Kathy D. Miller, MD: Hi. I'm Kathy Miller, Associate Professor of Medicine at the Indiana University School of Medicine in Indianapolis. I am pleased to welcome you to a Presidential Perspective, commemorating the 50th anniversary of the American Society of Clinical Oncology (ASCO).
I am honored to welcome 3 past Presidents of ASCO. Dr. Robert Young is President of RCY Medicine and past Chancellor, President, and CEO of the Fox Chase Cancer Center in Philadelphia. Robert was President of ASCO from 1989 to 1990.
Dr. Robert Mayer, the Steven B. Kay Family Professor of Medicine at the Harvard Medical School and Faculty Vice President for Academic Affairs and Medical Oncology at the Dana-Farber Cancer Institute in Boston. Bob was President of ASCO from 1997 to 1998.
Our youngest past President, Dr. Michael Link, is Professor of Pediatrics at the Stanford University School of Medicine and a physician at Lucille Packard Children's Hospital in Palo Alto, California, as well as the President of ASCO from 2011 to 2012. Gentlemen, welcome.
Fifty years is a nice, round number, and we thought it was a good time to take stock of the changes in oncology as a field, the changes in the Society, and maybe tempt you to do a little forecasting of the next 50 years. Dr. Young, when you think back to the ASCO during the decade in which you served as President, what major advance had the oncology field excited?
1974-1984: Cures Never Before Possible
Robert C. Young, MD: During that period, we began to see cures of patients with certain kinds of hematologic malignancies that had never been curable before. We saw that in pediatric leukemias, in some of the adult leukemias -- in Hodgkin disease, in non-Hodgkin lymphoma -- and in testicular cancer. Those were among the significant events that occurred in that period of time. We also began to see the initial impact of adjuvant chemotherapy given to patients at high risk for relapse for some of the more common solid tumors such as breast cancer and colorectal cancer.
Dr. Miller: Was there any thought at the time that those advances in hematologic malignancies were foreshadowing other effective chemotherapies, and that we would soon be knocking off solid tumors one by one?
Dr. Young: Oncologists are inherently optimistic, so the answer to your question is, yes -- absolutely. There was a very strong feeling that we simply had to use the same concepts, apply them to the common solid tumors, look for drugs that had different mechanisms of action and worked in different ways with different patterns of toxicity, put them together, and we should see the same kinds of outcomes that occurred in some of these unique malignancies that were beginning to be cured.
1994-2004: Molecular Testing to Individualize Treatment
Dr. Miller: Bob, your presidency was about a decade later. Had much changed in the field over that time frame?
Robert J. Mayer, MD: We learned that we couldn't just apply the principles of hematologic malignancies to solid tumors. In hematologic malignancies, we learned that cancers that looked the same under the microscope could be -- biologically, genetically, and molecularly -- very different. They could have a different prognosis and respond differently to treatment.
Nonetheless, the adjuvant or prophylactic treatment for breast cancer became refined with the knowledge that breast cancer is not a single disease but several diseases. Our understanding of the treatment of colon cancer in the advanced stage, as well as the adjuvant stage, grew. And lung cancer (particularly small cell lung cancer) became a more treatable, if not curable, condition. The need for molecular and genetic testing to define how we approach patients was recognized, along with the need for any institution that takes care of these patients to be able to provide those services.
2004-2014: Proof of Principle for Targeted Therapy
Dr. Miller: Michael, you were President only a few years ago. Rather than having you look back, can you look forward to the coming decades?
Michael P. Link, MD: In the era of my presidency, we experienced a return on investment of all of the science that had gone on before in the other eras. We began to understand the molecular underpinnings of the tumors that we treated. For the first time, we had a proof of principle that we could treat cancers according to the target specific to the patient's tumor and see dramatic responses.
