Leading the Charge in Oncology: A Conversation with ASCO's Dr. Clifford Hudis
In this episode of Precision Signals, Sean Khozin, MD, MPH sits down with Clifford A. Hudis, MD, FACP, FASCO, CEO of the American Society of Clinical Oncology (ASCO), to trace a career that began with a childhood memory of Brian Piccolo and Memorial Sloan Kettering, and now sits at the helm of the world's largest professional society in cancer care.
Dr. Hudis reflects on his path from Northeast Philadelphia to an accelerated BA/MD program, to a transformative fellowship at MSK under Larry Norton, and through three decades building the modern breast cancer clinic. He shares what it has meant to lead ASCO through a period of profound change: the rise of AI and real-world evidence, the persistence of access and equity gaps, the evolving science of clinical trials, and the tension between precision and pragmatism at the bedside.
Takeaways:
- Dr. Clifford A. Hudis reflects on his transformative journey from a modest upbringing to becoming the CEO of ASCO, illustrating the profound impact of early life experiences on career trajectory.
- The evolution of oncology, particularly in breast cancer treatment, is marked by significant advancements such as dose-dense chemotherapy and HER2-targeted therapies, reshaping patient outcomes.
- ASCO's guidelines are undergoing a revolutionary change towards dynamic, living guidelines, ensuring that oncologists have access to the most current and relevant treatment protocols.
- AI is positioned to become an integral component of clinical practice, enhancing decision-making and patient care, thereby allowing oncologists to focus more on patient relationships.
- The tension between science and societal perceptions of healthcare necessitates an ongoing dialogue to build trust and understanding, particularly in the face of misinformation and skepticism.
- Leadership in oncology requires not only clinical excellence but also an embrace of business acumen and a visionary outlook, fostering progress in a rapidly changing medical landscape.
Companies mentioned in this episode:
- ASCO
- American Society of Clinical Oncology
- Memorial Sloan Kettering
- Genentech
- MD Anderson
- Dana Farber
- NCCN
- NIH
- NCI
- AACR
- ACS
Transcript
Hi, everyone, and welcome to Precision Signals.
Speaker A:I'm your host, Sean Cozen.
Speaker A:In this episode, I'm joined by Dr. Clifford Hutus, an internationally recognized oncologist, scientific leader, and CEO of ASCO, the American Society of Clinical Oncology.
Speaker A:Cliff has had a remarkable career at the intersection of science, medicine, and leadership.
Speaker A:He trained in internal medicine and oncology, spent decades at Memorial Sloan Kettering, where he eventually led the Breast Cancer Service and contributed to some of the foundational advances that shaped modern cancer care, from chemotherapy optimization to targeted therapies and translational research.
Speaker A:Beyond his scientific contributions, Cliff has also played a major role in shaping the broader oncology ecosystem.
Speaker A:As Ask Co president during its 50th anniversary and later as CEO, he has helped guide the field through an era of extraordinary change, spanning precision medicine, immunotherapy, the COVID 19 pandemic, and now the rise of AI in healthcare.
Speaker A:But what makes this conversation especially compelling is is not just Cliff's resume.
Speaker A:It's the perspective behind it.
Speaker A:From his early days growing up in a modest household in Northeast Philadelphia, to entering an accelerated medical program at a young age, to becoming a leader in one of the most complex domains in medicine, his journey reflects a deep commitment to both scientific rigor and the human side of care.
Speaker A:In this episode, we explore that journey, starting with his early influences and path into medicine, then moving into the evolution of oncology as a field, and finally diving into some of the biggest questions facing healthcare today.
Speaker A:We talk about the transformation of cancer treatment over the past few decades, the role of professional societies like ASCO in translating science into practice, and how emerging technologies, especially AI, may reshape the way clinicians deliver care and and interact with patients.
Speaker A:And importantly, we discuss the tension and opportunity at the intersection of science and society.
Speaker A:How trust in science is built, challenged, and ultimately sustained.
Speaker A:This is a wide ranging and deeply thoughtful conversation about leadership, progress and the future of cancer care and research.
Speaker A:Let's step into the conversation and trace the signal beneath the noise.
Speaker B:Hi, Cliff.
Speaker B:Welcome to Precision Signals.
Speaker C:It's an honor to be here.
Speaker C:I'm happy to see you, Cliff.
Speaker B:It's so great to see you, and I've been looking forward to this conversation.
Speaker B:You've accomplished so much throughout your career, and you've been quite modest about it, which is one of the many things I admire about you.
Speaker B:But before we go into your professional accomplishments, I would love to dig into the early days where you grew up and what impact your early environment had on you in terms of your professional and personal trajectory.
Speaker C:Thank you very much, Sean.
Speaker C:I, I think a lot about my childhood because the older I get, the more I think it had, or the more clear I should say it becomes to me how critical it was in shaping the adult I became and the work I did.
Speaker C: middle class, typical of the: Speaker C:It was a newly built neighborhood in northeast Philadelphia with a lot of, I think, young striving families.
Speaker C:My father didn't have the opportunity to complete college and worked from age 18 or 19 continuously.
Speaker C:And my mother, once her little children were in school full time, went back to school herself and became certified and as a public school teacher.
Speaker C:So I'm describing what I think is a pretty typical middle American existence, but widening the lens a little bit.
Speaker C: The: Speaker C:And I've thought a lot about this, both in terms of things that have been written about the era, but also the things that we experience.
Speaker C:So I'll give you a couple of examples.
Speaker C: Number one, through the: Speaker C:And I think for me provided both an area of focus but also an optimism and excitement about the future.
Speaker C: It was the: Speaker C:I was 10 years old at that point.
Speaker C:So I do remember that era.
Speaker C:And the takeaway, in case I'm being too wordy, is that a very high quality, very rudimentary science and math education was possible in a public school system.
Speaker C:And I think a lot of us from that era benefited from both those resources and I think a remarkable optimism about what America might be able to achieve working together.
Speaker C:Say one more thing, at the sociological level, we may or may not come back to this, but I do think for TV channels and a small number of upper band vhf, a limited number of AM radio stations, I think Americans shared in information streams and maybe were a little more aligned than in the current day.
Speaker C: to recall that it was in the: Speaker C:So I'm sure things aren't quite as rosy, weren't quite as rosy as I recall, but I do think it Was different.
Speaker B:Yeah.
Speaker B:Clearly back then, it seems like science and medicine, the STEM fields, carried a certain kind of civic weight that unfortunately we don't have anymore.
Speaker B:Why do you think it was the case back then?
Speaker B:And have we lost focus on what's truly important today when it comes to education?
Speaker C:I don't think so.
Speaker C:I just think that we have created in this space, just as we have in so many others, an almost infinite number of possibilities, a high degree of personalization, lots and lots of choice.
Speaker C:And I'm not suggesting that it's necessarily better, but it was simpler.
Speaker B:Right?
Speaker B:Right.
Speaker B:Yeah.
Speaker B:I think it probably was easier to establish consensus back in, in those days.
Speaker C:And I think we didn't fill as many options.
Speaker C:I always have joked, when I grew up, the two words investment banker to me had no meaning to me.
Speaker C:The bank was the place in the shopping mall strip center where I took my passbook and deposited my lawnmower savings from mowing lawns, that is, or babysitting.
Speaker C:I mean, what did I know from investment banking as a thing?
Speaker C:That's just one example.
Speaker C:So maybe it was just my narrow world and maybe the rest of the world knew what was going on long before.
Speaker B:No, I can certainly relate to that.
Speaker B:I didn't really understand what the world of finance entailed until later in my career.
Speaker B:And to me, going to med school was perhaps the only option.
Speaker B:Music for a couple years was plan A, but obviously that didn't work out.
Speaker B:But a different story, it seems like, Cliff, based on what I read on your biography, you had a very early interest in science and math, which is quite interesting, I don't think.
Speaker B:You probably never wanted to be an astronaut.
Speaker B:You probably wanted to be a mathematician or a scientist.
Speaker B:Why was that?
Speaker B:Were there early influences that led you in that direction or was it just something organic?
Speaker C:I don't know how to answer that because I think it's multifactorial.
Speaker C:And I think that there were several things.
Speaker C:The first of all was a pragmatic one from my parents point of view.
Speaker C:A profession, be it medicine or law in particular, were the way forward in America.
Speaker C:And we, my brother and I, were programmed very solidly in that direction.
Speaker C:As I was happy, content, interested in doing math and science.
Speaker C:I'm sure I got support.
Speaker C:But the other thing that happened to me that was really just a very good fortune is my mother knew because she was a schoolteacher in the Philadelphia public school system, or I should say she had high confidence that there was going to be a strike, maybe a disruptive one, in my senior year of high school.
Speaker C:And so beginning in ninth grade, my parents stretched and actually sent me to a little private school outside of Philadelphia run by those founders of Philadelphia, the Quakers.
Speaker C:It was one of many of the Quaker schools in the area.
Speaker C:Very liberal, very small.
Speaker C:A real shock to a kid who'd been in public schools, frankly.
Speaker C:But the reason I mentioned that is the tiny classes.
Speaker C:My whole graduating class was, I think maybe 38 kids.
Speaker C:So AP bio and AP chemistry and physics and calculus were all available to me in classes of two or three or four kids.
Speaker C:And I think that made a big difference because essentially I was getting tutored almost one on one in my 10th and 11th and 12th grade classes.
Speaker C:I'm not saying I was so good at it.
Speaker C:I'm saying I had extraordinary opportunity because of that.
