In November, ASCO announced that Julie R. Gralow, MD, FACP, FASCO, will succeed Richard L. Schilsky, MD, FACP, FSCT, FASCO, as Chief Medical Officer (CMO) of the Society. Dr. Gralow will begin her new position on February 15, 2021.
Dr. Gralow’s long relationship with ASCO dates back to 1995, when she received an ASCO Career Development Award. Over the past 25 years, Dr. Gralow has been an active ASCO volunteer, serving on numerous ASCO committees, task forces, and guidelines groups. Most recently, Dr. Gralow served as Chair of ASCO’s Academic Global Oncology Task Force, which published new recommendations for establishing global oncology as a formal discipline grouped into four areas: global oncology training, global oncology research and practice, global oncology career paths and professional development, and overall global oncology.1
Julie R. Gralow, MD, FACP, FASCO
Richard L. Schilsky, MD, FACP, FSCT, FASCO
The recommendations come at a time when cancer incidence and mortality are soaring worldwide, with new cases expected to increase from 18.1 million to 29.5 million by 2040 and cancer-related deaths to increase to 16.4 million.2 In addition to her long career as a leading specialist in the treatment of breast cancer in the United States as Clinical Director, Breast Medical Oncology, Seattle Cancer Care Alliance; Professor, Medical Oncology, University of Washington School of Medicine; and Professor, Clinical Research Division, Fred Hutchinson Cancer Research Center, Dr. Gralow has also been active in reducing the burden of breast cancer in other countries.
In 2003, Dr. Gralow founded the Women’s Empowerment Cancer Advocacy Network (WE CAN), an international organization that supports patient advocates in low- and middle-income countries. She is also Adjunct Professor in the Department of Global Health at the University of Washington; serves as an advisory council member for the Uganda Cancer Institute’s adult Hematology/Oncology Fellowship Training Program and as Co-Chair of the ASCO Resource-Stratified Guideline Advisory Group; and is an editorial board member of the European Society for Medical Oncology (ESMO)/ASCO Global Curriculum in Medical Oncology. In addition to these roles, Dr. Gralow has served on the Medical Advisory Board of Global Focus on Cancer and on the Board of Directors of the Pink Oak Cancer Trust, a cancer treatment fund in Nigeria. In the United States, Dr. Gralow has served on the board of the Peace Island Medical Center, a 10-bed rural access medical center on San Juan Island in Washington State, and on the National Scientific Advisory Council of Susan G. Komen for the Cure.
Dr. Gralow’s expertise in global health has allowed her to collaborate with Ministries of Health throughout the world and with the World Health Organization (WHO) to reduce the burden of cancer, especially in low- and middle-income countries. Dr. Gralow also brings to her new position as CMO of ASCO vast experience in developing and conducting large, national cancer clinical trials; strategic planning; training of young investigators; and collaborations with the National Cancer Institute and the U.S. Food & Drug Administration.
The ASCO Post talked with Dr. Gralow about her career change, her vision for making personalized cancer care a reality for more patients, and her thoughts on formulating her new role as ASCO’s CMO.
Career Change
Why did you decide to leave your work in academic medicine to take on this leadership role at ASCO? Do you have concerns about losing the day-to-day patient connection that is such an integral part of your work?
I’ve been in Seattle for close to 3 decades, and some of my relationships with patients extend almost that long, so losing the day-to-day connection with my patients will be one of the hardest parts of this career change. However, as I think more about my role as ASCO CMO, a critical part of the job, and my primary focus of what we are all working to accomplish, is to do the best for our patients.
Over the years, I’ve connected with patients all over the United States and globally, increasingly through social media. So, I will continue to have that patient feedback and patient perspective I’ve always had. I just won’t be providing day-to-day clinical care anymore.
‘A More National and Global Voice’
Dr. Schilsky inaugurated the role of ASCO CMO in 2013. Over the years, he has shaped the position to include the launch of ASCO’s first-ever clinical trial (the Targeted Agent and Profiling Utilization Registry [TAPUR] Study), the establishment of the Center for Research & Analytics (CENTRA), and, most recently, the creation of the ASCO Survey on COVID-19 and Oncology Registry. How will you redefine the CMO position?
Ask me that question again in 6 months, after I better understand all that the position encompasses. Rich set up a terrific model, and I have some big shoes to fill.
You asked me what made me leave my academic positions in Seattle to take on the CMO role at ASCO. I think the focus of my work in both contexts will be the same but with a more national and global voice. It is important that we keep CENTRA in place, as well as TAPUR, which is matching patients’ tumor genomics with targetable drugs and providing data that would be difficult to acquire in any other setting. I’m thrilled to say that Rich will be staying on for some period as Principal Investigator of TAPUR while I get to know my new role. The focus on developing guidelines to advance oncology care and to ensuring quality of patient care will continue.
