In this installment of The ASCO Post’s Living a Full Life series, guest editor Jame Abraham, MD, FACP, spoke with Benjamin Besse, MD, PhD, Professor of Medical Oncology at Paris-Saclay University, Orsay, France, and lung cancer specialist at Gustave Roussy Cancer Campus, Villejuif. Currently, Dr. Besse is Head of Clinical Research at Gustave Roussy Cancer Campus and Chair of the Scientific Council of the European Organisation for Research and Treatment of Cancer.
BENJAMIN BESSE, MD
On what he learned from playing the piano: “The piano teaches you a lot of things, including the art of touching, because it is based on the way your fingers touch the keyboard. In a small way, it educates your sensory system and helps when you do a physical exam of a patient.”
On advances in lung cancer treatment: “Since the discovery of the EGFR-activating mutations in 2004, there has not been 1 year without a major therapeutic evolution in lung cancer. The discovery of more activating mutations in tiny patient subgroups has shown the emergence of promising molecular targeted therapies.”
On the role of immunotherapy for NSCLC: “Immunotherapy has rapidly become a clinical game-changer, driven predominately by results from clinical studies evaluating antagonist antibodies to PD-1 and PD-L1.... However, the optimal marker for patient selection is still a matter of debate within the community.”
Dr. Besse grew up in a middle-class family in a town called Suresnes on the outskirts of Paris. According to Dr. Besse, there were no physicians or medical professionals in the family who inspired his decision to pursue medicine. In fact, art and music were the dominant themes.
“For my mother, everybody is an artist, and she was an accomplished piano player,” Dr. Besse related. “In our family, music and academic school were mandatory up to 16 years of age, and then you could decide whether to stop school or music. And I have to say, I was very much better at school than at music. However, the piano teaches you a lot of things, including the art of touching, because it is based on the way your fingers touch the keyboard. In a small way, it educates your sensory system and helps when you do a physical exam of a patient,” explained Dr. Besse.
The French Approach to Education
Dr. Besse explained that the French education system offers a somewhat inflexible approach to education. During the time he was in school, “there was an exam after the first year of medicine, and only 12% of students could go on to the second year. But almost 100% of those who made it to the second year became physicians. Now the rules have changed a bit.”
For Dr. Besse, his decision to become a doctor came suddenly, almost out of nowhere. Dr. Besse explained that in France, medical education was made up of three cycles. The first is a 2-year cycle (PCEM) consisting of general scientific training not delivered in hospitals. There’s a competitive exam at the end of the first year. It is highly selective and assesses students in research, clinical care, and biology.
“All of a sudden, I was on course to become a physician, but I failed one of the prerequisite tests, which is highly selective,” he continued. “Only about 12% of students pass it, in fact. Although I considered giving up, and turning my attention to another field, a friend of mine told me failure is sometimes the right time to ask yourself: is it really what you want? And for me it was. So, instead of taking the same courses at the same university (the usual path); I changed from one university to another to start from scratch and not redo the same courses; then it clicked, and I was accepted to medical school,” he said.
The second cycle (DCEM) is for 4 years. The first year is devoted to general medicine training, and the three following years are dedicated to pathology and therapeutics. Courses are given in medical schools and hospitals. Students reach the third cycle only after being certified, and then they have a choice between two options: general medicine or specialized medicine. For this, you need to pass a national classifying exam (called the ECN) at the end of the sixth year.
The Path to Medical Oncology
Asked about his decision to pursue oncology as a specialty, Dr. Besse responded: “The first time I was in the hospital, I had to select one specialty. It was very early in my studies, and all the students around me were so confident in their decision to go to internal medicine or intensive care (all the ‘trendy’ specialities at that time), but I was still undecided. Toward the end, there were only two places left: one in medical oncology and one in psychiatry. The guy before me chose psychiatry, so I decided to try medical oncology. I remember all the other students noting I was going into a specialty that basically helped patients on their road to death, because at that time, medical oncology didn’t have many therapeutic options. Oncology was colored with these very strong images of suffering, pain, and death,” he said.
Dr. Besse continued: “It’s important to note that this was before the introduction of targeted therapies and immunotherapy, the scientific revolution that changed the image of cancer research and treatment. But in the end, I decided to do medical oncology because during my fellowship internship, I saw a medical oncologist writing the recipe for triplet chemotherapy, and it struck me that this is what I want to do. Just mix the ingredients and make the magic happen.”
Training at World-Renowned
Cancer Institute
Dr. Besse did most of his oncology training at the Institut Gustave Roussy, which is ranked the number one research and treatment cancer center in Europe and third in the world. Asked about his fellowship, Dr. Besse replied: “The duration of training in the specialty is 5 years after receiving a medical degree. The choice of specialty must be decided within the first year after acquiring a medical degree.”
According to Dr. Besse, the fellowship process in France is handled differently from in the United States. “In France, based on your ranking on the ECN national exam, you initially choose a speciality and a region of the country where you will be trained,” he explained. “For me, it was Paris and the surrounding area. After training 6 months at one institution, you transfer to another department, in the same hospital or in another hospital of the region. I spent 6 months in an ICU, 6 months in infectious disease, and the rest in oncology in various departments, with very different management of patients with cancer. At that time, some oncologists were giving extremely high doses of chemotherapy, and others were focused more on the supportive care side. I found it interesting to see the many ways to perceive and fight cancer. It was a very enriching experience,” Dr. Besse shared.