Speaker C:Yeah.
Speaker B:Correct me if I'm wrong, Cliff.
Speaker B:I believe your parents were quite dedicated to your education.
Speaker B:They actually took out a loan to send you to the Quaker school.
Speaker B:Is that true?
Speaker C:Yeah.
Speaker C:Because who had the money for tuition?
Speaker C:Right, right.
Speaker B:Yeah.
Speaker B:And also, it seems like you have talked about this in the past, that you started working at a very young age, around 14 or so, and you started to have real financial responsibility early on.
Speaker C:Not sophisticated, pretty simple.
Speaker C:If I didn't have money from a part time job, I couldn't take a girl on a date.
Speaker C:It was just that simple.
Speaker C:So you're right.
Speaker C:I started working in the summers probably at 14, and I had very mundane, almost silly sounding jobs.
Speaker C:You know, I. I certainly was, all through the winter, a babysitter.
Speaker C:All through the summer I was mowing lawns and washing cars, detailing them, that kind of thing.
Speaker C:But I think by the time I was 14 or 15, I was certainly working in a more formal way through the summers.
Speaker C: delphia through the summer of: Speaker B:So in terms of your interest in science, how did that come about?
Speaker B:I read somewhere that your interest in science goes back all the way to perhaps eighth grade grade when you were studying earthworm muscle biology.
Speaker B:And, you know, which is quite interesting.
Speaker B:And I believe that was a summer program.
Speaker C:Yeah.
Speaker B:Was that because of the encouragement that your parents were giving you, or did you have a natural draw to biology and the scientific entropy?
Speaker C:A couple of things happened.
Speaker C:I had an older cousin who went on to become an allergist.
Speaker C:He was a few years my senior and as he was going through high school already, knowing that he wanted to, to go to medical school.
Speaker C:And then as he went through college and beyond, he was always for me, the one mentor even that I, in retrospect, what I would call a mentor, because obviously my father, who had not gone to college, my environment didn't have professionals.
Speaker C:I really didn't know any doctors.
Speaker C:But in the summer of, I think you're right, I think it was probably 8th grade, I signed up for something called the Hahnemann Summer Science Program, which was maybe six or eight weeks of five days a week laboratory experience in this workspace of a scientist.
Speaker C:There, the person I worked with was studying muscle physiology.
Speaker C:And it turned out that one of the great models for that is the earthworm, which is, I don't know, 90 plus percent muscle.
Speaker C:So I was grinding up muscle and doing basic blots on the, on the muscle for her through the summer, and it was really exciting for me.
Speaker C:But I, I do want to just say one thing about this.
Speaker C:For me, in the end, the interest in science was a derivative, a secondary.
Speaker C:The interest for me in the end was in working as a physician and helping patients.
Speaker C:And in our modern Europe, that means, of course, being a scientist, it didn't always mean that.
Speaker C:If you think back on the history of this, and what I mean is the scientific method is a newer development than the actual laying on of hands, right?
Speaker B:The human aspect, you know, I think even today, and we're going to go into the world of AI and technology later, then one of the most important things is access to care and the therapeutic relationship between the physician and the patient that most likely technology can solve.
Speaker B:But we're going to save that for later as we dig into technology and AI.
Speaker B:And Cliff, you started med school at the age of 20, which is just remarkable.
Speaker B:Can you walk us through that?
Speaker B:It seems like you were very focused on becoming a physician and you realized very early on you wanted to pursue that path and you had, you carved that an accelerated route to getting there.
Speaker B:What was that experience like?
Speaker B:Because going to med school that early at a very young age could be.
Speaker B:It has benefits for sure, but it could, I'm assuming, could also be challenging.
Speaker C:Well, I think before we even get into it, it's worth remembering that while there is a convention in the United States, high school, four years of college, four years of medical school, in much of the world, there's a different model and lots of kids around the world are selecting or being selected for healthcare, including medical school in higher education systems that are four, five, six, seven years long and start as early as I did.
Speaker C:So you're absolutely right that in the American context it's something different, but in the global one maybe not so much.
Speaker C:I think the second thing though is what really happened to me was I was pretty sure that I wanted to go to med school.
Speaker C:There was a part of me and Sean, I don't know if you know this or not.
Speaker C:You know, in a certain way I'm probably very competitive, but in other ways not so much.
Speaker C:And I was not that enthused, looking forward to four years of college, the hyper competitive, immediate post Vietnam era of having to get in near 4.0 high MCATs and duking it out.
Speaker C:So the idea of some certainty was very appealing to me.
Speaker C:But what really happened was nothing quite that purposeful.
Speaker C:What happened was I applied early decision as a Pennsylvanian to the University of Pennsylvania and I got in.
Speaker C:I applied to Lehigh at that time also and as a safety school I thought, and Lehigh's a very good school with a strong engineering focus.
Speaker C:But obviously it's, you know, at least one level below the Ivy leagues when you think about it.
Speaker C:But at any rate, they had a little checkbox on their application form for $20 more you could be considered for a six year program.
Speaker C:They offered two programs.
Speaker C:One was with Hahnemann and one was with The Medical College, Pennsylvania.
Speaker C:The Hahnemann program, I believe was six years also, or maybe seven.
Speaker C:But what they did is took maybe 60 or 80 kids and they competed for some modest number of slots.
Speaker C:I don't remember the exact number.
Speaker C:The odd thing about the program between Lehigh and The Medical College, Pennsylvania was that it was much more defined.
Speaker C:They took 15 or 18 kids a year and they all went to med school.
Speaker C:Barring some catastrophe, I don't know, but I think Northwestern may have had a program like that and I think Brown may have had a program like that.
Speaker C:And there were probably a number.
Speaker C:I actually think we're going to talk about it, but I think these accelerated programs may come back a little bit because of financial pressures and other reasons.
Speaker C:But in any event, I got into it and for me that's all I needed to know.
Speaker C:Because now, number one, I didn't have to repeat certain preliminary courses in pre med because it didn't matter.
Speaker C:I didn't need to worry about my gpa, so I'd done AP biochemistry, Physics and I could just skip forward.
Speaker C:Same thing with calculus instead of going for the A's, you know, as a freshman.
Speaker C:And I think the other is that my MCATs and GPA weren't going to matter as long as I did okay.
Speaker C:And that's what happened.
Speaker C:I went to school that summer.
Speaker C:So you had to amass in the program three years worth of college credits over two years.
Speaker C:And they had some sleight of hand when they gave you some college credit for the first year of med school.
Speaker C:So I don't know how it worked, but.
Speaker C:But somehow I graduated.
Speaker C:And you would get a BA from Lehigh and then your MD four years later from the Medical College, Pennsylvania, as a six year program, I should say some of my friends in the program ended up doing it in seven years anyway.
Speaker C:They had opportunities to take a.
Speaker C:Create a gap year, do something else.
Speaker C:And they were a pretty remarkable group of students in retrospect, leadership, and to play other key roles in medicine.
Speaker C:So I don't think the program runs anymore for a number of reasons.
Speaker B:Unfortunately, you're right.
Speaker B:We don't have that many of them today.
Speaker B:The ones that we see are quite hyper competitive.
Speaker B:And I'm sure back then they were also hyper competitive.
Speaker B:What I'm the most jealous about here, Cliff, is that you probably only had to memorize the Krebs cycle once.
Speaker B:That's right.
Speaker C:No, it was a relief, but it's hard to remember, but the war in Vietnam ended just a few years before I graduated from high school.
Speaker C:There had been intense pressure, competition for medical school slots because of Vietnam, for other reasons, and that carried over into this decade.
Speaker C:So the idea that you could just decide that you wanted to go to med school was a laughable thing.
Speaker C:People did not get into med school with very good qualifications in those days.
Speaker C:And that may still be true, I don't know.
Speaker C:But I wanted to.
Speaker C:I knew I wanted to go to med school.
Speaker C:And if there was a way I could be assured I was taking it.
Speaker B:So Medical College of Pennsylvania, that was med school.
Speaker B:And then you went to Mount Sinai for residency, right?
Speaker C:No, no, no.
Speaker C:What happened was I went to the Medical College of Pennsylvania for medical school and remember its history.
Speaker C:Uniquely, that was the Female and Women's Medical College.
Speaker C: It only became co ed in: Speaker C: educational experience in the: Speaker C:Although now, of course, medicine is dramatically different across the board, with I think most med schools at least 50% women, if not more.
Speaker C:But in those days, it was an outlying institution with department heads, chairs, faculty, disproportionately women.
Speaker C:And I didn't know that that was unusual at the time.
Speaker C:So I stayed there and did internal medicine, and I did internal medicine for three years, and then I served as chief medical resident.
Speaker C:So that was a fourth year.
Speaker C:By then I was moving to New York.
Speaker C:I knew I wanted to do oncology and I knew I wanted to do a memorial.
Speaker C:But I had a gap year to fill.
Speaker C:And in that year, for another reason, I was able to get a job as an emergency room doc up at Sinai.
Speaker C:The side story there, it's not related to much, is that there was a guy by the name of Dave Wagner who ran the emergency medicine program at mcp.
Speaker C:He wrote one of the first textbooks of emergency medicine and he was one of the founding parents of, of the specialty.
Speaker C:As a specialty.
Speaker C:You know, we forget how things are always evolving, but emergency medicine wasn't a board recognized specialty when I began my training.
Speaker C:And so because I had done internal medicine in this program that was so strong in er, I had some street cred as an ER doctor.
Speaker C:Moonlight in the ER a lot.
