Andrew J. Cowan, MD, is an associate professor at the University of Washington and the Clinical Research Division of Fred Hutchinson Cancer Center in Seattle.
“Doctor, will I able to continue getting teclistamab? It’s keeping me alive, but I hear that Medicaid funding might be cut … I’m so anxious.”
“Doctor, I heard about the NIH funding cuts ... How are they affecting your clinical practice?”
So often in treating hematologic malignancies, despite all the advancements in our therapies, I’m reminded of the fragility of our health and humanity. When I reflect on this, I consider that as much as we think we have control over our lives, external factors, such as unexpected disease progression for our patients, may often unpredictably change the course of the future. On a larger scale, our societal fragility is always most evident during times of rapid change, which all of us in the United States have experienced over the last few months. The last time we experienced this type of change was during the COVID pandemic, but any brief review of human history tells us that upheavals and times of renewal are common in human society and, more generally, in nature.
Over the past several months, my clinic has been inundated — as I’m sure many have — with calls from anxious, worried patients like the examples above. Many have been concerned about how potential cuts in Medicare or Medicaid funding will affect their care and treatment. Others see the news about the potential cap on indirect costs and cuts on NIH-funded research and ask how it will affect my practice. Much of the time, I’m not able to answer these questions directly but, rather, seek to reassure and tell patients that we will get through this. It’s reminiscent of the COVID pandemic; the fears of a rapidly spreading infectious disease mirror the concerns about a new push for austerity in the United States.
What are we to do? I take inspiration from the insightful but sometimes polarizing Nassim Taleb, who wrote the book Antifragile: Things That Gain From Disorder. The core argument of the book is that successful systems are antifragile, meaning that they thrive under stress! In many ways, I think hematology research and clinical care have already proven to be antifragile. Let’s review some examples of how groundbreaking research and advances in clinical care and research in hematology has often been borne out of challenging situations or circumstances:
- Arsenic for acute promyelocytic leukemia (APL). After the tumultuous years of the Cultural Revolution in China in the 1970s, scientists, including Zhang Tingdong from Harbin Medical University, discovered the clinical effectiveness of arsenic, a traditional Chinese medicine, for the treatment of APL.1
- Bone marrow transplantation for hematologic disorders. Despite many early setbacks and failures, E. Donnall Thomas, MD, persisted in his experimentation on human bone marrow transplantation.2
- World wars and the discovery of nitrogen mustard. Even before the rapid expansion of biomedical research funding following President Richard Nixon’s signing of the National Cancer Act in 1971, Louis Goodman, MD, and Alfred Gilman, PhD, realized in 1946 that nitrogen mustard compounds, derived from the lethal gas used on the battlefield in World War I, could be used to treat cancer.3
- The origins of cellular immunotherapy. Many might forget that the early history of gene therapy in cancer was mostly remembered for its failures in the 1990s. We are indebted to the scientists at the University of Pennsylvania and Fred Hutch, among others, who were willing to undertake bold experiments and clinical trials in the early 2010s, paving the way for breakthrough cellular therapies for hematologic malignancies.4,5
- Bendamustine for lymphoma. This alkylating agent was originally developed in East Germany during the Cold War, at a time when East German scientists had limited access to Western drugs and therapies. Scientists were forced to innovate in tough circumstances — leading to the development of a drug that is still used globally for lymphoma.6
In today’s chaotic and uncertain times, it is tempting to give in to despair, to “doom scroll,” or to lose hope in the future. However, as you can see, science has often thrived under difficult circumstances, and many important discoveries were made during eras of immense change and uncertainty.
How can we continue to make hematology clinical care and research more resilient in the face of challenging times?
My first suggestion is to not give in to cynicism or hopelessness — no more doom scrolling! Try to reassure patients that we will continue to fight for the best clinical care and research for them. Second, be an advocate! Don’t assume that someone else will take up the banner and speak out — be that person!
Finally, use difficult times as a sense of purpose for pursuing something you’ve always wanted to do. Write the investigator-initiated trial that you think could change outcomes. Put together a self-funded trial and collaborate with other institutions. Work with philanthropy to fund the study that pharmaceutical companies won’t.
Ultimately, we need to give our patients and their loved ones hope. We can make hematology research and clinical care resilient by continuing to pursue innovative research and clinical care despite the tumult that surrounds us.
Andrew J. Cowan, MD
Associate Editor
References
- Jiang Y, Shen X, Zhi F, et al. An overview of arsenic trioxide-involved combined treatment algorithms for leukemia: basic concepts and clinical implications. Cell Death Discovery. 2023;9:266.
- Blau CA. E. Donnall Thomas, M.D. (1920–2012). Stem Cells. 2013;31(2):221-222.
- Goodman LS, Wintrobe MM, Dameshek W, et al. Nitrogen mustard therapy; use of methyl-bis (beta-chloroethyl) amine hydrochloride and tris (beta-chloroethyl) amine hydrochloride for Hodgkin’s disease, lymphosarcoma, leukemia and certain allied and miscellaneous disorders. J Am Med Assoc. 1946;132(3):126-132.
- Porter DL, Levine BL, Kalos M, et al. Chimeric antigen receptor–modified T cells in chronic lymphoid leukemia. N Engl J Med. 2011;365(8):725-733.
- Terakura S, Yamamoto TN, Gardner RA, et al. Generation of CD19-chimeric antigen receptor modified CD8+ T cells derived from virus-specific central memory T cells. Blood. 2012;119(1):72-82.
- Gandhi V, Burger JA. Bendamustine in B-cell malignancies: the new 46-year-old kid on the block. Clin Cancer Res. 2009;15(24):7456-7461.
The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.
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