From the Stethoscope to the Microscope

EDITOR’S NOTE: In honor of National Women Physician Day on Feb. 3, Moffitt Cancer Center’s Women in Oncology group is highlighting the ways women physicians and researchers are contributing to the prevention and cure of cancer.

During the height of the Vietnam War in 1968, four physicians were drafted to serve in the U.S. Public Health Service. The experience forced them to integrate research into their practice and led to multiple health care breakthroughs, including the discovery of statins and the identification of a family of receptors that now serve as the targets for one-third of all medications.

Since then, physician-scientists have been a driving force in biomedical research. They account for 37% of Nobel Prize winners. However, the number of physician-scientists is dwindling. The number of medical doctors who engage in research has fallen from a peak of 4.7% of the overall physician workforce in the 1980s to about 1.5% today, according to data published in The New England Journal of Medicine.

At Moffitt Cancer Center, women physician-scientists are carrying the torch, working to offer the best cancer care in the clinic and discover new treatments in the lab. They hope to help push the oncology field forward and serve as an example to young women physicians entering the field.

Treating Patients of Today and Tomorrow

Growing up in Switzerland, Martine Extermann, M.D., Ph.D., leader of the Senior Adult Oncology Program, wasn’t used to traditional dinner table conversation. She was part of an academic family who routinely discussed science and research. A future in academia seemed predetermined, but in the middle of medical school, she decided to forge her own path.

Extermann explored missionary work and found a passion for oncology. She came to Moffitt for her post-doctorate work and decided to stay on as junior faculty in the Senior Adult Oncology Program instead of returning home for a job in private practice.

“As a young researcher, you always have a phase where you just pedal in circles,” Extermann said. “You try many ideas, and they don’t work. Then you try and try again. You’re not very clear what your career will be and what kind of work you will do.”

Then one day, everything changed. A major journal accepted Extermann’s paper on comorbidities being independent to functional status. She was suddenly viewed as an expert in the field, and she realized she wanted to dedicate her time to clinical research.

Martine Extermann, M.D., Ph.D., left, and Didem Ilter, Ph.D., collaborate on a research project during one of Extermann’s days in the lab. As a physician scientist, Extermann splits her week among the clinic, lab and other duties.

Extermann now spends two days a week in clinic seeing patients and uses the rest of the week to juggle her many other responsibilities, including research, grant writing, coordinating clinical trials and her duties as leader of the program. But no matter what, she sets aside one day a week for research- related work only, no interruptions.

“When I was a fellow in oncology, I asked myself: What’s important for you? I want to see my cancer patients be better treated, and I want to be part of it,” she said. “In my mind, I treat two types of patients: I treat the patients from today with the best cancer care I can do, and I treat the patients of tomorrow with my research.”

Extermann’s research has been a part of many groundbreaking studies in the senior adult oncology field, including proving chemotherapy is tolerable and feasible in older patients and creating a scoring tool to determine the risk of chemotherapy toxicity for older patients.

Looking back at where she could have been, Extermann knows she would have been bored if she took the private practice job in Switzerland all those years ago. As she settles into her senior investigative phase, she’s hoping to keep evolving the field.

“If you do research, you have to know how to reinvent yourself. The types of projects you do at the beginning are not the ones you are going to be doing at the end,” she said. “Now that I have gone up the ladder, let’s take some risks. I am going to focus on projects that are going to be more daring. Maybe they will work, maybe they won’t, but they may advance the field.”

Changing the Standard of Care

Christine Chung, M.D., chair of the Head and Neck-Endocrine Oncology Department, was pursuing an advanced degree in molecular biology and working in a research lab when she met researchers with a medical degree. She saw how they focused on translational research that would improve patients’ lives instead of basic science. She suddenly realized a new career path was unfolding: a physician who also pursues research.

Christine Chung, M.D., uses her experience with patients in the clinic to shape her research, and she can bring innovations from the lab back in clinical trials.

