- Every family has been touched by cancer, and the diagnosis remains dreaded for good reason.

But today's guest is at the forefront of research to improve not just care, but the outcomes for people living with cancer.

She's Dr.

Cheryl L. Willman, this week on "Story in the Public Square."

(lively music) (lively music continues) Hello, and welcome to "Story in the Public Square," where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G. Wayne Miller, also with Salve's Pell Center.

- And our guest this week is Dr.

Cheryl L. Willman.

Dr.

Willman is the Stephen and Barbara Slaggie Executive Director, Mayo Clinic Cancer Programs, and Director, Mayo Clinic Comprehensive Cancer Center.

She's joining us today from Minnesota.

Dr.

Willman, thank you so much for being with us.

- Thank you.

Thank you so much, Jim and Wayne.

- You know, it seems like every week there's news about new promising cancer therapies at the same time that people are still getting sick and some are still dying.

From the broadest of perspectives, what's the current state of cancer research and cancer treatment?

- I think this is an incredibly transformational, exciting time.

We have tools we've never had to understand an individual's cancer risk from birth through the process of living.

And we have incredible new therapeutics to give people hope.

- What are some of those therapeutics that are sort of coming online now that you're most excited about?

- I'm really excited about immunotherapies, harnessing our own body's immune system, that fights cancers and fights infection, to really attack a cancer.

We can do that through vaccines and what we call CAR Ts or cellular therapies.

These are just bringing incredible hope to many patients.

- So has the incidence of cancer in the US and abroad, which is, by the way, the second leading cause of death after heart disease, has it risen during your career?

And give us sort of an overview of where it stands now, both in the US and abroad.

- The complex answer to that, Wayne, I would say yes, cancer incidence continues to rise.

Cancer outcomes, or our ability to treat the disease, also continues to improve.

It's really interesting, 'cause what we call cancer patterns are different among different races and ethnicities across the US, rural versus urban, and that's true across the world.

For instance, lung cancer is the most common cause of death worldwide.

Two million people die a year from lung cancer across the world.

It's also one of the most common cancers here in the US.

So the cancers we're affected from very much depend on where we live, what we're exposed to, and our own genetic predispositions.

- So can you get into a little detail on what we're exposed to, again, both here in the US and abroad, factors that may influence whether or not you get cancer?

Or factors that when you do get cancer, things that we breathe, things that we ingest, things that we're just walking past, you know, to use kind of an absurd example.

- Yeah, it's a really difficult question, but I think it's the most promising area of our research right now.

So first of all, there's a genetic predisposition.

About 15% of us inherit genes from our parents that predispose us to breast or colorectal cancer, or certain skin cancers like melanoma in my family.

And then there's the process of living.

And all of us live in a complex world where we breathe particular carcinogens or causes of cancer, or our diet may expose us to particular chemicals that we believe cause cancer.

But the actual link to proof of causation is complicated, and is a very intense area of what we call cancer genomics or environmental research today in cancer causation.

- So if you're somebody who's concerned about what you're being exposed to environmentally, it often feels like the number of things that we need to avoid, not do, or the things that we should be doing, the list gets longer and longer every day.

Is there a simple way to think about sort of managing our own risks and exposures?

- Again, it's a complicated question, but I do think that's true.

There are certain things we know, cigarette smoking, tobacco use, really increases our cancer incidence dramatically.

Another theory today is our weight.

Being obese dramatically increases our cancer incidence.

So there are certain behaviors, healthy living, avoiding things that we're often told to avoid dramatically reduces our cancer risk.

So it seems simple, because we live in a complex world.

But I think those guidelines are really, really helpful.

- So can you get into genomics in a little bit more depth?

I mean, you don't choose your parents.

You come into the world with genes that they gave you.

Talk some more about that, and what people who may have a risk can do in terms of screening, in terms of changing habits and anything else, please, Dr.

Willman.

- Thank you.

