Dr. Raza to bring the patient back front and center into every conversation about cancer. To look at everything we are doing in the cancer paradigm through the prism of human anguish. And let everyone see what are the human costs of pursuing cancers to the last. Susan your book readers will find an interesting mix. It has poetry, patients stories and a lot of technical and clinical analysis in it. What were you thinking . Who is your intended audience . Dr. Raza it was not so much the audience but the way i was trying to tell the story. First, i was only going to write about my patients with nothing personal but once i told the stories in deep, granular detail, i felt dishonest holding back my own. Somehow, there was a level of insincerity in going into the depths and profundity of patients feelings and anguish of families without talking about my own. And then i started thinking about my own. Susan what does poetry do for you . Dr. Raza yes, i felt a cleavage in my mind as if my brain was split. I tried to match it seam by seam but could not make it fit. One thought joined to the thought before. A sequence, out of reach like balls around the floor. Why did these few lines speak volumes to me . Because when i am facing a patient, whether it was my own husband who was at the Cancer Center and in a cruel twist, he was diagnosed with the cancer that he had spent his life fighting since the age of 15 or whether it was sitting across an examination room from a total stranger who within 20 minutes will be telling me the most intimate details of their lives. When i hear those, i feel my brain is split in two because on one hand, i know pretty much what is coming their way by listening to their stories. But on the other hand, there is a wonder about the essential mystery of this individual sitting in front of me. What will their journey be like . What obstacles will they meet . And my brain was split. As Emily Dickinson describes. When you ask me what poetry does for me, i come from a deeply oral culture. The oral tradition is such that as long as we can remember, we were made to memorize poetry. Because, two lines of poetry called a couplet like two strands of dna. Within those 25 words or less is a macrocosm. The same way a few thousand strands of dna can create a protein or a sperm or an egg into what their natural existence should be. To me, there are great parallels between science and poetry. Between the double helix of dna and the lines of poetry. Susan what exactly is cancer . Dr. Raza cancer is the immortalization of a cell in simple words. It is freedom from growth controlling signals either from within itself or outside of itself. Unchecked growth for no essential purpose that it is serving except its own purpose of continuous proliferation and division. That is what we call purposeless growth and malignant growth which can set up killing itself along with the host. Susan how many kinds of cancer do we know about . Dr. Raza hundreds. And within each sorry, within each cancer there are hundreds of cancers that exist. There are infinite variations. Traditionally, we classify cancers as belonging to an organ. A breast cancer, an ovarian cancer. But there is molecular, genetic, fundamentally cellular levels. There are cancers associated with a certain genetic mutation for example. Whether it exists in the lung or the kidney. That genetic mutation could cause a cancer in each organ. We will then classify a cancer not on the basis of organs which would be selflimiting but on the basis of fundamental biologic characteristics which would lead to a variety of cancers, ad infinitum of cancers. Susan and therein lies the challenge. Dr. Raza therein lies the challenge. Susan have scientists identified the trigger point that starts the initial mutation . Do we know if it is in society or the body what starts the process . Dr. Raza it is interesting that when you trace the history of cancer which my colleague at Columbia University has done. If you look at the history of cancer, you can go back millennia and find malignant growth being discovered. And the word cancer was associated with malignant disease and what has happened to understand the origin of this very strange, alien sort of growth in the body. And only once the code for the dna was finally understood and biology morphed more towards a reductionist approach of molecular biology and then understanding genes, all of these things combined together finally began to shed a light on what really is happening at the molecular level inside these cancers. And that is when it was realized that no matter what the fundamental cause of the disease is, eventually, what has gone wrong is the messages coming out from the genes that are controlling either helping growth or suppressing growth. Something has gone wrong with one of these two types of signals within the cell. Not only is it fairly well accepted that cancerous growth is a result of the malfunctioning of the genetic messages. Susan things can trigger those malfunctions like smoking or other causes are external . Dr. Raza a third of lung cancers can be directly attributed to what we call the exosome. It is in the collection of transcribed dna that can change into a message. The message is carried to the proteins. A collection of that kind of dna is called exome. It is not just the exome. It is seed and soil that have gone wrong. Susan how pervasive is cancer . Dr. Raza a lot of numbers are thrown around but one in two men and one in three women in their lifetime will be faced with this growth. Susan how curable are they . Dr. Raza this is the good news that today we are curing 68 of the cancers that are diagnosed. Who wouldve imagined that one in two men and one in three women would face cancer . The first is the population is aging and cancer is a disease of older age. The more older people, the more cancer will occur. And secondly, we have learned to detect cancer earlier and earlier. We are finding more and more cases now. It is not as if the incidence of cancer is increasing that because the population is living longer and because of Early Detection, that seems to have gone up. You asked me if this is an automatic death sentence it used to be. The stigma associated with it. But now, we are curing practically 70 of the patients because of related section and because of the other main reason which is the antismoking campaign. Going back to your point about exposure. These are very important things because of the rich lives being saved. Susan that seems like a lot of good news so where is your frustration . Dr. Raza on the surface i should be proclaiming victory from the rooftops right now that we have gone from basically a universal death sentence as you said to curing 68 of cancers today. Only 32 of the people die. I ask a fundamental question. The people we are curing, 68 , my frustration is why are we still using the approach of slash, and burn . Why are we not finding better ways of treating cancer instead of poisoning it out or burning it out . Pediatric oncologists are forever thumping themselves on the chest. Look it what you are doing to the children. 