What I bring to this position, which is a bit different, is the perspective on global health disparities, since I have a lot of experience in this area, especially in low- and middle-income countries. I will bring a global eye to the position while still focusing on our members in high-resource countries as well and determining what we can do to give the best care to all our patients. However, increasingly, genomic and molecular testing and cancer therapies are becoming more expensive, and we need to figure out the best way to steward our limited resources, even in high-resource countries, to make sure patients have access to the best possible diagnostics and clinical care. We also need to examine the practice of adding a second, third, and fourth drug, like multiple checkpoint inhibitors, all together to achieve a small benefit.
Looking at these issues with my global eye, I may be a bit more critical of spending a lot of money for care that provides marginal benefit for a few patients while adding no benefit for the majority.
Future of Oncology: More Personalized Care
Given these thoughts, what is your vision for the future of oncology?
What we are learning more and more is that the optimal treatment of cancer is to tailor it to the individual cancer type and the individual patient. We have to look at all the genetic factors that contribute to the development of a patient’s cancer, including the acquired and germline mutations, as well as the tumor’s genomic factors to determine the most effective treatment for an individual patient. Because cancer cells are inherently unstable and keep mutating and changing to get around treatment, we have to examine the tumor’s genomics over time.
We also have to take into consideration a patient’s personal lifestyle before recommending treatment. For example, what phase of life is the patient in? What are his or her goals for treatment? What is the patient’s age, comorbidities, and family and career status?
My vision for where we are going to personalize care, and we are already starting to do this, is to step back from the standard-of-care. We need to take all of the patient’s information to get a better picture of how to optimally treat that patient to have the best chance at a cure and to reduce treatment toxicities.
I have my breast cancer hat on here, but we now have many patients with metastatic breast cancer that can be considered more of a chronic disease with which patients live for many years. They are on endocrine therapy, and the disease is quiet. Or maybe we don’t see any evidence of disease, or there is very little evidence of disease, but it is not life-threatening. But even in that patient population, although endocrine therapy compared with chemotherapy or immunotherapy is quite mild in terms of side effects, at least from my perspective as a treating physician, treatment can still be very limiting in terms of quality of life.
So, even for those patients who have an excellent lifespan ahead even though they’ve had a cancer recurrence, we still have to work hard to ensure a good quality of life by minimizing symptoms and not overtreating them. Then, we have another group of patients with breast cancer in which the cancer is not a chronic disease and progresses quickly despite multiple types of treatment. So, there are all kinds of different situations.
Managing Cancer in the Era of COVID-19
The COVID-19 pandemic has presented many challenges for patients with cancer as well as clinicians and researchers. What will be the long-lasting impact of the pandemic on oncology care, for example in the use of technology such as telemedicine? How is ASCO responding to the fallout from the pandemic?
ASCO recently published its Road to Recovery Report: Learning From the COVID-19 Experience to Improve Clinical Research and Cancer Care. This report details comprehensive recommendations to guide our eventual recovery from this pandemic and reinforces our commitment to address cancer care disparities that predated the pandemic and that were exacerbated by the coronavirus.3
COVID-19 forced us to utilize technology like telemedicine to solve some problems that were limiting our ability to care for our patients, including access to clinical trials that were burdensome for no good reason before COVID
but that have now led to reforming the way clinical trials are conducted. We are all becoming experts in Zoom video conferencing and in telemedicine, and the technology has allowed us to conduct virtual research visits and reduce the need for in-patient visits to study sites. These changes are here to stay.
Separate from clinical trial improvements, we’ve learned that we can have telehealth virtual patient visits without compromising Health Insurance Portability and Accountability Act (HIPPA) compliance or diminishing high-quality patient care. During the COVID-19 pandemic, the Centers for Medicare & Medicaid Services and health insurance carriers expanded coverage for telehealth services on a temporary basis. We will have to see whether this coverage becomes permanent after the pandemic is over.
Reducing Health-Care Disparities
This year has seen increases in racial injustice and in health-care disparities in the United States. Please talk about how you might address these concerns both domestically and worldwide, especially in low-resource countries, after you become CMO of ASCO.
Obviously, these issues have existed for decades, and I’m thrilled to see that now we are finally paying more attention to racial injustice in this country and to the inequities and health-care disparities we see, especially in minority populations.
I have looked at the issue of health equity across the globe for years, and inequities exist in our country as well. Through my work with WE CAN, which I created to bring together breast and cervical patient advocates in low- and middle-resource settings, I’ve seen examples of what could be done to reduce health inequities.
Early in December, the Best of ASCO Africa 2020, which is co-sponsored by the Uganda Cancer Institute, the African Organization on Research and Training in Cancer (AORTIC), and the Oncology Nursing Society (ONS), was presented virtually. The meeting highlighted the scientific progress published during the ASCO20 Virtual Scientific Program in June. You might think a lot of the studies presented during the meeting are not applicable in Africa, because many of the latest drugs and diagnostics are too expensive for low- and middle-income countries. However, a lot of the information presented in these studies does apply to patients in Africa.