Once again, hematologic malignancies led the way, so we began to have specific therapies for some of these diseases that were previously considered incurable, except by the most intensive bone marrow transplantation procedures. Now we have targeted agents that lead to long remissions, and these improvements can translate into the solid tumors as well if we understand the targets. For the future, we have to understand the heterogeneity of cancers, that breast cancer isn't a single disease -- it's many different diseases, depending on the molecular drivers. We have to individualize the therapy, and of even greater importance, we have to understand that the targets don't know the difference between a hematologic malignancy and a solid tumor. We see the same targets in lymphoma that are present in some solid tumors, and targeting them appropriately will lead to dramatic responses.
The paradigm for the future is the ability to individualize therapy, and we hope that we will become smarter about how we target these molecular drivers. Hopefully that will lead to less toxic and more specific therapies.
A 'Small Enterprise' Hires Its First Employee
Dr. Miller: During this 50 years that the field has progressed and changed so dramatically, ASCO as an organization has grown. The first ASCO meeting had all of 50 people attending and only 3 scientific presentations. When you think back to your time as President, what was the state of the organization, and what were the pressing issues that ASCO the organization was trying to deal with?
Dr. Young: The first meeting that I attended at ASCO was in 1968, and that meeting had about 200 people, but it was a half-day session immersed in the American Association for Cancer Research meeting. We were still a fairly small enterprise at that point, and most of the data were from simple trials, testing the application of chemotherapy to a variety of tumors. By the time I was President in 1990, we were about 4000 strong. We had our own meeting, and it was a full meeting with a lot of randomized trials being presented and a lot of basic science data being explored. It was a very different organization from the one that I first joined.
A significant challenge that ASCO has always faced as it continues to grow (it is now 34,000 members) is the management of such a huge enterprise. In my presidential year (1989-1990), we hired the first full-time employee that ASCO had ever had. This is a remarkably rapidly growing organization.
One challenge arose when state organizations began to form that primarily focused on the interests and concerns of the practicing oncologist in the community. A rift was growing between the academic oncologists who had formed the Society and were its historical leaders and the community-based oncologists. At that time, there was a big threat that they would split off and that we would have separate academic organizations and community oncology organizations. We worked very hard during that period of time to address the interests and concerns of the community oncologists in a way that brought them strongly into the organization, so that now it exists with a remarkably balanced mix of community oncologists and the academic enterprises that are university based.
From an American to a Global Society
Dr. Miller: We talk a lot about ASCO being a volunteer organization, and I did not realize until you were speaking just now that it was that recently that the organization hired its first full-time employee. That is amazing. Bob, during your era, about a decade later, were there new challenges for the profession or the organization?
Dr. Mayer: There were tremendous new challenges. When Bob and I began with ASCO, it was a contract facility. It was managed by a company in Chicago who had a large portfolio of other organizations. We weren't special; we weren't full-time for those people. We began some programs. We began a journal, the Journal of Clinical Oncology. We began a young investigator program, but it was all through this part-time group. In 1994 or 1995, ASCO hired its own executive vice president, a wonderful choice -- a former ASCO President named John Durant, who had been a senior administrator at the University of Alabama in Birmingham. He set up shop in Alexandria, Virginia, in a relatively modest office space, which was the office when I was President.
The office has now moved twice and is much larger. When I was President, there was not just 1 full-time employee as in Bob's time; there were 48-49 employees, and I thought that was a lot. Of course, we are 5 or 6 times larger at this point. ASCO became a year-round organization.
Bob pointed out the need to balance between the academic and the community oncologists. We are the American Society of Clinical Oncology, but in the broadest context we are the world organization for clinical oncology. We had an increasing number of international members, and we needed to recognize them. So, in my tenure, we placed a slot on the board of directors for a non-American, non-United States member, and now there are several. I wouldn't be surprised if, in the future, we have an ASCO President who is not based in the United States. The organization grew structurally. It grew in terms of its membership. In my time, the membership was18,000-19,000. In Mike's, it was even higher. There has been a constant progression of growth.
Dr. Miller: In the early 2000s, Michael, when you were President, you had more than 300 full-time employees?