Speaker B:That is remarkable.
Speaker B:Yeah, I did see that at Mount Sinai.
Speaker B:You did a year as an emergency physician.
Speaker B:I couldn't connect the dots there, but that explains it.
Speaker B:What was that experience like?
Speaker B:Because it's very different than practicing internal medicine or oncology.
Speaker C:It strengthened my desire to do oncology for.
Speaker C:Again, you're starting to see the theme.
Speaker C:Despite what it might look like, there's a deep insecurity in me about competence and skill.
Speaker C:And what I mean is I like narrow and deep expertise where I can feel sure of myself.
Speaker C:So when I was in medicine and chief medical resident, like many, I was one of those people.
Speaker C:I knew the literature, I could spout off the statistics, I could run morning report, all of that stereotypical stuff.
Speaker C:The ER at Mount Sinai was a triage doctor.
Speaker C:The way they worked, at least in those days, when patients came in, they were either triaged to surgery or to medicine.
Speaker C:So the ER was really just acute internal medicine.
Speaker C:If you think about it, it was sickle cell crisis and asthma, myocardial infarction and stroke, sepsis, diabetes out of control and so forth.
Speaker C:All of that one thing that's, that's maybe surprising, maybe not, but there's a lot of anxiety if you are making decisions that you are about who's sick and who's not sick, who needs to be admitted and who needs, who's safe for outpatient follow up.
Speaker C:And when you're wrong, I think you could be pretty tragically wrong.
Speaker C:So I liked oncology and I already knew it when I got there, but I liked oncology in part because there was a luxury that when a patient with or suspected of having cancer had a complaint as an internist, at least Initially, you took that complaint seriously, and there wasn't so much of a focus on figuring out if it was legitimate or not.
Speaker C:I may be wrong about this, but my view of it always was that if my patient with cancer complains of back pain, it was reasonable for me to start with the assumption that it might be metastases, work it up, and then rule out the bad things.
Speaker C:And, you know, I think in internal medicine, family medicine, because of the financial reality we live in, and then because of the volume, there's a little different algorithm to things.
Speaker C:I may be wrong about that.
Speaker C:I don't want to overstate it, but for me, with my psychology, I liked being given the freedom to assume, in a sense, the worst and then work my way back.
Speaker C:The other part of it was, and we'll probably get to this, but the thing that I found most rewarding in the end about oncology was with scientific knowledge, with clinical skill, that one could actually reassure patients and families and walk them back from their worst assumptions about what things were to something closer to reality.
Speaker C:And the cure rates and long term survival that we now see in oncology, with upwards of 20 million survivors in America today, are the testimony to that.
Speaker C:But all those people need help getting across the Rubicon from diagnosis and fear to reassurance.
Speaker C:So that's the part, the human part of it that I actually really did enjoy.
Speaker C:And I'll say not based on wishful thinking, but based on fact and data.
Speaker C:Hmm.
Speaker B:Yeah.
Speaker B:Remarkable.
Speaker B:By the way, Cliff, one of the things you said about how sick a patient is, do they have to be admitted or not?
Speaker B:It is half art, half science.
Speaker B:I remember during the white coat ceremony in our med school, one of the things that they told us was, if you don't learn anything in the next four years, just make sure you learn one thing.
Speaker B:How sick is the patient?
Speaker B:And that is some that sometimes cannot be quantified.
Speaker B:Now, we can go into contextual learning with AI later, but it is clinical intuition and it's.
Speaker B:And I didn't understand at the time what they meant until I was in residency and I had to admit patients.
Speaker B:It's one of the toughest things to do.
Speaker B:How sick is this patient?
Speaker B:Do I let them go or do we admit them?
Speaker B:And sometimes the numbers don't tell the full story.
Speaker C:Right.
Speaker B:So going back to your interest in oncology, you touched on several factors, so it seems like obviously the science was quite intriguing to you.
Speaker B:The series of the illness and the human aspects that are associated with that, the closeness to patients, it seems like that was Quite motivating for you at the time.
Speaker B:Did you have a sense that the field was on the verge of a major change?
Speaker C:Yeah, I didn't understand it.
Speaker C:So it was a superficial thing, I remember, and I've looked to try to find this cover of either Time magazine or Newsweek, and I haven't found it.
Speaker C:So it could be that I've invented this.
Speaker C:But I recall this idea sometime before I was in oncology of targeted therapies being developed, specifically immunotherapies.
Speaker C:There was a cover at one point of one of the popular magazines that described the smart bombs that we were going to see developing.
Speaker C:And this was early.
Speaker C:I mean, I don't know whether, for example, Genentech had yet started to produce, you know, humanized monoclonal antibodies, but we knew what was coming.
Speaker C:And I should say one more thing.
Speaker C:When I did my oncology rotation as a resident in Philadelphia, the clinic that I went to was run by really dedicated people.
Speaker C:A woman named Roz Joseph, who was an early American Cancer Society professor, and she'd run hemonc at Temple and at MCP and a guy by the name of Manny Besa.
Speaker C:And they were profoundly influential for me because the clinic was filled with this unique mix at the time for me of optimism about the future, incompletely developed science, lots of potential serious illness, and grateful engaged patients.
Speaker C:All of which meant a lot to me.
Speaker C:I remember doing a report as a resident, and they must have laughed at me at the time, but it was just a funny thing to ask me to do.
Speaker C:And I remember I created a little database, pre database as a piece of paper with.
Speaker C:And I could list all of the active drugs in oncology on two sides of a single sheet of paper and their mechanisms of action.
Speaker C:That's how.
Speaker C:How early it was.
Speaker C:So, yes, there was huge belief that the future was not going to look like this, that we were going to make rapid progress.
Speaker C:And I've not been disappointed.
Speaker B:Sure, yeah, A lot has happened.
Speaker B:For sure, a lot has happened since I went to med school.
Speaker B:And it's remarkable.
Speaker B:I remember when I was trained at nci, and I may have told you this, that in the early days of my experience at nci, we were doing studies to test the feasibility of molecular profiling just to see if it's even feasible to do molecular profiling on patients with lung cancer.
Speaker B:And this was not that long ago, or at least I'd like to think it wasn't that long ago.
Speaker C:It wasn't.
Speaker C:That wasn't even a phrase that we would utter in my training.
Speaker B:Right Right.
Speaker B:Cliff, one of the things that I found out was that you were quite focused when you were in residency on going to msk.
Speaker B:It was a singular destination for you.
Speaker B:Why is that?
Speaker B:I found that quite intriguing, I think.
Speaker C:Naivete and a number of things.
Speaker C:But I do think in the end, a kind of simplistic naivete.
Speaker C:When I was a little boy, I had seen James Kahn.
Speaker C:He was the actor in the Brian Story.
Speaker C:And I may not even have the facts exactly right.
Speaker C:I'd have to go back and watch it again.
Speaker C:But my recall through the years is that Brian Piccolo, I think, had a midline germ cell tumor and he was of course a professional football player for the Chicago Bears.
Speaker C:And he got sick and died of that tumor at Memorial Sloan Kettering.
Speaker C:It was a real tear jerker of a movie for a kid.
Speaker C:And in my head it established in a very basic way the preeminence of Memorial Song Kettering.
Speaker C: o move to New York in the mid-: Speaker C:And I'll say on interviewing, at the time, the fellowship struck me as more like a residency than any other program because of its size, I can't remember, but there might have been between 13 and 16 fellows per year in medical oncology.
Speaker C:So it was the size of a small internal medicine residency, actually, at least at the time.
Speaker C:And most of the other fellowships were much smaller, closer to apprenticeships, I should add, because for people listening to this who don't know, it's worth remembering that there wasn't such a thing as medical oncology until Barney Clarkson, who was president of ASCO in 19, I think 72 or 3, with volunteers beseeched the American Board of Internal Medicine to create the subspecialty.
Speaker C: The first exam was around: Speaker C:So if you fast forward to when I was applying to residency, to fellowship rather, it was a mere decade later or a little more.
Speaker C:So I think the formality and structure of the fellowships that we have today, and I have to say it's not me, but supported by lots of hard working folks at asco, that wasn't something that existed.
Speaker C:But Memorial, probably MD Anderson and maybe Dana Farber among others, I didn't have the ability to go look at those programs.
Speaker C:I had to be in New York.
Speaker C:But I suspect they would have struck me the same way at that time.
Speaker B:Very interesting.
Speaker B:When you started as a fellow at msk, what was it like?
Speaker B:Did it live up to the expectations that you had?
Speaker C:So I think I was a slightly different kind of fellow because I had been independent, I'd already been running the ER at Sinai, and I was essentially taking a step back and having a minute by minute supervisor.
Speaker C:That was a little funny, but it was probably good for me.
Speaker C:On the other hand, it blew me away because when I walked in, I still remember this so clearly.
Speaker C:And you may have seen this at the nci, too, I don't know.
Speaker C:But when I walked in my first weekend on call, the outgoing fellow handed me.
Speaker C:Of course, we had cards in those days, a stack of cards for the inpatient service he was covering.
Speaker C:And that service was sarcoma patients.
Speaker C:And there were maybe 13 of them.
Speaker C:I don't know that I'd ever seen a sarcoma in my internal medicine residency in Philadelphia.
Speaker C:And then there were 13 and a couple of other impressions from that very first year.
Speaker C:We used to do month long rotations through the various services.
Speaker C:The testes cancer service at that time at Memorial, I can't remember, but there were at least 30, 35, maybe more inpatients getting curative chemotherapy for testes cancer.
