very complicated battle across the insurance companies, the individual patient's, et. cetera. These battles are common.

SIEGEL: Because I've read your work, because I'm familiar with the public TV series that's been based on it, I trust your instincts about creative experimentation using the medications off-label, say, or doing procedures in novel ways. But isn't there a risk in that kind of medicine of a lot of quackery and much snake oil being sold in the name of idiosyncrasy by people whom I shouldn't trust as much as I trust you?

MUKHERJEE: Absolutely, and, you know, I clearly point that out in the piece that, you know, medicine needs standards and guidelines. We need standardized medicines. I mean, we've seen this. You know, you go to a website and someone is offering some snake oil for something or the other in cancer. It's a very important thing to remain within guidelines, but it also needs some freedoms, some creative freedoms. And if you don't fall appropriately in those creative freedoms, I think we'll be badly stuck.

SIEGEL: Do newly-minted oncologists who are finishing their residencies in this era, do they know a lot more than oncologists in the same situations 15 years new?

MUKHERJEE: Absolutely, they know - I mean, I was in rounds this morning with a fellow, and I was just remarking how much the stable landscape has changed. One of the most incredible things is that these newly-minted oncologists know so much more about cancer.

They talk about genes, they talk about genetic mutations, targeted therapies, immune therapies, words that, you know, barely were in the vocabulary, at least in the hospital. It was certainly in the vocabulary of science forever, but they were not in the vocabulary in the hospital. And all of a sudden they are part of the vocabulary of the hospital. And the way they evaluate patients, the way they evaluate a kind of journey has changed. It's quite remarkable.

SIEGEL: Even though you and other oncologists now understand tumors and cancer cells much better than people did even 10 or 15 years ago, it hasn't yet hugely altered the chances of survival. Do you feel fairly hopeful about that? That is, does it seem to you that the trajectory is going towards still greater understanding of the disease and ultimately some kind of cure?

MUKHERJEE: I feel absolutely hopeful. And part of the reason I wrote this piece was that it began to restore my hope as I, as an oncologist, began to see these dreams about, you know, unique fingerprints of cancer, immune therapies, targeted therapies. As I began to see these dreams move from the scientific literature publications into the clinical literature, it almost restored my faith in my own discipline.

I describe this in my book, "The Emperor of All Maladies" - I describe a moment about 10 years ago, when I felt very despondent about what was happening in cancer care. It seemed to be stuck. I just - quite the opposite now, it feel it kind of - it feels like the blood is flowing. And sometimes the blood flows in wrong directions, but it's still flowing, and there's a kind of new energy that one feels in cancer wards.

SIEGEL: That was oncologist Siddhartha Mukherjee, talking about this Sunday's New York Times Magazine article on improvising ways to treat cancer. He also has a new book out this month called, "The Gene: An Intimate History." Siddhartha Mukherjee, thanks for talking with us.

MUKHERJEE: Thank you very much. Transcript provided by NPR, Copyright NPR.

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