For example, I chose an abstract on HER2-positive breast cancer to present at the Best of ASCO Africa meeting that is not practice-changing and that used the standard-of-care monoclonal antibody trastuzumab to treat the study participants. But it gave me the opportunity to talk about the benefits of trastuzumab, which WHO added to its Essential Medicines List in 2015. Presenting this state-of-the-art abstract to participants at the Best of ASCO Africa meeting allowed us to have a dialogue about what we should be doing in Africa to treat women with HER2-positive breast cancer, where the average woman with breast cancer does not have access to HER2 testing much less access to anti-HER2 drugs.
I do think the ASCO Annual Meeting is the place for the presentation of the highest-quality state-of-the art trials, and ASCO could be a participant in translating these data in low- and middle-income countries. I’m fascinated to see how the Africans are using these study data in their own situation, and I think this is being done by other low-resource countries as well. That said, however, we should never be in a situation in which ASCO tells other countries how to treat their patients with cancer but rather we should be conveners to distill treatment information.
ASCO has such great respect around the globe, and that gives us great opportunities to partner with other countries to learn how best to provide care to meet their needs; this actually applies to certain regions and populations in the United States as well. So, I think we can reverse translate some of what we’ve learned in other resource settings to address some of the disparities and inequities in the United States.
"ASCO has such great respect around the globe, and that gives us great opportunities to partner with other countries to learn how best to provide care to meet their needs."— Julie R. Gralow, MD, FACP, FASCO
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Global Organizations Collaborate
A large percentage of ASCO members, about 40%, reside outside of the United States. What are ASCO’s plans to partner with other global societies to reduce the global cancer burden, which is expected to increase from 18.1 million to 29.5 million in 2040?
This issue of how we can better partner with other societies and organizations is going to become a high priority as I take on my new position as CMO of ASCO. We do currently partner with ESMO, for example, on updating its global training curriculum. My hope is that we will partner with not just other medical societies, but across medical specialties as well, because the treatment of cancer is a multidisciplinary effort.
In 2018, the National Center of Oncology in Azerbaijan partnered with ASCO, the American Society for Clinical Pathology, and the ONS to produce an ASCO Multidisciplinary Cancer Management Course in Baku, Azerbaijan. More than 200 health-care providers specializing in oncology attended the conference, including radiation and medical oncologists, surgeons, pathologists, nurses, and medical students from Azerbaijan, as well as from Iraq and Georgia.
It was the desire of some of the physicians in Azerbaijan, as well as ASCO and ONS participants, to have a session in which all of the meeting participants were brought together to discuss patient cases and the role of nurses in those cases, as well as the role of physicians. It was a very successful session and helped elevate the status of nursing in these countries.
In the future, we will be having dialogues with other organizations, including WHO and the United Nations, to see how ASCO might collaborate with these entities to address the growing burden of noncommunicable diseases in low- and middle-income countries and achieve the goal of universal health coverage. I won’t be the only leader at ASCO making decisions on what we should be promoting on a worldwide level to reduce the global cancer burden, but we have to be aware of what issues are preventing greater access to oncology care in these countries, because ASCO’s voice matters throughout the world.
Formalizing the Field of Global Oncology
ASCO’s Academic Global Oncology Task Force developed recommendations for formalizing the field of global oncology, with an emphasis on training, research, and career development. How can ASCO members become involved in these global initiatives?
Many oncology medical students and fellows are very interested in having a global experience of treating patients even if, ultimately, they are not looking to pursue global oncology as a permanent career focus. I think the same is true for many practicing oncologists.
ASCO International (www.asco.org/international-programs) provides several areas of international career development ASCO members can participate in as mentors. ASCO is also planning to have more scientific sessions on global oncology during its Annual Meeting, which will provide more opportunity for members interested in the field to volunteer their time.
Even making just one trip to a low-resource country opens your eyes to the barriers faced by physicians and patients in other countries, and I think the experience makes you a better physician when you come back to the United States.
DISCLOSURE: Dr. Gralow has served on the Steering and Data Safety Monitoring Committees of Roche/Genentech; on the Advisory Board and Data Safety Monitory Committee of AstraZeneca; on the Advisory Boards of Puma and Pfizer; as a member of the Data Safety Monitoring Committee of Novartis, Immunomedics, and Radius; and as a consultant for Sandoz/Hexal AG, Genomic Health/Exact Sciences, and Inbiomotion.
REFERENCES
1. Gralow JR, Asirwa FC, Bhatt AS, et al: Recommendations from the ASCO Academic Global Oncology Task Force. JCO Glob Oncol 6:1666-1673, 2020.
2. National Cancer Institute: Cancer Statistics. Available at www.cancer.gov/about-cancer/understanding/statistics. Accessed December 22, 2020.
3. Pennell NA, Dillmon M, Levit LA, et al: American Society of Clinical Oncology Road to Recovery Report: Learning From the COVID-19 Experience to Improve Clinical Research and Cancer Care. J Clin Oncol. December 8, 2020 (early release online).