Speaker C:I mean, a disease I had never seen that was one service.
Speaker C:Leukemia would have, you know, 8 to 12 or 15 acute leukemic patients.
Speaker C:So the volumes and concentration of expertise became apparent immediately.
Speaker C:All the docs at Memorial by then were already single disease experts or single organ system, you know, lung cancer or breast cancer, what have you.
Speaker C:And that depth of expertise, that narrowness of focus, all of that was really shocking.
Speaker C:And I don't know that I understood before I got there that it would be like that.
Speaker C:And it was.
Speaker C:But it was a.
Speaker C:Obviously it was a very pleasant thing to discover because the skill and expertise that I saw demonstrated every day were extraordinary.
Speaker B:Sure, you eventually, Cliff ended up leading the breast cancer service at msk.
Speaker B:Where did your interest in breast cancer come from?
Speaker C:Well, again, if there's a through line in my career, it's mostly just being in the right place at the right time and getting extraordinarily low lucky with the breaks that came away.
Speaker C:So when I was at Sinai in the year before, the odd thing about the structure at Mount Sinai in those days, that a famous oncologist, James Holland, he had his own department there.
Speaker C:It wasn't a division of internal medicine.
Speaker C:So there was surgery, there was pediatrics, there was medicine, and there was oncology, just like that.
Speaker C:By the way, Hahnemann in Philadelphia had for a while the same thing, as I recall.
Speaker C:And one of the leading faculty on that service that year was Larry Norton.
Speaker C:And he had tremendous cadre of patients, but also of dedicated fellows and residents and junior faculty.
Speaker C:And whenever an oncology patient rolled into that triage medicine er, I described if they belonged to one of the members of that oncology team, they came down to the er, they saw them all.
Speaker C:So there was this distant vision of this intense leader, Larry Norton from Mount Sinai, who I didn't really get to know back then, but I knew who he was.
Speaker C:Okay, fast forward.
Speaker C:I go to Memorial.
Speaker C: We start in July of: Speaker C:And again, it's has.
Speaker C:It's no testament to anything except my good fortune at being there.
Speaker C:So Vince DeVita of NCI fame had been recruited as physician in chief and by Paul Marx.
Speaker C:And he in turn recruited Larry, who was a lymphoma doc and a breast cancer doc from Mount Sinai to move over to Memorial.
Speaker C:And Larry showed up mid year, maybe, I don't know, October, November, something like that.
Speaker C: In the fall of: Speaker C:And then of course, the next month I was.
Speaker C:And so Larry was just finding his way into and through the Memorial system.
Speaker C:And I was a veteran of six months, so I could order an X ray or, you know, get a few other small things done.
Speaker C:And the other thing that happened was Larry, for whatever reasons, I mean, he would get to clinic, he might be a few minutes late sometimes.
Speaker C:I, having been independent, was used to just writing orders and executing.
Speaker C:So I remember, and I don't know if Larry would remember this or not, but I remember he would come into clinic expecting there to be a bunch of patients to see.
Speaker C:And I'd seen them and they were gone.
Speaker B:That's great, right?
Speaker B:Was Larry recruited to start the breast cancer program?
Speaker C:Was that Larry was recruited to do that.
Speaker C:And in those early days, it was breast and GYN and was really derived from a developmental therapeutics program because it was early days of chemo chemotherapy.
Speaker C:So there was some phase, a little bit of phase one and small phase two and even small phase three studies that had been done.
Speaker C:The earliest randomized trials looking at CMF and variations therein for adjuvant chemotherapy.
Speaker C:All of that was happening in those days, but the people doing it actually were affiliated as the developmental chemotherapy service.
Speaker C:So they would do breast cancer and they would do other diseases that were chemotherapy responsive maybe at the time.
Speaker C:So it was carved off.
Speaker C:Larry started to build it, and that was his charge A couple of.
Speaker C:A number of amazing things in retrospect, but in no particular order, But I'll just point out Larry was really interested in technology.
Speaker C:So in first year or two that he was there in building the clinic, we had this rudimentary.
Speaker C:IBM had an operating system, it was something like Windows, I'm blanking now what we called it, but we actually built, or had built for us a little computerized graphical interface medical record.
Speaker C:In retrospect, that didn't work very well and whatever, but it was interesting that Larry introduced that into our breast cancer clinic.
Speaker C: couldn't have been much past: Speaker C:I'm not 100% sure.
Speaker C:The thing is that the service was housed as only would happen in New York City in a two bedroom apartment next door to the hospital.
Speaker C:That was our office suite.
Speaker C:So Larry had the primary bedroom and the faculty that he had recruited, Antonella Serbon, Tari Gillespie and John Crown, occupied the second bedroom and part of the living room.
Speaker C:So when I was recruited, I think I was the fifth member of the team and I literally had a little corner wedged into the side of the living room with my, my files and my initial workspace.
Speaker C:That's how we started.
Speaker C:Larry, though I want to say this, there were two things that in retrospect were extraordinary.
Speaker C:The first is, and we'll probably come back to that, an optimistic vision for the future is something that I think is really critical to successful leadership.
Speaker C:I didn't see it labeled that way at the time, but that is for sure something Larry had.
Speaker C: The second is the: Speaker C:That was an era in breast cancer of rapid transformation.
Speaker C:I may not have the timeline exactly right, but in more or less this order, granulocyte colony stimulating factor, paclitaxel, paclitaxel, trastuzumab, BRCA testing, aromatase inhibitors.
Speaker C:And this may seem smaller in retrospect, but the oral chemotherapy drug capecitabine, they all appeared in a 10 year window.
Speaker C:It was a remarkable era.
Speaker C:So every meeting was exciting.
Speaker C:Every time we got together, there was something different happening.
Speaker C: outside of breast cancer, but: Speaker C:The big improvement from a systemic therapy point of view was that decade, right?
Speaker B:Remarkable.
Speaker B:Speaking of trastuzumab, Cliff, your scientific work really helped shape modern breast cancer treatment, including dose dense chemotherapy in Combination with HER two directed therapy.
Speaker B:When you were doing that work back then, in real time, it seems like you did feel like there's an inflection point around the corner.
Speaker B:But did it really feel like that or was it more like incremental?
Speaker C:Well, first of all, I did none of this work alone.
Speaker C:In all cases, it was a team.
Speaker C:For example, we had the original patent on GCSF at Memorial, and that was licensed out to Amgen, so we had access to it.
Speaker C:Larry had always, as a modeler, been pushing for optimal doses given at the maximum frequency.
Speaker C:I'm oversimplifying what was called the Norton Simon hypothesis.
Speaker C:The availability of GCSF is partly what I think he would say attracted him to Memorial at the time, because he could put into practice the theory that those dense treatments would be superior to those that were less dense.
Speaker C:So we began to design clinical trials, and I was mentored in this by Larry, but got to do them.
Speaker C:It's absolutely true.
Speaker C:So it was doxorubicin, high dose cyclophosphamide, doxorubicin, paclitaxalcyclophosphamide.
Speaker C:And this all led into the cooperative group efforts that eventually marked Citron, a community oncologist from Long island, got to run as a principal investigator.
Speaker C:All of this, frankly, was really because of Larry's leadership.
Speaker C:I was one of many people, I think, to benefit from being in this rich environment where a lot of people could share in success.
Speaker C:I mean, Mark Skolnick came through our clinic, beta testing, BRCA testing for myriad genetics, and we got to do that Trastuzumab.
Speaker C:I mean, here again, Jose Bisalgo was a fellow at the time after me, working in John Mendelssohn's lab.
Speaker C:And of course, John had the EGFR antibody that he had developed, and they demonstrated the synergy with various chemotherapy agents for HER one blockade, egfr.
Speaker C:And I think modeled that as well with what was called 4D5, which was the original generic company name for Herceptin before it was Trastuzumab.
Speaker C:And so I was just in this place where all this was happening and witness to it.
Speaker C:And to some degree, I was a bit of.
Speaker C:I was a collaborator, but I just got to help implement the last couple of steps.
Speaker C:The clinical translation of all of this exciting work.
Speaker B:Well, of course, another remarkable thing scientifically that I noted is your work on the link among inflammation, obesity and cancer risk.
Speaker B:That's essentially a broader lens than treatment alone.
Speaker B:How did that come about?
Speaker B:Obviously, more recently, in recent years, a lot of folks have been thinking about inflammation, but at the time that was not in vogue.
Speaker B:How did that interest come about and how far do you think we've gone today?
Speaker C:First of all, it is really again, testimony to just being lucky.
Speaker C:So a couple things happened.
Speaker C:The first is, as a service chief, the way you're evaluated in a place like Memorial was the success of the people that you're training.
Speaker C:So no longer was it really my job or appropriate for me to be the principal investigator, first author and presenter.
Speaker C:That's good.
Speaker C:But the goal is to have people coming up taking on those opportunities.
Speaker C:And so what that meant was that I distributed to my colleagues and peers and mentees and trainees a lot of the opportunities that had been my area of focus.
Speaker C:So somewhere in there, and I'm sure I was on the faculty about a decade by then, but one day I was introduced to a colleague, a gastroenterologist working across the street at New York Hospital Cornell by the name of Andy Dannenberg.
Speaker C:And Andy was a gastroenterologist, clinical gastroenterologist, but really a laboratory scientist.
Speaker C:And he was very focused on these anti inflammatory drugs, the COX inhibitors.
Speaker C:Most specifically at the time you'll remember, Celecoxib had come out and a couple of others, brand name vioxx.