“I wanted to be the person who discovers new medicine and the person who changes the standard of care rather than just following the standard care guidelines set by someone else,” Chung said.

In school and in training, Chung always sought out projects that would help build her translational research background. She found clinical medicine and research formed the perfect balance.

“I can breach the two fields. I can ask the questions that form in the clinic and directly take it to the lab and test it,” Chung said. “And if something promising comes out of my lab, I can design a clinical trial and actually see how the fruit of my research benefits my patients.”

While Chung says she loves traversing both fields, it’s a difficult job, one that often spills over into nights and weekends. She takes care of patients, does both bench-based research and clinical research, leads the Head and Neck Program and chairs a National Cancer Institute head and neck cancer steering committee that oversees clinical trials conducted nationally.

“On a good day, I feel like I am Superwoman who can do all my jobs well. On a bad day, I feel like an absolute failure who cannot do any of them well.”

Despite the challenges, Chung’s passion continues to fuel her, and she has been instrumental in advancing her field. Her work over the past 25 years has led to the creation of two phase 3 clinical trials that could change the standard of care for head and neck cancer treatment in the next five years. One trial is investigating the combination therapy of EGFR pathway inhibitors and PD-1 inhibitors. Earlier trials showed the combination significantly increased survival and response rate, and the treatment has already become part of new National Comprehensive Cancer Network guidelines for head and neck cancer treatment. The other phase 3 trial will study EGFR pathway inhibitors combined with PD-1 inhibitors and TGF-beta inhibitors.

Chung hopes her success will inspire other young physicians to also consider a career in research.

“We need physician-scientists to ask clinically relevant questions. Without seeing patients, that is hard to do, and if you don’t have any research background, it’s very difficult to understand the research process,” she said. “You have to understand both ends to ask the right questions, formulate into a hypothesis-driven project and test it to the point we can actually use it in patients.”

Saving More Patients

Breast cancer treatment has advanced significantly with improved understanding of disease subtypes and tumor biology. Treatment options would not have evolved if it wasn’t for research. This evolution and the desire to find even more ways to help patients is what drives Heather Han, M.D., research director and medical oncologist in the Breast Oncology Department.

“It’s very important for me to be a medical oncologist who is also doing research because it gives me hope and optimism that we are going to be one step closer to saving more lives,” Han said. “If I did not have research that can help make changes and improvement on patients’ lives, it would be very difficult to go through my day to day seeing the sick patients.”

For Heather Han, M.D., doing collaborative research gives her hope for finding new ways to treat the patients she sees.

As the department’s research director, Han focuses on collaborative research with scientists, surgeons and medical oncologists that aims to study all stages and types of breast cancer. That includes studying novel therapies tailored to specific patients and subtypes of breast cancer, as well as how to decrease side effects and toxicity in patients undergoing chemotherapy.

When it comes to HER2-positive breast cancer, the group is investigating immunotherapy with dendritic cell HER2 vaccines. The vaccines are made from a patient’s own immune cells to help boost the immune system to target cancer cells better in combination with HER2-targeted therapies. The team is currently running clinical trials for early and advanced stage HER2-positive breast cancer.

Han chose to work at Moffitt 15 years ago because the cancer center offered her the support to work in both medicine and research. Now, she appreciates the opportunities to help young physicians who want to also focus on research that could change the breast cancer field.

“There needs to be more physicians that work in the research space because there are so many fields to tackle,” Han said. “Even though basic scientists are in the lab and translational scientists are trying to take the ideas to the clinic, if you don’t have the clinicians’ input who have clinical experience and have an idea of what we need to improve upon, it would be hard to make differences in the field.”

Han understands the challenges of recruiting physician-investigators since many medical school graduates want to focus only on clinical medicine. She wishes doctors could be exposed to research opportunities earlier in their training or careers so they could find more opportunities to practice medicine in academic settings.

“This work is important, and it’s fun and rewarding at times because you get a result quickly. It’s not like a lab when you don’t get immediate reward. With clinical research, you can analyze data quickly in real time while it’s potentially helping patients.”