One of the most exciting areas we pursue here at Mayo, and many cancer centers do across the country, is the cancer genome.

So we believe here that probably all of us should have genome or DNA sequencing at birth.

I think this is becoming increasingly commonplace.

We offer it here at Mayo Clinic.

It's an important piece of knowledge all of us should have.

Probably 15 to 18% of us inherit cancer genes that will predispose us to getting cancer early in life.

We call these early-onset cancers.

It's really interesting.

And the disease biology, or the causation of an early-onset cancer, when I get colorectal cancer at age 30, for instance, not age 60, we believe is because of genes we inherit.

So that 15 to 18% of us that have those inherited genes should know about that, because it would tell us to do cancer screening earlier when we can deliver cure and identify those lesions early.

So that's a huge hopeful change in cancer medicine.

The other 75, 80% of cancers occur later in life.

And it's thought to be due to two reasons.

One is we're aging.

That makes our immune system less effective at deleting or getting rid of an early cancer.

And it also is just the mutations we acquire through the process of living in our genome that drive those cancers later in life.

So again, cancer screening at any age is particularly important.

- So obviously that's true, Dr.

Willman, but not everyone can get cancer screening.

You know, we've talked often on the show about health deserts, places where people cannot get, you know, even basic care, even primary care, let alone something more advanced as DNA screening.

Talk about that, because that's a legitimate problem for a lot of people.

And I know it's something that you and your staff have looked into.

- Yeah, it's a huge challenge in cancer is just access.

Access to cancer screening, access to cancer knowledge, and access to treatment.

So two programs that we're developing here at Mayo that I'm really excited about is a program called Cancer Care Beyond Walls.

And in this program, we're using virtual and digital tools to deliver chemotherapy or a cancer screening test in your home.

We can deliver drugs to your home.

We can deliver a test like that to your home.

You can spit in a tube and send it back.

So how do we make cancer treatment, cancer screening accessible to anybody anywhere is through programs like Cancer Care Beyond Walls.

We can set an iPad-like device in your home and be able to talk to you virtually and digitally, and have on-the-ground teams deliver that chemotherapy in a home setting.

So these programs are absolutely transformational.

And here at Mayo through Mayo Clinic Platform and our artificial intelligence programs, our digital platform and tools programs, we're developing what I would call plug-and-play technologies that anyone can access in their home, and health systems also can use from us, to really make access to cancer screening and cancer care much more universal.

So through programs like that, we really wanna change the world.

- Yeah, that's fascinating work.

What are the barriers for that being adopted more widely?

Is it funding?

- I think it's several things.

So first of all, we need policy and reimbursement changes in our government because today where you bill and collect for health delivery, if you will, or health diagnosis, is hospitals and health systems.

We need to change that.

We need people to be able to get healthcare anywhere, and be able to be insured or covered to receive that care anywhere.

So these are national policy changes we're working on.

In our Cancer Care Beyond Walls program, our Clinical Trials Beyond Walls program, where we create access to clinical trials and new therapies for people anywhere in the world, we need to change how we bill and collect for healthcare.

Shouldn't have to be facility-bound.

And so I think these are interesting new initiatives we're exploring, and trying to develop the medical evidence to justify.

So again, you can develop all the technology and tools, but we have to develop the structures where people can access them, and where that care can be provided anywhere.

- Are there any champions of this kind of policy change in politics today?

You don't have to name individuals, but are there people in politics, both at the federal and the state, and even the local level, who are pushing for this, who understand the nature of the problem and understand that there has to be change for the health of Americans to improve?

- Yes, there are.

It's a great question, Wayne.

There are several senators that we've worked with, both Republican and Democrat.

We're really interested in creating much better healthcare access in rural or non-urban settings, for instance, or in tribal settings where I've had a lot of deep experience.

Where can we deliver broadband so people can do these virtual digital tests in their home or in their community where those things aren't accessible?