Speaker C:These were Cox 2 specific targets.
Speaker C:So there's a whole lot of science going on looking at the benefits of narrower COX inhibition.
Speaker C:They found.
Speaker C:This is a little bit of a long answer to story, but he found a link between Her2 activity and Cox2 and because of that, I think he found his way to our team and was introduced to me.
Speaker C:But the broadening the lens, I have to introduce one other subtlety here.
Speaker C:There is this long standing paradox in breast cancer.
Speaker C:Why is it, if the majority of breast cancers are hormone receptor positive and driven by estrogen, we think, and the incidence of estrogen receptor positivity, if anything goes up with age, older women are more likely to have a hormonally responsive breast cancer than the younger ones, who typically have what we call triple negative.
Speaker C:Now, there was always this fun little riddle game you could play on rounds with residents and fellows.
Speaker C:It could take the whole afternoon.
Speaker C:Why then is the incidence of this breast cancer driven by estrogen higher with age?
Speaker C:In particular after menopause, when your peak exposure to estrogens have fallen?
Speaker C:It's just.
Speaker C:And there's no simple answer, obviously.
Speaker C:However, there's a second link that has become very clear in the last few decades as the challenge of obesity has become so ubiquitous in the west.
Speaker C:In General, led by America.
Speaker C:But we're not alone in this.
Speaker C:And that is rising incidence of some of the most common epithelial malignancies, breast being one of them, prostate being another, colon cancer being another, and there are others.
Speaker C:So those are two little bits of background.
Speaker C:So Andy and I was a clinical, if you will, liaison to the lab.
Speaker C:I'm not a laboratory scientist, but I went to the lab meetings every week for years and I provided clinical relevance.
Speaker C:For example, a very simple one is if you're going to study induction of mouse mammary tumors, how do you do that in a menopausal context?
Speaker C:Because mice don't have a natural menopause, it turns out.
Speaker C:So that was a simple reason to do oophorectomies in the mice and make sure that we were creating a more accurate model.
Speaker C:There were lots of those things.
Speaker C:So the, the short version of all this is that over time we made, I think, two related discoveries.
Speaker C:The first is that in white adipose tissue, once the cells, the adipocytes become significantly large or sufficiently large, eventually they ask for their ability to survive a nutrient supply and they die.
Speaker C:And when they die, they induce appropriately, phagocytosis.
Speaker C:The macrophages gather secrete enzymes and induce other often immune active cells to join the party, if you will.
Speaker C:You could visualize these things.
Speaker C:They're visible in the white adipose.
Speaker C:They're called crown like structures.
Speaker C:They've been described for years to diabetes docs and others had described them.
Speaker C:We didn't discover them.
Speaker C:All we did is highlight their existence in white adipose.
Speaker C:Interestingly, we also could see them often in people who had an obese physiology without being obese by bmi.
Speaker C:The reason all this matters, and to tie up this long story is a fairly straightforward signaling cascade activates aromatase when this inflammation is present, I. E. Obesity could be associated in a biochemical way with increased activation of the gene that produces estrogen.
Speaker C:So then you have at least a plausible link between a common problem, obesity, and a disease that has a somewhat enigmatic link to age and obesity, which is postmenopausal breast cancer.
Speaker C:The last part of this is getting ahead of the story, but it relates very much to how I ended up at asco.
Speaker C:Is it's just another example in the end that public policy and public health are really ultimately important levers for us as oncologists to be thinking about.
Speaker C:Right.
Speaker B:It certainly widens the aperture and one can have a tremendous amount of impact pulling back a little bit and looking at the entire ecosystem.
Speaker B:Speaking of asco, you were quite engaged with ASCO even before stepping in as a CEO.
Speaker B:In fact, you became ASCO president during its 50th anniversary.
Speaker B:And can you walk us through that, your engagement with ASCO and leading to the role as the ASCO president?
Speaker C:Well, a couple of things again came together.
Speaker C:The first was Larry Norton's exposure to all this.
Speaker C:And Larry, he would say these things over and over again, but a place like Memorial, and I think this is true at MD Anderson, Mayo Clinic, in the Harvard system and elsewhere.
Speaker C:You'll recall Joe Simone.
Speaker C:And Joe Simone wrote a book later in his life that were rules about how to survive in academic medicine.
Speaker C:And a couple of those rules were important, but one of them was these were two that related.
Speaker C:The first is the institution doesn't love you back.
Speaker C:And the second is that you're only as valued at your institution as they believe you're valued outside.
Speaker C:So that's background.
Speaker C:What Larry came from the Cooperative Group system, which was a jewel of the nci, if you think about it, that was fundamentally the system in the pediatric world that gave us the transformation of acute lymphocytic leukemia in children.
Speaker C:It gave us the rapid evolution of breast cancer, care of lymphomas, and so on.
Speaker C:The cooperative Group system was remarkable.
Speaker C:But for a guy like me working inside the big thick walls of Memorial, Larry's engagement with the CLGB dragged me out into the world and gave me this exposure to lots of other people.
Speaker C:That's how I came to know Eric Weiner, for example, so closely, is it was our shared role in the clgb.
Speaker C:So I say that because I developed, I think, the habit of saying yes to external networking opportunities.
Speaker C: hich I think think was around: Speaker C:There was a competition.
Speaker C:I remember some of the famous names in breast cancer medicine came and looked at the job.
Speaker C:Probably none of them would come and work for Larry.
Speaker C:But be that as it may, I ended up with the job as the internal candidate.
Speaker C:And every time I was asked to do something with the clgb, with the nci, with the NCCN that was being founded in those days with the asco, with AACR didn't matter.
Speaker C:I was asked.
Speaker C:I just said yes and overextended myself.
Speaker C:I found a home with ASCO because it sits at that for me a sweet spot of clinical relevance, translation, practicality, but also cutting edge science that matters for patients.
Speaker C:And I worked my way up.
Speaker C:I just had good fortune as a reasonably well known breast cancer doc to prevail in the election and win a seat on the board.
Speaker C:The unpredictable thing is at that time ASCO used to elect the treasurer directly.
Speaker C:So the board had whatever number of seats it had, it had the president, but it also had an assigned role as treasurer.
Speaker C:And it was just luck again that I was elected into that seat.
Speaker C:Which meant that for my first three years on the board, I was part of the leadership team and I was mentored by the cfo.
Speaker C:And that gave me a one on one mini unprofessional MBA if you will, in how the professional society worked.
Speaker C:And then I stood for president, which was a three year term.
Speaker C:It was president elect president and past president.
Speaker C:And you're exactly right, it was by happenstance the 50th anniversary.
Speaker C:So I had the good fortune to spend six years sequentially on the board, which is not something that would normally have happened.
Speaker C:And by then I was just thinking about new and different ways to make an impact.
Speaker C:And I was in my mid-50s.
Speaker C:And so when my predecessor, Alan Lichter, decided that his time as CEO 10 years was enough and it was time to move on, I threw my hat into the ring.
Speaker B:Sure.
Speaker B:Going back, Cliff, to your role as fiasco president, I noticed that your presidential theme was science and society.
Speaker C:Yeah, how quaint.
Speaker C:We thought that there was a problem then between a divided population and poll.
Speaker B:Right.
Speaker B:You were ahead of your time because that phrase feels even more relevant today.
Speaker C:You know, it felt so sincere to me.
Speaker C:So I'll tell you what that was about for me because it's still relevant.
Speaker C:And maybe in the end there's some optimism here.
Speaker C:There was a period of time, you may or may not recall it, through multiple Republican and Democratic administrations, when in dollars, the NCI and NIH were flat funded for the better part of a decade.
Speaker C:And what that meant over that decade is that the organizations that we rely on to drive scientific progress and clinical progress in America were essentially facing in the end a 25% cut because of the inflation and the loss of purchasing power.
Speaker C:And I was on the Government Relations Committee at ASCO at the tail end of that.
Speaker C:And I remember knocking on doors, House, Senate, Republican, Democratic, and just asking the simple question, when did we decide to cede scientific leadership to others?
Speaker C:And you can name who they'd be.
Speaker C:China, looming, but small countries that were investing heavily, be it Israel or Singapore or what have you.
Speaker C:The real question was, why would America decide to give up this leadership?
Speaker C:And again, I think, I don't know precisely who listens to this podcast, I think you have a sophisticated audience, but the American investment in the NIH and the NCI to this day are unmatched.
Speaker C:Not close.
Speaker C:There's no government that comes close to this level of multi year commitment and this substantial infusion of funds.
Speaker C:So these are jewels.
Speaker C:And I was mad.
Speaker C:Why were we giving this up?
Speaker C:But the good news, fast forwarding a little bit.
Speaker C:But by the end of the Obama administration, especially the second one, we had, of course, the moon, the moonshot and the, and strong, unremitting, steady to this very day, bipartisan support for at least adequate funding at the NIH and at the nci.
Speaker C:And this is held steady.
Speaker C:And so the reason I highlight that is I remember in my 30s and 40s feeling pretty cynical, like many people about government.
Speaker C:I have a different point of view right now.
Speaker C:There's lots to be worried about, there's lots of reason for suspicion.
Speaker C:However, with time, concerted coordinated effort and I mean, yes, asco, but aacr, acs, can, AACI and many other organizations, both in oncology and more broadly across medicine, banging on doors on the Hill and basically asking for the exact same thing in a consistent fashion, we have achieved a degree of steady support and we saw it play out this year.