20 80 of them will end up with problems that will make life very difficult for them. Why . Because look at what we are doing for them. The second issue of the curable population is that susan, do you know that one in five new cancers appear in cancer survivors . What is the reason for that . One reason is that whatever caused the first cancer is still there but a second one could be look at what we did to them. How much did we create by giving them poisons . Did that also contribute . That is my one frustrations. If research and all of this influx of hundreds of billions of dollars in 50 years with hundreds of thousands of the most Brilliant Minds in the world working in this area have only come up with treatment that still rely on those stone age strategies, what is the use of this research . Arthur miller, the great playwright, said something which has always stuck with me. Which is if today does not offer justification for hope, then tomorrow is the only day worth investing in. Today, if all of this money, all of this intellectual focus and attention has gotten us no other better than a few except for a few cancers from which targeted therapies dont depend on these cures, on the other hand, there are people for whom the diagnosis is not a death sentence. That would be bad enough. What do we do in that final terminal moment . That itself is something that is cause for us to pause and really think deeply about what we are doing. The primary rule of medicine is first, do no harm. What are we doing to these 22 of people for whom we know from the moment of discovery their chance for a cure is 0. 00. Susan why has the system not responded . Why do they continue to use these methods . Dr. Raza first of all, it is not for lack of trying. We have all been trying to develop new strategies. It is always easy to look back in hindsight and start pointing fingers but the first person i point a finger at is myself. What have i been doing . I have been on the front line of this whole paradigm for years. Where are my solutions . And, a couple of reasons for it are i dont want to go into a personal thing right now but i wanted to answer in a more general way why has Cancer Treatment failed so spectacularly to come up with a new solution . We pin our hopes on something for a decade and then we go on to the next fashionable cycle and i have lived through multiple cycles of great excitement followed by crushing disappointments. I will give you an example of this. In the late 1970s, early 1980s, it was all about the oncogene which is a normal gene present in our body and animals found to cause cancer in them. We realized we were getting genes that can cause cancer within our bodies. Changes in their control. We knew there was so much excitement that once we find the gene causing pancreatic cancer or others, we come up with an antidote and the solution should be easy once we have found a gene. Almost a decade to do more research but it turns out that the oncogenes are not that easy a target because in any given cancer, there are mutations in the given oncogenes. They need a lot of nutrition. How do they get nutrition and make new blood vessels . Why dont we choke off their blood supply and starve them to death . That became the holy grail in the 1990s until we discovered that we were very successful in curing mice with this approach. There are a lot of healthy mice running around new york because of that but when we tried to translate it and bring it to the bedside, it was a spectacular failure but for a couple of cancers. Mainly, that approach failed. And then we pinned our hopes on sequencing the human genome. Around the time it was sequenced, there was treatment for chronic milo leukemia. There is a chronic and stable phase. If the patient that can be targeted with one drug. This was done and this became the most successful treatment of a cancer with a targeted therapy. It grows to be a little bit of a disservice to the rest of the cancer field. Because we believe that now all we have to do is find that one gene that causes the one cancer in each organ and target it too. It turns out that no, the actual cancer cell that exists in let us say an organ like the lung or the brain or the pancreas is a moving target. It is constantly picking up new mutations each time it divides. It makes dna editors. Because cancer cells are dividing so much more rapidly, they pick up more and more mutations. Each time a cancer cell divides into two, it is making potentially two new cancers with new mutations. The complexity of cancer comes mainly from an inability and our inability to develop new therapies is because it is a very complex disease. Within the cancer cell, the signal is more complicated and distorted and intricate than the trafficking of the london underground. And it keeps changing because it is acquiring new mutations. The disease is so complex now, trying to understand it at the genetic and molecular level every single signaling. It would take a thousand years to come up with a solution and it may never be a solution for that unless we catch it when it is just starting and kill it. Susan as a lay person listening, the argument should be that researchers should continue to pursue other avenues then just those that are being investigated. Is that an interpretation of what you just told me . Dr. Raza i think that would be a harsh interpretation, susan because along the way we may be failing our patients but we are rarely successful in understanding the biology of cancer. Which is going to help the patient in the end. I am just saying it will take much longer. I wouldnt say it is always a death sentence at all. There are they have shed dramatic light on to our understanding of how cells divide. How life happens. How