Dr. Raphael Pollock welcomes the next generation of sarcoma specialists

Dr. Raphael Pollock

Sarcoma Alliance volunteer Kalyse Engebretson interviewed Raphael Pollock, MD, PhD, a sarcoma surgeon and director of the Ohio State University Comprehensive Cancer Center in Columbus. 

What does a typical day look like for you? 

Many mornings I have a 6 a.m. or a 6:30 a.m. administrative meeting, followed by scheduled meetings, conference calls, one-on-one appointments and finishing typically with a work-related dinner probably three out of five nights because my role right now is I’m the director of the Ohio State University Comprehensive Cancer Center. I have a budget of $120 million, more than 300 faculty and 4,000 employees, and approximately 2 million square feet of research and clinical space that I am responsible to administer. I do it with a very large group of other people. They are extremely competent in what they do as an administrative team. But the bulk of my energies now are focusing on that responsibility. However, I still have time for a very small clinical practice and laboratory research practice -- both of which focus on sarcoma as they have for the past three decades.

How many patients do you have in general?

I have a very large practice but I no longer do this myself because of my other demands. We have asked two other surgeons to become my partners, Dr. Valerie Grignol and Dr. Joal Beane, both surgical oncology fellowship-trained practitioners, both of whom have research interests in the disease as well. So we have an integrated practice. Overall the practice is probably caring for upwards of several thousand sarcoma patients. ... The last time we looked about a year ago, we’re seeing about 400 sarcoma patients a year between the Wexner patient center and the Nationwide Children’s center.

Do your patients come from all over the U.S. then?

All over the U.S. and worldwide. It’s very gratifying to be able to reach so many people from so many places.

What do you find most interesting and/or enjoyable about your job? 

Probably the most enjoyable aspect, given that I’m going to be 69 years old next week, is being able to pass the baton onto the next generation and really help them get firmly grounded in sarcoma medicine, broadly defined, helping to build multidisciplinary teams, clinics and research platforms. Being able to see my personal ambitions for sarcoma programs going forward with the active recruitment and involvement of younger individuals. So the sense that the baton is being passed and feeling very positive about that happening and trying to facilitate it. That’s probably the very best part.

Earlier, when I was involved directly and with a much higher commitment to patient care, it was an opportunity to help people improve their lives through what we could deliver in our understanding and also it’s a very pleasurable part of what we did and still do. Our research programs are based on patient tissue acquisition. Describing what we’re trying to accomplish, seeing patients come to a quick understanding of that, and being so eager to participate and help us reach those goals, is also just extremely gratifying. One of the things that we routinely do, if the patient is interested, is to bring them to our research lab so they can meet the team that’s going to be working with the tissues that they’re donating. [This gives them a] better understanding of the questions that we’re trying to answer and is reinforcing for the people in the lab as well, as they get a chance to meet the people who are donating the tissue they’re going to be working with.

I remember a patient from Mexico who donated tissue and we were able to ultimately establish a sarcoma cell line from his tissues. He came and visited us in the lab after he had recovered from surgery, after the cells had started to propagate, and we were able to sit him down in front of a microscope and he could see his own cells moving around in culture. ... To him it was just fascinating, and to us it was the height of gratifying to see someone be able to connect those dots in such a dramatic way. Very moving.

One other thing that I would mention that I find really gratifying, that people may not know about me, I have chronic lymphocytic leukemia. [I have] gone through a clinical trial and will be on a targeted therapeutic for the rest of my life. My situation is such as I will probably never go into remission but I’m living in balance with the disease. So I get a lot of personal gratification from being able to talk from a personal perspective with my patients about issues such as clinical trials, what it feels like to have cancer fatigue -- which I experience on a daily basis -- confronting your own mortality, those are also very gratifying in their own ways.

And another very gratifying part of what I do is, I have 5 children, one of whom is a second-year medical student here at Ohio State and one is an undergraduate at Ohio State and is applying for medical school here as well. Two daughters, they both are very, very close with each other. It’s a wonderful experience, just as it’s wonderful being able to talk to patients directly about cancer fatigue in clinical trials, it’s also wonderful to have children who are interested in careers in academic medicine and talking with them about how that can best be accomplished. Helping them write research reports and things of that sort also has tremendous validation and meaning to me. ... Again, it’s the next generation coming up. I think we are all going to be very well-served by such talented youngsters as they mature into academic physicians.