Speaker C:I won't get into politics, but I'll just point out that there was a multi hundred million dollar increase in the final NIH budget through appropriations in January this year and that reflects in a modest bump even for the nci.
Speaker C:And in these times that's pretty remarkable testimony to strong bipartisan support.
Speaker C:So all this to me was a reason obviously to be at asco, to play one small part in this huge multi year effort.
Speaker B:So if you were to define science and society today, would the definition be the same?
Speaker C:Well, so yeah, I think the problem's the same.
Speaker C:But I lost my own thread here because I forgot that we were really starting with that.
Speaker C:What really pissed me off when I was coming into the ASCO presidency was, forgive me, the teaching of unscientific methods to explain the evolution of our existence, the belief that there could be magic instead of science.
Speaker C:And the one thing, I'm not much of a scientist, but there's one thing I believe to my core, and that is that magical explanations will never ever be the right ones for how human physiology works or the rest of it.
Speaker C:And so I thought that we needed to make sure that patients understood at that time the remarkable impact that our investment in science has had.
Speaker C:And they needed to be brought to us as strong allies.
Speaker C:And we see lots of that.
Speaker C: overall progress from the mid-: Speaker C:No, I couldn't have imagined some of the pushback against scientific progress that we are having to confront today.
Speaker C:I will say it's not a fight.
Speaker C:It's a question of an engaged, informative dialogue to help people understand that there are reasons that people have been angry at mainstream science and mainstream medicine.
Speaker C:There are reasons.
Speaker C:There is a kernel of legitimacy in some of the complaints.
Speaker C:But that does not, in the end, change the truth of science.
Speaker B:Right.
Speaker B:I agree.
Speaker B:You know, looking back, I had the opportunity to engage with Harold Barbas when he was leading the nih.
Speaker B:I was a pre doctoral fellow at nci, and I, I think, used to talk about his experience majoring in English and literature and the fact that his ability to communicate is one of his secret weapons.
Speaker B:And I believe during his tenure, one of the reasons that he managed to increase NIH funding was his ability to translate very complex topics.
Speaker C:He could tell a story.
Speaker B:Right, Exactly.
Speaker B:He could tell his story.
Speaker C:You know, I just have to say.
Speaker C:Cause you mentioned that I had the privilege of working for him as well.
Speaker C:He was, of course, the CEO and president of Memorial for a while.
Speaker C:And to his credit, you know, one of the things he did early in his time is he called me up and he came one morning, just one morning, and sat in my clinic as an observer while I saw patients.
Speaker C:And I really appreciate it deeply that he took a minute to do that, because he was never a practitioner, he was an M.D.
Speaker C:But of course, he was strongly committed to science throughout his career.
Speaker C:But he understood that in the end, all of our institutions and the whole house of medicine is dependent on clinical patient interface.
Speaker C:And he wanted to see it in the flesh, I think.
Speaker C:And I think it informed him.
Speaker C:And I'm sure he did it with many others.
Speaker C:I assume I was not the only person he did that.
Speaker B:Yeah, makes sense.
Speaker B:Cliff, you succeeded Alan Lichter, as you mentioned, as the CEO of asco.
Speaker B:What was the transition like going from being a clinician scientist to the CEO of a very large and complex enterprise?
Speaker C:So, first of all, I will say I had the hubris to think I could do it.
Speaker C:It would be no big deal.
Speaker C:That was incorrect.
Speaker C:But I think, and I've said this before, I think for those of us, and you're in the same boat, who have clinical training and have worked in academic or clinical medicine, who then take on any kind of a meaningful business role, I actually think medicine is a pretty good training ground for business leadership.
Speaker C:The transition for me was, I think, at the same time surprising and unsurprising.
Speaker C:What I mean is there was, I thought I could navigate the business aspects of running a 500 person organization on my own.
Speaker C:I never could have, but I was really fortunate because Alan had put in place both a structure and staff of talented people who could support me.
Speaker C:As I learned at a rapid pace and continues to this day.
Speaker C:Leadership is a team effort as far as I'm concerned.
Speaker C:And the infrastructure was really all there, thanks to Alan.
Speaker C:And I think at the same time, I learned quickly that unlike medicine, you don't really have to issue stat orders.
Speaker C:There's time to think and reflect.
Speaker C:And part of that, you know, it's like level layers of the onion.
Speaker C:Decisions have impacts and sometimes in, in medicine, pushing a drug, invoking a procedure, ordering a test, you just do it and then whatever happens, you have to deal with.
Speaker C:But I think in our situation, outside of the acute clinical situation, that is, one has to think about repercussions on people, on programs, and sometimes it's complicated.
Speaker C:Almost as I say, three dimensional chess that you're playing.
Speaker C:The luxury is that you can take your time to think a little bit about that.
Speaker C:And I'll just close by saying this.
Speaker C:There's no universe in which I was qualified on my own to run that organization.
Speaker C:But there is a universe where the organization, the institution, was so strong because of what had been put in place there that it could tolerate a neophyte like me and bring me along.
Speaker B:Well, whatever infrastructure was in place, Cliff, you had to drive the organization towards remarkable evolution because so much happened in the next few years after you stepped into the role of the CEO at asco, Oncology essentially moved into a new world with immunotherapies, targeted therapies.
Speaker B:And then the pandemic happened.
Speaker B:Rising cost pressures and now AI.
Speaker B:So you've had to pivot a lot since you joined asco.
Speaker B:Which one of the shifts that you've experienced during your tenure do you think demanded the deepest reinvention of ASCO itself?
Speaker C:Well, it's interesting you ask because I think a lot about.
Speaker C:I'm at my tenure mark right now and every year is different.
Speaker C:In fact, every week is different.
Speaker C:That's one of the interesting things about the role.
Speaker C:There is a pattern to what we do, but the topics, the discussion, the issues, they're constantly evolving.
Speaker C:When I first got to asco, we were coming off of, I don't know, two decades, a decade and a half of pretty Remarkable growth.
Speaker C:We had gone from a small organization founded by physicians to ultimately a self managed organization.
Speaker C:We had grown from 20 staff to hundreds.
Speaker C:We had developed several linked organizations.
Speaker C:All that happened before I got there.
Speaker C:When I walked in the door at asco, there were, I don't know if I remember the numbers exactly, but let's just say 16 departments, 16 direct reports.
Speaker C:To me there was not an overarching single strategic plan.
Speaker C:There were plans for various programs.
Speaker C:And I was not smart enough to juggle all those balls, keep all those plates spinning in the old Ed Sullivan show way.
Speaker C:And so I ended up spending the first time, year and a half, without wanting to be a bull in a china shop, gently but steadily reorganizing the leadership and the structure.
Speaker C:So we built an executive leadership team by de facto, without calling it that, engaged in strategic planning.
Speaker C:And then when the time was ripe, essentially established formally this new layer beneath the CEO reporting to me, so that I now had six or seven, depending on the time, direct report supports with them having departments that were relevant and associated in their challenges.
Speaker C:So that was one transition Covid hit, obviously, just a few years later.
Speaker C:And this is interesting because I think the organizations across the organized medicine organizations, that is, that were led by physicians probably had a little bit of an advantage.
Speaker C:We all saw this coming.
Speaker C:We were talking about it.
Speaker C:You and I can remember January and February of that year.
Speaker C:And because of that I knew that we were going to close.
Speaker C:I knew that we were going to go home and not come back.
Speaker C:And I can remember this vice president and I should say ASCO had a very forward looking structure that I inherited.
Speaker C:We had what was called a results oriented work environment, which meant that most of the staff were not necessarily expected to be physically present in the office nine to five, five days a week.
Speaker C:They were expected to get their work done and held accountable as adults or as many CEOs or whatever.
Speaker C:That made it much easier for us to pivot to remote work than many other organizations.
Speaker C:It no longer distinguishes us because I think the whole world has fundamentally shifted to that kind of a structure now with us still struggling nationally to get people back to the office.
Speaker C:But that pivot was huge.
Speaker C:And I remember suggesting to everybody that we have a test day.
Speaker C:It was Friday, March, I think, 13th, that we have a test day because we would come back on Monday.
Speaker C:I knew we weren't coming back by then, but they, you know, it was just so interesting because the staff and I talked about it on Tuesday and Wednesday of that week, said reluctantly they would give it a go.
Speaker C:And that was the last day.
Speaker C:So that was, that was for sure, for all of us, a huge challenge.
Speaker C:Because of course, behind the scenes for us as running this large meeting every year, the loss of our annual meeting was an existential challenge, to be sure.
Speaker C:And despite our technical prowess, the conversion to all remote for the next year and a half challenged our ways of working and our productivity, I think, in ways that you couldn't necessarily see and might not be measured.
Speaker C:But it was a real challenge, I think.
Speaker C:The other big thing, of course, was, as you say, the most recent wave of AI.
Speaker C:And in the background is all of the scientific progress.
Speaker C:I wouldn't say that immunotherapy or precision oncology or any specific intervention is necessarily such a big challenge for an organization like asco.
Speaker C:It's the thing we're teaching about now.
Speaker C:It's the subject matter of educational programs and scientific abstracts.
Speaker C:And they will continue to evolve.
Speaker C:They evolve across diseases, as a matter of fact.
Speaker C:So some years breast cancer has a lot going on.
Speaker C:Other years melanoma has a lot going on or whatever.
Speaker C:So those aren't the, those aren't the organizational level challenges for us.
Speaker C:That's more like business as usual.
Speaker C:Thank God.
Speaker C:That's right.
Speaker C:Well, thank God there's always some new science and always some new modality and some new.
