Sanjiv Agarwala, MD is Chief of Medical Oncology & Hematology at St. Luke’s Cancer Center and Professor of Medicine at Temple University School of Medicine, Philadelphia, Pa. He recently joined the Advisory Committee of the Institute for Clinical Immuno-Oncology (ICLIO). We caught up with him in between patient clinics to talk about the many different hats he wears.
What pulled you into oncology in the first place?
Sanjiv Agarwala, MD: I was always interested in the whole issue of cancer cells and how they are just normal cells that are misbehaving. I was very interested in leukemia initially and bone marrow transplantation (BMT). Those early days of BMT were very intriguing.
On a personal note, I have a friend—who’s still alive, actually—who was incidentally diagnosed with adult acute lymphoblastic leukemia (ALL), and he received a bone marrow transplant. I actually did some of his bone marrows myself. That was a real-life example of how, someone who really was almost written off, went on a clinical trial at the City of Hope in Los Angeles and was cured and now is married and living a normal life.
In terms of the immune system and immunotherapy, I became interested in melanoma, which is immune-mediated, and the issue of how our own body’s normal defenses try to recognize cancer cells. It is fascinating to me how cancer cells evade the immune system by hiding and finding all these ways to not get destroyed by immune cells, and how the immune cells try to find ways to get around that; now, our immunotherapy agents are helping them. So that’s kind of why I went into oncology.
You have practiced medicine in India, New Zealand, and the U.S. What would you say are some of the key differences in the way that medicine is practiced in these places?
Dr. Agarwala: Well, India is a Third World country. The medical education there is excellent, but obviously there is a lack of resources. You have a whole different set of diseases, of course—more infectious diseases and things like that—and patients in Third World countries like India do not have access to many of these expensive and exciting new treatments.
So medicine is a more basic system there, where if you can afford things, you can get anything you want; but the public system is constrained by what resources there are. In India, it’s more like, “Okay, let’s take care of basic cancers, and immunotherapies are in the distant future.”
New Zealand (NZ) is very much a state-of-the-art setup. It’s a much smaller country with only three million people and a public health system like the United Kingdom—which has its issues, but it works well. I think the NZ [health system] is also different than the U.S. in the sense [that] it’s more public than private.
Of course, in the U.S., it’s a very different system. So I’ve gotten to see all three sides of this, which is interesting and kind of an eye-opener for me: A very backward, poor, resource-poor public system, an in-the-middle system like New Zealand, and then what might be viewed as an over-the-top system like the U.S. where money is no object.
How would you say that breadth of experience informs your daily clinical practice in the U.S.? Is it something that you find informs your decision making?
Dr. Agarwala: I’m much more appreciative of what resources we have here. I tend to be a little more conservative for that reason in my decision making. I do think of costs. I think of how fortunate we are and our patients are to have access to anything they want—so I do think of that. I don’t think it affects my medical decision making, but I do think about cost when I’m deciding what treatment to give. I want to go with the data because I don’t want to do things outside and off-label if we don’t have the data; I’m sensitive to the costs of the healthcare system.
I think sometimes we in America do not have an appreciation of how fortunate we are. It would be a really good idea for almost every physician to spend time in a Third World country, for example, to see what constraints they work under and how we don’t have those. So I think my experience gives me a good appreciation of the value of our healthcare system.
It also makes me more frustrated because drugs are so expensive in the U.S. and there’s just no competition. Why do all the drugs cost the same when there are seven of them that are very similar in their efficacy and no one’s competing on price?
What does a typical day look like for you?
Dr. Agarwala: I wear several hats. I see patients and do clinical research, which overlap, and then I’m administrative as chief of the department. I intermix my administrative meetings and research meetings with my clinical meetings. I have a great team here of physician assistants, nurses, and researchers. Patients get seen, they get treated, things move on, and I’m kind of like “in and out” and see them as needed. Of course, I see them where there’s a reason to see them, but I don’t always have to see them if they’re doing well and if they’re getting treated on a regular basis.
When I am traveling, my clinic still functions, patients are seen, treated, and everything is managed and I’m available by phone if needed. My typical day is in a little disarray really, where I have a couple of patients, then an administrative meeting, then a research meeting, and then a few more patients and it all seems to work—but I don’t compartmentalize it.
I think it’s actually much more efficient for me to be a little flexible and not to have a clinic day, for example, or an admin day. That doesn’t work well. I think it’s good to overlap and that way I’m able to do everything I need to do in a day; and if I have to travel somewhere, I can do that as well, as opposed to having fixed days and fixed time slots.
You have to kind of create the schedule that has some space so that you can squeeze those admin and other pieces of work in among your research and clinical work.
Dr. Agarwala: Correct, because my patients are coming in every day. I see patients when I’m here. Whenever I’m here, I’ll see them as needed. If a patient needs to be seen urgently, it’s very hard to say, “I don’t have a clinic day until next week.” I’ll see them tomorrow. I’ll overlap something else and I’ll just kind of wrangle it, you know? It’s innovative and it’s a little bit of making the system work for you as opposed to the other way around.
You’re a prolific author and you’ve been the PI for multiple clinical trials, particularly in immunotherapy. How do you manage to be so productive?
Dr. Agarwala: I think it’s the matter of having really good collaborators. The nice thing is that if I’m on 20 projects, I might take the lead on two of them, but the other 18 people have taken the lead on other projects and I contribute. All of us together can be highly productive. So that’s how we do it—having very good collaborators, good communication, being available. It’s also very busy, of course. There’s a lot of travel involved, so you’re on the road a lot, but then you kind of like try to make that productive as well.
As a new member of the ICLIO Advisory Committee, what do you hope that ICLIO will achieve in the next two to five years?
Dr. Agarwala: I’m delighted to be on ICLIO’s Advisory Committee. ICLIO has this goal of doing exactly what I love to do. I have done a lot of speaking in terms of just going out there and teaching people about immuno-oncology, side effect management, decision making—that’s what I do and I’m very pleased to be a part of that for ICLIO and to contribute in any way I can.
ICLIO is incredibly important because immuno-oncology is changing even faster than we anticipated. As more oncologists who have never been exposed to immuno-oncology in the past get thrown into it, there’s potential for disaster. While the drugs are very safe, if you don’t recognize what you need to recognize, you can have some potentially very bad outcomes—and even if it’s five or 10 percent of the patients, that’s not acceptable. So I hope that what we’re able to achieve is to really get the word out that immuno-oncology is mainstream, and you better know it now.
ICLIO is like having a friend in immuno-oncology, providing online education and other workshops. I tell my referring docs to go ahead and treat a patient but give them my cell phone number and my email, so they can reach me if they need to. That gives them tremendous confidence and I think that’s what ICLIO can provide—we’re here for you.
We’ll offer programs and meetings, but it doesn’t mean that, hey, you’ve got a patient that you’re starting to treat and you haven’t done this in a while because it’s not what you do every day—don’t worry. You let us know and we’ll be there for you. One of us will be able to answer your questions in real time or very quickly so that you can get your patient through this safely. I think that’s where our value can be quite amazing.