A Valuable Period of Research
After some internal reflection on his career path, Dr. Besse took 2 years off from his training to do translational research in Barcelona with Rafael Rosell, MD, Director of the Cancer Biology and Precision Medicine Program at the Catalan Institute of Oncology, Hospital Germans Trias i Pujol. “Being abroad was fantastic,” he recalled. “It was exciting and different than I expected. I thought I would spend 20 hours a day working in the lab, but it was a bit more relaxed. I learned not only about cancer biomarkers, but a plethora of things concerning life and medicine.”
According to Dr. Besse, at that time, he was a young man who was eager to learn and grow. “It was a transformative year,” he continued, “and when I returned to France, I felt different about the world around me. For one, being separated from my family and the comfort zone of home made me more independent. And working with people who were from different backgrounds was also edifying. I learned to be spontaneous and grab opportunities that arose. I definitely would suggest studying abroad to young medical students; it offers a worldliness that ultimately will help your career in multiple ways,” said Dr. Besse.
A Career in Lung Cancer
Dr. Besse completed a residency and fellowship in medical oncology at Gustave Roussy as well as a doctoral fellowship in molecular biology at the Paris-Saclay University.
He then became Associate Professor in Oncology at Gustave Roussy Cancer Institute.
Asked how he became a lung cancer specialist, Dr. Besse replied: “When I began my career, I was rotating between different oncology programs. However, the head of the lung cancer unit had left to pursue a career in the pharmaceutical industry, and although he returned 4 years later to Gustave Roussy, there was a void in lung cancer. I was simply told I had to fill it, and there I was, a lung cancer specialist. It was actually a great time to enter the field, as targeted therapies were emerging.”
Rapid Advances Changing the
Face of Lung Cancer
Asked to summarize advances in the treatment of lung cancer over the arc of his career, Dr. Besse commented: “Since the discovery of the EGFR-activating mutations in 2004, there has not been 1 year without a major therapeutic evolution in lung cancer. The discovery of more activating mutations in tiny patient subgroups—such as BRAF and MET mutations as well as ALK, ROS1, NTRK, and RET rearrangements—has shown the emergence of promising molecular targeted therapies for non–small cell lung cancer (NSCLC). Currently, up to 40% of patients with NSCLC, who are not only light smokers or never-smokers, are eligible for targeted therapies. It means lung cancer is now a sum of rare diseases, each requiring a specific strategy.”
Dr. Besse continued: “Immunotherapy has rapidly become a clinical game-changer, driven predominately by results from clinical studies evaluating antagonist antibodies to PD-1 and PD-L1, which have demonstrated prolonged tumor responses in patients with advanced NSCLC. However, the optimal marker for patient selection is still a matter of debate within the community. PD-L1 immunohistochemistry is the standard and should be the preferred testing in any new case of advanced NSCLC. The field is now moving into investigating the combination of immunotherapies with standard chemotherapies or radiotherapy, to enhance the benefits to patients, but there are several challenges, such as adverse immune reactions and increased costs of combined treatments. Research is also focusing on optimal biomarkers and defining the mechanisms of resistance.”
Guest Editor
Jame Abraham, MD, FACP
Dr. Abraham is Chairman of the Department of Hematology and Medical Oncology at Cleveland Clinic and Professor of Medicine at Lerner College of Medicine.
Dr. Besse noted that despite the game-changing advances in lung cancer, the overall 5-year survival of patients is still around 16%. “We must integrate new tools, in our treatment strategy, such as liquid biopsy as a guide to treatment and the addition of local treatment such as radiotherapy to systemic treatment in the metastatic setting. In the European Organisation for Research and Treatment of Cancer (EORTC) Lung Cancer Group, we have developed a consensus on the definition of oligometastatic disease (under the leadership of Prof. Anne-Marie Dingemans and Prof. Silvia Novello) to enroll more homogeneous patient populations in clinical trials. It was one of the first consensus reports from the Lung Cancer Group, reflecting its vitality,” Dr. Besse concluded. “Better diagnosis and management of patients equate to better survival.”
Wearing Multiple Hats
Dr. Besse is Chair of the Scientific Council of the EORTC, Chair of the French National Thymus Network RYTHMIC, and a member of international societies (including the International Association for the Study of Lung Cancer, ASCO, and the European Society for Medical Oncology [ESMO]). Recognition of his work includes an ASCO Merit Award and an ESMO fellowship for translational research. His work has appeared in numerous peer-reviewed publications, including The Lancet Oncology, JAMA Oncology, Journal of Thoracic Oncology, Lung Cancer, European Journal of Cancer, and Annals of Oncology.
Decompression Time
What does a super-busy oncology leader do to decompress? “Given my genes, I should pursue music as an off-work avocation to decompress, but it’s not happening,” shared Dr. Besse. “I just don’t have the family gift for music. Instead, I am an amateur cook, something I love to do. It not only gives me pleasure but also relaxes me in a way that is hard to describe. My father was the one who cooked at home, so I think that rubbed off on me.”
“I definitely would suggest studying abroad to young medical students; it offers a worldliness that ultimately will help your career in multiple ways.”— Benjamin Besse, MD, PhD
Tweet this quote
Dr. Besse continued: “As a physician, you take care of patients, and cooking is a way to take care of your family, a way to bring them together and show them love. I can cook for hours, as it takes me away from the pressures of the hospital clinic and research lab. I’m constantly improving, but I cannot invent my dishes; I must follow recipes—sort of like following guidelines in oncology. In the end, it’s all about being with people you love.”