Speaker C:Some of this exciting technology, be it ADCs or one of these days, broad solid tumor use of car ts, whatever it is.
Speaker C:That's us doing what we do, right, distributing knowledge, education, contextualizing it.
Speaker C:These other things are real pivots.
Speaker C:AI that we're living through right now is for sure a real pivot for all of the economy, including us.
Speaker B:Cliff, you have a very intimate view into the world of oncology as it's implemented on the ground.
Speaker B:The point of routine care.
Speaker B:And obviously that can be far removed from the scientific enterprise of cancer drug development, let's call it.
Speaker B:So are there gaps that you see having a frontline view into the point of routine care and how oncologists think and practice and the challenges that they face and the science that's evolving so rapidly.
Speaker B:Do you see a gap?
Speaker B:If so, how would you characterize it?
Speaker B:And do you think that that gap is actually shrinking or growing?
Speaker C:Well, I don't have a way to quantify it.
Speaker C:I'm optimistic that the gap's going to narrow, and I think it is because of AI, but I think it's because I think AI is going to become the support tool that is a forcing function for the delivery of optimal care.
Speaker C:In more environments, to more people.
Speaker C:And so let me explain what I mean.
Speaker C:I think going back for several decades there have been data and I'm often challenged when I cite this.
Speaker C:So if we need it, I'll find that prostate cancer reference.
Speaker C:But I think it was at some point in the VA system in recent years where it was proven that so long as all men had access to current standard of care for prostate cancer, the outcomes were the same.
Speaker C:And the reason I mention that is that that demonstration undoes the argument that there are certain demographic populations or others who have some inherent reason for worse outcomes.
Speaker C:Simplifying this, it looks like you could.
Speaker C:It's been estimated that you could make a 15 to 20% improvement in cancer mortality.
Speaker C:Simplify simply by making sure that all patients everywhere, but let's just say in the US for this discussion, receive current known optimal standards of care.
Speaker C:That's not a science problem, that's a distribution and access problem.
Speaker C:Right.
Speaker C:Why are some patients in some circumstances not getting it?
Speaker C:One of the reasons, but not the only one, because there are other structural reasons, is the dissemination of knowledge, the core function of a professional society like asco.
Speaker C:And here's where I'm really bullish optimistic on AI.
Speaker C:So before we started recording, I think you were mentioning your level 2, probably it is autonomously driving car.
Speaker C:I use this analogy all the time because where I think we're going to end up soon isn't a world where every oncologist has to be an expert at various LLMs and the deployment of AI.
Speaker C:I think that AI is going to more resemble 120 volt electricity and running water.
Speaker C:It's going to be in the walls.
Speaker C:You're going to utilize it often by choice, but often without thinking about it.
Speaker C:So take your car.
Speaker C:If you weren't auto, you know, didn't set the cruise control in your car, but you were simply driving.
Speaker C:I'm pretty sure that what I'm about to say is correct.
Speaker C:You have the sense that you're autonomously controlling that Tesla.
Speaker C:I believe this is a car you have.
Speaker C:But should you fail to pay attention for a few moments and start to drift out of the lane as you approach the broken white lines, what does that car do?
Speaker B:It beeps.
Speaker B:It alerts you.
Speaker C:Right?
Speaker C:My car steers me back into the center of the lane.
Speaker B:Oh, and that too, right?
Speaker B:Yes.
Speaker C:I have to deflect when I set the cruise control in my car.
Speaker C:It's not as high tech as a Tesla.
Speaker C:It will self drive, maintain a safe distance, steer around curves as long as it feels my finger on the steering wheel.
Speaker C:If I look away, it's not.
Speaker C:It's not going to allow me to look away and it doesn't allow me to take my hand off the wheel for more than some variable amount of time depending upon speed and so forth.
Speaker C:But it is self driving to a large degree.
Speaker C:The point is, I think we have to start to imagine the electronic medical record and clinical care that same way.
Speaker C:So I think that we will have what looks and feels like autonomy, order tests, order treatments and so forth.
Speaker C:And when we're doing it in a way that's concordant, we will believe we are autonomous.
Speaker C:And when we are drifting out of the lane, we will get firm knowledge.
Speaker C:I think that's going to allow us to deliver more consistent, higher quality care in the not so distant future.
Speaker C:The other thing I have to add, and you did not ask this yet, you might, but I actually think it's a reason for real optimism is that I think this kind of support is going to be the transformation that we've been waiting for for literally 20 to 25 years in the digital world, which is, I think that this will allow docs to be more humanistic in their time with patients.
Speaker C:Because so much of the scut work that we have spent our decades doing will become the output of the machine rather than us.
Speaker C:We have to see it, we have to read it, we have to edit it, we have to know what's in it.
Speaker C:But there's a lot of work that's time consuming.
Speaker C:I lived through my former institution's transition to epic.
Speaker C:EPIC is a great medical record system.
Speaker C:I have no complaints about it.
Speaker C:But to be good at it, you have to use it a lot.
Speaker C:And its potential to support this kind of improved outcomes I think is not even remotely tapped yet.
Speaker C:But coming.
Speaker C:So that's the big transition.
Speaker C:ASCO launched ASCO's AI journal recently.
Speaker C:I don't know that there's going to be a long lifespan for a publication like that.
Speaker C:I think it's hand holding for our community, it's guidance for our community.
Speaker C:It's a platform for now.
Speaker C:It strikes me that it'd be like a journal about indoor plumbing.
Speaker C:In another 10 years, who's going to care, right?
Speaker B:So you're envisioning AI becoming a utility, basically, and also by extension, you are essentially painting a very interesting picture of a symbiotic relationship between AI and clinicians in this case.
Speaker B:So, Cliff, what is ASCO doing?
Speaker B:You already mentioned the journal to essentially engineer that symbiotic relationship.
Speaker B:I know that You've done very interesting work around the ASCO guidelines.
Speaker B:Can you tell us more about that?
Speaker C:Yeah.
Speaker C:So I think again, everything is moving fast and you alluded to that this is a pivot.
Speaker C:So one of the most popular and important products that ASCO's volunteers create are the guidelines, which are the amalgamation of the experts opinions about how to take all of the clinical science that we hear about on a constant stream and convert it into practical, usable guidance for the care of patients.
Speaker C:So we're not the only ones that do this.
Speaker C:NCCN does a fantastic job.
Speaker C:Actually.
Speaker C:I was on the breast committee for the NCCN for years before I came to asco.
Speaker C:It's a really valuable resource if there's a difference.
Speaker C:The NCCN guidelines are far more complete than ASCO's.
Speaker C:They're far more flexible in a lot of ways.
Speaker C:But the ASCO guidelines are deeply researched academic products.
Speaker C:So if you look at NCCN guidelines, it's pretty common for the ASCO guidelines to be cited in the nccn.
Speaker C:And that's rightly so that they're really complementary or they, they can be.
Speaker C:All of that said, with this revolution in AI, which again I, I'm an optimist about this, it became very quickly apparent to all of us that the old way of producing guidelines as bespoke, painstakingly constructed three to five thousand word documents, nine to eighteen months production time, that this is just not going to work.
Speaker C:Because if a paper is published in the New England Journal on Monday, whatever the day they come out, many clinicians expect that they're going to find that and have it contextualized for clinical care by Tuesday.
Speaker C:And they're right to expect that.
Speaker C:They're not wrong.
Speaker C:So we embarked on what turns out to be a pretty dramatic transformation of the entire guidelines program at asco.
Speaker C:We started because we had the good fortune to collaborate with the folks at Google Cloud who like everybody, look at our big problem and think it's a nothing problem because they think They've solved this 20 times before in much larger scale.
Speaker C:But they were fantastic for us because the culture of rapid testing, evolution, redirection and accountability that Google brought to us, it was so interesting to me.
Speaker C:I just have to say, we thought, if you will, that we were the client and they were providing service.
Speaker C:But within about five minutes the tables were turned on us and they were driving ASCO staff to perform up to their, to up to them and deliver to them on a two weekly basis.
Speaker C:So what we imagined first was our members complained rightly that it was hard to find the content of our guidelines.
Speaker C:So Sean Cozen on a given Tuesday at 3 o', clock is seeing somebody with non small cell lung cancer.
Speaker C:They believe there's an ASCO guideline and they want to find it.
Speaker C:What are they doing?
Speaker C:They're going to Google search box and hoping they get a hit with the right guideline.
Speaker C:A person looking at breast cancer who wants to know what the ASCO guideline is for the completion of an axillary dissection in early stage breast cancer might look at a list of ASCO guidelines and there might be three or four different guidelines by title where that information might appear.
Speaker C:And those guidelines, by the way, might be 1, 2, 4, 6 years old, who knows?
Speaker C:So Google built a version of their Gemini chatbot, if you will, constrained in the following ways.
Speaker C:I'm oversimplifying, but it was important.
Speaker C:Number one, it would only read from our material.
Speaker C:Number two, remember in the earliest days there was a lot of worry about hallucination.
Speaker C:I think this is starting to fade and we knew it would, but at the time we needed to program it.
Speaker C:So there's essentially a rheostat between absolute fact and creativity that we had to dial all the way to absolute fact.
Speaker C:So if you ask it, for example, what is the correct dose of ivermectin for colon cancer, it says ASCO does not have a guideline on that topic.
Speaker C:It doesn't invent an answer.
Speaker C:And so number two, because everybody was so cautious and suspicious about all of this, every single line of the answers it gives are referenced.