Dr. Link: Approximately, yes, and that number has changed, with turnover and other changes. It is an amazing organization, partly because of the dedication of its members. At that time, ASCO became the organization for all professionals who take care of patients with cancer, from a research environment to nursing to social services. All of those became part of the umbrella of ASCO. That was what the organization was determined to do, and to become the "spokesorganization," if you will, for all of these constituencies and for the cancer patient as well. This was when patient-oriented resources were developed, such as cancer.net. We became more involved in the politics and the costs of cancer care and how these factors ultimately affect patient care.
These are the issues that a mature organization faces in standing as the organization representing the cancer patient and all of those who touch the cancer patient and are involved in their care. From 1 employee to 30 employees in Bob's era, to the hundreds that are there now, it is an amazing organization. The degree of commitment to the mission is simply fantastic. I benefited from the fact that I had an amazing and mature organization to work with.
Dr. Miller: One thing that changed during this time was the role of the President in bringing people together. The President is often the public face and voice of the profession, including identifying the theme for the annual meeting.
Dr. Mayer: In my presidency, we focused on end-of-life care because it seemed to be very important as something that permeates the practice of being an oncologist. We thought at that point, and still do, that all too often oncologists are focused on giving types of therapy with the goal of shrinking disease, but in most circumstances, there comes a point when the goals have to change. We had debates. During my presidency, we had a debate (which filled a hall) about physician-assisted suicide. It was a very current issue and was not something that had been discussed under the ASCO tent before.
What Does the Future Hold?
Dr. Miller: Bob, as we think forward to the next 10 or 20 or 50 years, what is the biggest challenge that you see for the profession or for the organization?
Dr. Young: We have demographic challenges. Our society is getting larger and older. Cancer is a disease of the aging population, and many more cancer patients will need care. The ability to deliver that care -- having the manpower (physicians, nurses, physician assistants, a whole variety of individuals) in a setting of rising healthcare costs and changing healthcare delivery mechanisms -- is going to be a big challenge, not just for us but for any medical society.
Applying some of these targeted therapies requires us to completely reassess our clinical trial structure. The ways that we did clinical trials when I was President or when Bob was President were vastly different from how we do them now. Many things are changing, but I doubt very seriously whether the focus of ASCO on the delivery of the best possible care to cancer patients is likely to change in the next 50 years.
Dr. Miller: How do we keep attracting new people to the profession and to ASCO?
Dr. Mayer: I am in an academic environment in a medical school, and the fascination that young people have for oncology is incredible. Bob and I were among the first to receive board certification in medical oncology from the American Board of Internal Medicine. It was a bold step, supported by ASCO, to legitimize oncology in comparison with cardiology or gastroenterology. Now we're on a par level [with other specialties]. Young people balance the fascination of science with the humanism of taking care of patients with the desire to make a difference, because there are so many exciting things for them to be doing at this point.
Dr. Miller: Michael?
Dr. Link: The field is now poised at one of the most exciting inflection points that we could possibly imagine. We have the science -- we understand cancer in a way that we have never before. If they read the newspaper, young people understand how exciting it is now. I agree with Bob. What we do as oncologists and as role models is to combine what comes from the laboratory and from the science of oncology with the delivery of care. There is still that personal connection with patients, which is like no other.
If we demonstrate that these elements can be combined in a single profession, we will attract the best people coming out of medicine. It is one of the most exciting fields to pursue. I am somewhat biased but believe that you should do pediatrics as well, because who doesn't love a child? Certainly, all of the fields of oncology experience the wonderful combination of the newest and most exciting science with taking care of people and making a huge difference in their lives.
Dr. Miller: Gentlemen, it has truly been an honor. As a field, we reach for the stars and stand on the shoulders of giants when we do so. I have been honored to have 3 of the past Presidents take us for a walk through history and a little thinking about the future. Thank you for your time and for your years of service and inspiration to all of us. And thank you for joining us in a Presidential Perspective. This is Kathy Miller, reporting from ASCO 2014.