How do we change the payer mixes?

So there's a lot of interest from our federal government in funding and supporting our Cancer Care Beyond Walls, our Clinical Trials Beyond Walls initiatives, because they really are transformational programs that will change, I think, how we deliver cancer care, how we deliver healthcare in general, and create access in communities to these kinds of critical tools in the future.

So there's very significant interest.

I just gave a talk at the National Academy of Medicine in Washington, D.C.

Several members of CMS were there and approached me.

How do we continue this work?

How do we develop the evidence?

And how do we change policy to really make these things happen?

- I wanna get really clinical, I guess, for just a minute.

So at sort of a fundamental level, when somebody is diagnosed with cancer, what does that actually mean?

What is happening in that person's body?

And let's take something like pancreatic cancer.

- Okay, so what we think happens is you either have a genetic predisposition or you've been exposed to some sort of environmental insult, or your immune system is sort of faltering that allows this tiny growth in one of your body organs to begin to grow.

And that grows larger and larger.

So one of the keys in early cancer detection is early detection.

So for instance, investigators here at Mayo have a new CT scan using AI that can detect a pancreatic cancer one to three years before it's normally seen on a CT by a radiologist.

If I can do that and I can come to that person's home and actually create devices or imaging studies in their community to detect that cancer, and I have a way to go up the pancreatic duct and eliminate that cancer, that's a future cure.

That's where we're trying to move at Mayo in the early detection, early screening broad healthcare delivery programs.

So these kinds of tools for early lung cancer detection, early pancreatic detection, are being developed.

- Somewhere along the way, I remember, and if I'm wrong about this, just stop me, but I think I learned at some point that cancer cells are formed periodically in the body and the immune system typically destroys them and washes them out of your system.

Is that accurate?

- That's absolutely accurate, Jim.

You have the knowledge base.

That's exactly correct.

And in fact, not to upset everybody, but all of us probably acquire about a million mutations a day in our cells from the process of living.

And our immune system is constantly looking for those to clear and get rid of those cells.

- And so that's my next question is, why do some cancers then evade the immune system and then actually become a problem that the body can't handle on its own?

- Two reasons.

One is the mutation in the cancer cell itself may shut off the immune system.

And that's actually really common.

One of the Nobel Prizes that Jim Allison received, I think you know, is that certain cancer cells mutate and create a protein they secrete that just shuts off the total body's immune system.

So they become hidden or silent.

So a lot of immunotherapy is working to reverse that, to make the cancer cells seen again by the immune system so it can be eliminated.

So a strategy that cancer has is to try to outsmart our body by hiding from the immune system through these actual cancer-causing mutations.

- Can you say just a little bit about the CAR T-cell therapy.

Can you say a little bit about the leaps that had to be made, and the science, to bring that kind of technology to bear in the treatment of cancer?

- So the whole CAR T field started from what I just talked about, the recognition that cancer cells actually secrete a protein, this time it was called PD-1 or PD-L1, that shuts off the immune system.

And it's like, how do I get rid of that protein?

Can I make a T-cell, which is a type of immune cell, targeted to that PD-L1 to knock it out or scoop it up?

That was the beginning of CAR T therapy.

So now CAR T-cells are often directed to antigens or proteins on cancer cells, like B-cells or solid tumors like a lung cancer, and you're creating an immune cell to go in and directly attack the body's cancer.

So we can develop CAR Ts now to different types of cancer, and they'll go into the body, find that cancer cell as an active immune cell and try to attack the cancer directly.

- So Dr.

Willman, in my journalism over the years, I've written many articles about cancer and cancer patients, and one thing that comes up almost always when you talk to a cancer patient, aside from the science and the healthcare and what we've been talking about here, is the emotional stress, which is significant.

Can you talk about that?

Because that's another side of this coin that is critical.

- Well, I get pretty personal about this.

As a two-time cancer survivor myself I know what that feels like.