Speaker C:And there's a second window in our tool that they built for us that shows you the source material, highlighting the data was produced so you know whether it was current or not.
Speaker C:And in yellow, highlighting the specific text that supports the answer.
Speaker C:The idea being that you shouldn't rely on the chatbot's answer to your question, but you should find it easy to see the source and then integrate it.
Speaker C:Now, I have to say for all of that, the cultural shift and the teaching that we got from it was what it was really worth.
Speaker C:I don't think the product can have a long lifespan in this world because I think our community is going to use broad commercial tools like Doximity, Open Evidence and others.
Speaker C:They are going to be the go to.
Speaker C:I think last I heard, Open Evidence, for example, had something like three quarters of all American docs as users.
Speaker C:So the benefit for us was it changed our way of thinking and it highlighted for us the importance of part two.
Speaker C:Part two is that all of our guidelines have to be dynamic and up to date all the time.
Speaker C: ate cancer question and get a: Speaker C:So we piloted last year the creation of a.
Speaker C:They're called living guidelines.
Speaker C:That's terminology in the guideline world, but from a practical sense, you could call them dynamic, which is to say always tested and updated on a regular cadence.
Speaker C:Right now, I think our lung cancer guidelines, non small cell divided into driver, those with driver mutations, those with that, I think those guidelines, none of them go more than eight weeks now without assessment.
Speaker C:They either are left alone or updated every eight weeks to make sure they're current.
Speaker C:But our ambition is to convert the entirety of the guidelines program to that format by the end of this calendar year.
Speaker C:I don't know if we'll make it, but we're going to be close.
Speaker C:And so the output of the ASCO Guidelines Assistant in the end is just higher quality, more current guidelines.
Speaker C:And our vision is that they will be fed out into this broader ecosystem for everybody to license.
Speaker B:Right.
Speaker B:Well, it's clearly a highly valuable data asset per se, because combing the universe, the Internet, for data relevant to treatment decisions is hit or miss, depending on what you pick up.
Speaker B:So I think even moving forward, for the world of AI model development, having access to the type of expert driven and vetted information and data is critical.
Speaker B:As you know better than I do.
Speaker B:Cliff, I read somewhere that you have characterized the guidelines assistant as a discovery tool versus a clinical decision support tool.
Speaker B:Is that true?
Speaker B:And if so, what do you mean by that?
Speaker C:Yeah, so that's what I described.
Speaker C:We certainly would never say, and we, I think, I'm sure we have disclaimers on it that you can use the answers it gives you to guide it helps you discover the source in the form of our guidelines.
Speaker B:Makes sense.
Speaker B:So you don't want to do the thinking for the oncologist.
Speaker B:You present them with the information.
Speaker C:Right.
Speaker C:I don't think we're ready for that.
Speaker C:And I think in the early days, the oncologists should, and they certainly still are, very suspicious of the answers they get.
Speaker C:But in the end, I just don't think in a modern workflow somebody's going to interrupt their day living in the epic or whatever ecosystem oracles that they're in and then go pull in the ASCO tool to double check something.
Speaker C:I think as these become successful, they're going to end up integrated into the existing ecosystem, that's my guess.
Speaker B:And if we do Everything, right.
Speaker B:It seems like you painted a picture for us that we can, in a way, I'm paraphrasing, liberate clinicians, physicians, oncologists from the mechanics of the enterprise.
Speaker B:You know, flipping pages, trying to find the right information, checking boxes, doing billing codes and so forth.
Speaker B:So how far?
Speaker C:I'm very optimistic.
Speaker B:When do you think we're going to be there?
Speaker B:And are you getting signals from your membership oncologists in the trenches that they are actually finding AI today useful in terms of decompressing themselves so they can focus more on the patient?
Speaker B:Are we there yet?
Speaker C:Right now it's anecdotal, but I can share an anecdote.
Speaker C:I'm on a board of a university that has a medical school and we had a presentation scheduled at 5 o' clock in the afternoon from a senior leader in the internal medicine or family medicine department.
Speaker C:I can't recall now.
Speaker C:And it was his clinic day, and five minutes to five, he logs onto the Zoom for this executive committee call.
Speaker C:And as he's starting as a small enough crowd, I just jokingly asked, I said, I'm kind of surprised you had clinic today and here you are on time for this call.
Speaker C:How'd this happen?
Speaker C:He stopped and he said, For three, 20 years, I would have missed this call.
Speaker C:He said, we rolled out.
Speaker C:I'm going to name a product a bridge in our epic medical record system.
Speaker C:Several months ago, I was reluctant to do it because, you know, it listens to the clinical interaction and it generates an epic note that you then proofread and sign.
Speaker C:He said, in the last few months, using a bridge, I have become an on time doctor for the first time in my career.
Speaker C:If they turn off a bridge, I will quit.
Speaker C:That's just an anecdote, but I've heard it.
Speaker C:I've heard it from ASCO members and others.
Speaker C:Now there are many who, when I talk about this, their first reaction is, I don't have the time, I can't learn it, I haven't done it.
Speaker C:But almost all the clinicians who have started to use that kind of listening software, which uses AI to generate the notes.
Speaker C:Almost all of them report very positive experiences.
Speaker C:This is not like the earlier generation of dictation software that many of us grew up on.
Speaker C:This is something operating at a higher level.
Speaker C:This is one part of the product.
Speaker C:You know, what about prior authorizations being generated?
Speaker C:What about interactions with order entries so that you get automatically generated order sets that you then proofread and sign?
Speaker C:I just think the opportunity here to streamline and reduce errors is so profound.
Speaker C:All of which gives the doc the ability to sit and put a hand on, you know, the, on.
Speaker C:On the back of a patient and, and really be there as a.
Speaker C:As a healing physician.
Speaker C:So this is why I am really optimistic about healthcare and the delivery of high quality care being supported and made better through this moment.
Speaker C:I just think it's really the possibilities there.
Speaker C:I may not turn out to be right.
Speaker C:Can't predict.
Speaker B:No, I hope you're right.
Speaker B:And if we do everything thoughtfully, I think that world would be possible.
Speaker B:And in a way, Cliff, we would be going back to the future when again, the therapeutic bond with the patient was so strong.
Speaker B:Maybe one day we can start making house calls again.
Speaker C:I never stopped.
Speaker B:Cliff, this has been a fantastic conversation.
Speaker B:I have one final question.
Speaker B:When you think about the next generation of oncology leaders, what capabilities do you think matter the most for them?
Speaker B:What do you think?
Speaker B:Essentially they need to understand that earlier generations may not have had to master.
Speaker C:In which domain of leadership do you mean?
Speaker B:I think to be an effective.
Speaker B:That's a great question.
Speaker B:I think to be.
Speaker B:Maybe we can divide it into being an effective clinician taking care of patients and an effective leader driving an enterprise forward.
Speaker C:Yeah, I think they're a little different.
Speaker C:I think, you know, organized medicine.
Speaker C:As I started to formulate this sentence, I found myself laughing because I was about to say has gotten more organized and somehow on the ground it doesn't feel like that, but it certainly has gotten more structured in ways that can be a challenge for clinicians and leaders to navigate.
Speaker C:So I think that from an enterprise side, I think the more clinicians take advantage of opportunities to learn the basics of business, which really are the same as the science that we would learn in biology or elsewhere.
Speaker C:There are rules, there are consistent outcomes that people should understand.
Speaker C:I think that's really useful.
Speaker C:You remember that there's a leadership development program at asco and to some degree it answers that need, but the scale isn't there to do it for all the hundreds and thousands of people who really need that exposure on the clinical side and the science side, I actually think the most important thing is enthusiasm, curiosity, and to suppress the cynicism, because if you think about the conversation that we're having, we have lived through, certainly I've lived through, and you're younger than I am, but I'm now, I hate to say this, this is mortifying to me, but for me it's four plus decades of life as a physician.
Speaker C:Right.
Speaker C: duated from medical school in: Speaker C:So that's 43 years ago.
Speaker C:The world has changed dramatically.
Speaker C:There's been a tremendous amount of turmoil and yet the promise of the near and long term future has never been greater.
Speaker C:That's always true, but it's only going to be realized if people believe it's possible.
Speaker C:I want to close with something.
Speaker C:I thought about this before you interviewed me, and I don't deserve any credit for this, except that I listened.
Speaker C:Albert Bourla, the CEO of Pfizer, was interviewed by, I think a reporter, I guess, at Fortune magazine in the last month or two, I can't remember, a relatively short podcast of 10 or 15 minutes.
Speaker C:In this he was asked about his career and leadership.
Speaker C:And he said something that is obvious.
Speaker C:Self evident, I think, and true, but worth repeating because you asked about qualities of a leader.
Speaker C:He said really smart people always will identify all the reasons that something you propose isn't going to work.
Speaker C:And he said this.
Speaker C:It's important to point this out.
Speaker C:You they will usually be right, he said.
Speaker C:However, interestingly, people don't follow that.
Speaker C:They follow the visionary who could imagine a better tomorrow.
Speaker C:And even though they're going to be wrong most of the time, they're going to keep fighting for it and people are going to keep following them.
Speaker C:And I don't know that I necessarily fall into that phenotype, but I aspire to, and I think that's something that people should be thinking about.
Speaker C:You can find 50 reasons that things are going to be bad and get worse, but that's not actually what's important.
Speaker C:What's important is to recognize all those and still find some way to make things better.
Speaker B:Well, on that note, thank you so much for your time.
Speaker B:This was a great conversation.
Speaker C:Thanks.
Speaker C:Sa.