What might most people be surprised to learn about your job? 

Probably the amount of time that is spent in necessary, but not particularly useful, meetings. There’s a lot of it. These are not things that you can avoid but they are not particularly interesting or gratifying compared to some of the other possibilities we just discussed. ...

This morning I got up at 4:45 to go to an early morning meeting. It was 12 degrees outside when I left my home.

Wow! What time do you go to bed? 

Usually I’m something of an insomniac, maybe that’s something that a lot of people might not be aware of. But I’ve been living on about 4 hours of sleep ever since the middle of high school.

How do you survive?!

That’s a good question.

What’s the most challenging part of your job?

I would say that there are several things: Helping patients who are beyond the possibility of cure, but providing help and insight in a very compassionate and humane manner is an awesome responsibility and it’s implicitly challenging to be able to be sensitive to the needs of other people in that particular life-defining context. It’s not something that can, or should, ever be done in a casual manner. It’s implicitly challenging.

A different type of challenge in an administrative context is, frequently, because of my leadership position, I’m put in the awkward position of two people wanting the same thing and only one can have it -- sort of a zero-sum proposition [in which I am] trying to see how we can negotiate between these two people to come up with a solution that is workable for them.

There are things that people feel very passionate about -- the extent of their surgical privileges vis-à-vis another practitioner, for example, access to operating rooms, resources that are finite to be used to expand a research program where several people are competing for the same dollars. Those can be very vexing, particularly when you have a situation where the two people are people you have worked with for a long time, you consider them friends, and you know for example that they are actually friends with each other. And yet, here they are, coming before you in a somewhat adversarial, zero-sum context and how do you adjudicate that? How do you make this whole and have everyone come forth satisfied is a real challenge, and one that we confront on a constant basis.

What keeps you inspired/motivated?

Seeing this next generation of younger people, developing, rising up, eager to try to move the edge of the envelope forward is one thing that is very inspiring. That, coupled with the tremendous bravery that our patients demonstrate, quietly, on a day-to-day basis. The things they have to cope with, the difficulties, and yet the strong will to not only survive but to surmount these challenges is truly inspirational and keeps my engines fully revved to try to be of help in that.

Is there anything else that you want to add or that you want people to know?

None of this will be possible without the strong connection with the community at large and their philanthropic generosity. Grants do not cover many areas that are critical in career development and research opportunities. The work of your group and the people in the community who are supporting the efforts of the Alliance is really critical to achieving our overall success. We’re just very, very grateful not only to your group, but also to the people supporting your group.

At the end of the day, it’s people helping people and you don’t get any better than that.

Big Data research includes sarcoma

By Suzie Siegel

Dr. Bill Dalton is betting on Big Data.

In 2006, when he was CEO of the Moffitt Cancer Center in Tampa, he led the development of the Total Cancer Care Protocol and M2Gen, a for-profit subsidiary.

As part of Total Cancer Care, more than 140,000 patients — including 3,392 with sarcoma — have given permission to have their blood and tissue samples stored and analyzed at Moffitt and to be followed throughout their lives. This produces huge amounts of data that researchers and M2Gen can analyze further.

“We have one of the oldest and largest databases of its kind, especially in molecular genomics,” said Dr. Dalton, MD, PhD, now executive chair of M2Gen, a health-informatics company. “We are continually updating patients’ data to try and learn from each patient’s experience.”

Researchers group patients' de-identified data by their similarities, and then break out the groups with more and more similarities. For example, they might start with patients whose cancers had NTRK gene mutations, and then create a subset that have Ras mutations, too. Because some patients may have the same genetic mutations, patients with different kinds of cancer might be able to take the same drug.

Sarcoma is rare, and doctors often struggle to enroll enough patients in the clinical trials needed to gain FDA approval of a new drug. We may benefit from trials that enroll patients with different cancers who have the same mutations. Targeting these mutations in a person’s cancer is called precision or personalized medicine.

In sarcoma, the first targeted treatment was imatinib (Gleevec) for gastrointestinal stromal tumor (GIST), which often shares the same mutation as chronic myeloid leukemia (CML). The FDA approved imatinib for CML in 2001 and GIST patients followed soon after.