aging happens. It is dramatic and spectacular. The problem is none of those things have been translated into proven therapies for our patients. That is my frustration. Im not saying that this is wasted effort and money. Absolutely not. What i am saying is that and we have current patients. We cant just worry about the future. We have to worry about who has cancer now. All im saying is that my frustration comes in fact, one of the things you pointed out was why not take off our blinders and see the situation for what it is . And we need to keep understanding the biology. How should we progress in the area . On the other hand, that approach will not work for our patients that we have right now or who are coming in the future. And try to reallocate the resources so is least in the future we avoid these kinds of end stage patients that we are seeing. Susan your patients have less of a chance of surviving their disease. Tell me about what you treat. Dr. Raza i began my career actually because i have been interested in biology all of my life, since i was a kid. I started becoming a serious oncologist. And then evolution really caught my attention and i became deeply occupied by this concept of evolution by natural selection. And that led me to seriously start looking at embryology and how life comes into existence. And i wanted to become at six or 17 years of age, a molecular biologist. But in pakistan where i grew up, we did not have such an opportunity for postgraduate studies at this level at least. My only entry into science would be through going into medicine. And i reluctantly went into medicine thinking i would finish my medical education and then move on to what i really wanted to do in the lab. Except when i saw the first patient. That changed my life forever. As i knew that from that moment on, i could not look at anything except through the clinical glasses that had been provided to me. The suffering of patients and how urgent it is. And that keeps coming back to me. I will give you an example. My husband died after almost a fiveyear long battle with cancer. He was diagnosed and our daughter was four years old. When he died she was eight. Eight and a half or something. After he died, a few weeks later, my daughter who was eight years old got the flu. A really nasty one. After almost a week of suffering, she started to improve. One morning i was in the living room working early in the morning and she came out of her room sobbing. Every mother is immediately convinced that she has had a relapse and something is terribly wrong. I rushed over are you much worse . And she was inconsolable. Once she was calmed down a little, this is what she said. Actually, mom, i feel much better today. I feel totally fine. But now i know what it means to be so sick and how good it feels to get better. And my dad never got better. That is the kind of moment that makes you realize what real suffering is all about. This child, eight years old, who experienced this, the sudden insight. I felt like my eyesight and intellectual interest were suddenly given an insight by interaction with patients and direct experience of disease at that level. Once i got interested in cancer, basically, i had a choice between two things. Study a solid tumor or a liquid cancer. And why i chose the liquid cancer was because that in a solid tumor, let us say there is a tumor in the long and i wanted to study it i would have to rely on surgeons to cut it out, give it to me and god knows what small part i would get. I would have to segregate it. So much artificial things happen to the tumor. And secondly, i want to study it again and another tumor arises and it is not the same as the first tumor. Solid tumors to me were a very difficult challenge from the perspective of an investigator. On the other hand, in a liquid tumor like leukemia, cells are circulating throughout the body and you can put a needle in and get as many as you want. Or get a bone marrow biopsy periodically. And you can monitor this before, during, or after therapy you can study them as many times as you want. It became much easier to study in the lab. For all of these reasons, sorry to give you such a long answer, but the science, the obsession i had with the disease it comes because this had been developing since i was very young. And there is a method to the madness that took me to this unpronounceable disease according to my husband mylopdisplastic syndrome. Once i began to study the liquid tumors i began to study acute mylopdisplastic leukemia. I began studying and treating this kind of leukemia. In 1977i began studying and treating this kind of leukemia. By 1984, it was apparent to me beyond a shadow of a doubt that this disease was so complicated that in my lifetime we would not be able to cure it. Anyone that gets cancer, the best news you can get is that it was diagnosed early so they have a good chance of a cure. If Early Detection was the only chance of cure, i began to Pay Attention to my patients that would give a history. Six months or a year they had low blood counts. And that was called preleukemia. Why didnt we catch it then in the earlier stage, preleukemia . Why did we let it become this kind of terminal rapidly growing, aggressive disease. I turned my attention to study preleukemia and following those patients. You asked me what kind of cancer am studying . I began to study this kind of leukemia because it was a liquid tumor. I ended up focusing my attention more on the preleukemic disease which is called mds for short or mylopdisplastic syndromes. Although one lady said it stands for my disease stinks. That is what i study now. Susan how often in your profession do people treat and research . Dr. Raza rarely now. There was a time when we could do both. But the Knowledge Base has expanded so much now that it is literally impossible to do both. But i am one of the oldtimers, lucky me that gets obsessed with this. I say if im given 72 more lives, i will do each time the same thing in honor of my patients. Susan your book told the story of a number of those. I wanted to show a video of one that you referenced briefly. This is julia williams. We will watch a little video and talk about why it is important to hear the stories. Lets watch. [video clip] i found there was a real absence of truth about living with this disease. When i started writing, i vow i know this is really depressing and dark but i swore i will always be honest with