In the past, GIST had often been classified as gastrointestinal leiomyosarcoma (GI LMS). Although my LMS was vaginal, I was checked for the mutation when I was diagnosed in 2002, just in case. My first sarcoma oncologist, Dr. Andy Burgess, now retired from MD Anderson Cancer Center in Houston, told me that imatinib for GIST was the best thing that had ever happened to him in his life.

One of Dr. Dalton’s sons was diagnosed with GIST last year and is doing well on imatinib. “I’m becoming a student again,” Dr. Dalton said, as he learns more about sarcoma. As a physician, he treated patients with multiple myeloma.

My tour to learn more about Total Cancer Care began at Moffitt, where I peered into the pathology lab near the operating rooms. If possible, a diagnosis is made while the patient is in surgery to help the surgeon know how to proceed. With sarcoma, for example, surgeons try to take some normal tissue around the tumor — just in case some microscopic cancer cells have spread that far. In ovarian cancer, surgeons often take much more.

Tissue donated for research is snap-frozen, usually with liquid nitrogen. When tissue is needed for patient care, hospitals store tissue in wax, technically called formalin-fixed paraffin-embedded (FFPE) tissue blocks, said Michelle Fournier, manager of Moffitt’s central biorepository (also known as a tissue bank).

“But that isn’t the best for genomic sequencing,” she said. Ten years ago, Moffitt couldn’t extract good quality genetic information from paraffin blocks, but it now has the technology, Dr. Dalton noted. This matters because Moffitt often receives FFPE samples from other hospitals when patients seek second opinions.

If a patient may benefit from genomic testing, most Moffitt doctors use FoundationOne, Fournier said, which is not always covered by insurance. She said Moffitt wants to create its own genomic-testing lab.

Samples of blood and other bodily fluids are also important parts of Total Cancer Care, she said. Like their colleagues elsewhere, Moffitt researchers hope to develop technology to allow the use of liquid biopsies. Drawing blood for a biopsy would be easier on patients than minor surgery to remove tissue.

Genesis Blanco, left, and Michelle Fournier, right

“I have a lot of patients who say they came to Moffitt because of the research,” said Genesis Blanco, a Total Cancer Care research coordinator.

Total Cancer Care draws from electronic medical records (EMR) created by clinic staff, as well as results of surveys from patients. This two-part system helps ensure accuracy, Dr. Dalton said. “I’d sometimes trust patient-reported outcomes for such things as patient’s pain over EMR.”

M2Gen, built on 30 acres near the main Moffitt campus, promotes research using the Total Cancer Care data. The data are de-identified so that researchers don’t know who the patients are. M2Gen partners with five pharmaceutical and biotech companies, which provide funding for further analysis of the data.

M2Gen also looks into the future. Researchers use statistical algorithms to predict how someone’s cancer might change if it spreads and what treatment options might be available.

In 2014, Moffitt and the Ohio State Comprehensive Cancer Center in Columbus, cofounded the nonprofit ORIEN (Oncology Research Information Exchange Network). M2Gen manages the network.  Seventeen cancer centers participate.

"We’ll be up in Canada next month, and then in Europe,” seeking more partners, Dr. Dalton said.

M2Gen is leading the Avatar Research project within ORIEN that does whole exome sequencing, which looks at the part of DNA that encodes protein, as well as RNA sequencing on tissues collected as part of TCC. Dr. Dalton would like to create a portal so that patients could learn how their donations of tissue and data are advancing research.

ORIEN is using resources on a focused group of Total Cancer Care tissues. “For Avatar we’re looking at a subset of high-risk patients who may be in need of clinical trials,” explained Erin Siegel, MPH, PhD, Scientific Director of TCC.

In this Avatar Research project, researchers in and outside of the ORIEN network can ask to use the data for specific projects. For example, Dr. Damon Reed is looking at teenagers and young adults up to age 40. Dr. Reed, MD, is director of the Adolescent and Young Adult Program at Moffitt and medical director of its Sarcoma Department. Working with Dr. Reed, Moffitt will include over 250 sarcoma tumors in the Avatar project.

"We need champions in this research, like Damon,” Dr. Dalton said.