You know, that feeling you have a diagnosis of cancer makes your feet, like, connect to the earth.

It's shattering.

I don't know that there's any more fearful diagnosis, perhaps cardiac disease in human beings, that shakes them so much.

What I wanna say though now is there's just so much hope through early cancer screening and detection of small lesions that we can ablate and get rid of through better treatments.

There's a lot of hope for a lot of cancers.

So even though I said earlier that cancer incidence is rising, cancer survival's also rising, because we're getting better and better and better at developing less toxic therapeutic mechanisms for this disease.

But it comes back, Wayne, to the question you asked me earlier, how do we make sure all Americans can access those capabilities?

- Dr.

Willman, you're, you've done pioneering work in the field of individualized medicine.

I think it sort of sounds self-evident, but for those who maybe aren't quite familiar with what that is, could you tell us a little bit about it and why it's so promising in the field of cancer research?

- I can tell a quick story.

So about 10 years ago, I was really interested, my expertise is leukemia, and particularly leukemia that occurs in little children.

And we were making great strides here in the United States with hugely increasing survival of children with leukemia because we developed better drugs.

And yet I noticed there were 20 or 30% of kids, we could give them the most massive chemotherapy and they would have a horrible experience, quite honestly, for four years with that massive chemotherapy.

And we weren't curing them.

They were still dying.

And I wanted to do a study at that time with the National Cancer Institute, so I asked for 1,000 samples from the Children's Oncology Group of children who simply never responded to chemotherapy.

One of the interesting things I didn't ask for, that we looked at though of those 1,000 children, is a large fraction of those kids turned out to be Hispanic and American Indian.

And what we did is we sequenced the genomes of all those cancer cells.

And we found a new mutation, which no one had reported before, that created a particular type of leukemia.

And we found that this particular mutation was much more prevalent in Hispanic and American Indian children with leukemia.

And what we found, as we found the mutation that was individualized, we found a specific mutation in this group of children, is that the pharmaceutical industry actually had a drug on the shelf that targeted that mutation.

And we immediately got approval from the FDA to start a clinical trial testing that drug in these children.

And I remember to this day, the first child that got that drug was an eight-year-old little boy in Colorado who was going through what we call induction chemotherapy, the first phase of really intensive chemotherapy, was a soccer player.

Remember his dad?

He fell on the soccer field, had a massive bleeding episode, went to the University of Colorado to their hospital.

And the doctors up there called me up, "Hey, Cheryl, we think this kid is one of those kids that maybe you're studying."

And we sequenced him, I remember that weekend.

I remember folks in my lab poring through the genome sequences over the weekend.

He had this mutation.

We got permission.

This was a mutation in a gene called JAK, J-A-K.

We got permission to use the drug from the pharmaceutical industry.

That child is an adult today, and he's alive.

And it was the most dramatic thing I've ever seen.

So that is individualized medicine.

When you can find the specific mutation, you can target a drug to that mutation, and you give somebody a cure.

It's one of the most beautiful stories in my career.

It's absolutely true.

But we wanna repeat that kind of story every day.

So that's my story about individualized medicine.

Started with genome sequencing, started from finding the mutation.

And we were blessed that a pharmaceutical industry had already developed a drug to this particular mutation that we could use.

And then we ran very large national clinical trials proving that we could give great hope to this group of children who had, prior to this, just not been surviving.

- I think we've probably already addressed this, but I wanna come back to the issue of how do you scale that from an individual example to, you know, a population of tens of millions of people who could potentially benefit from that?

Are there specific barriers beyond policy to what will make this ultimately available to the people who need it?

- Yeah, so the issue here is access again.

So today at Mayo Clinic, every cancer patient who comes through our doors has comprehensive sequencing of their cancer.

We look for clues.

Are there mutations in particular genes that we can tailor or individualize this person's treatment to them?

In a big project I'm funded for by the National Cancer Institute called Participant Engagement and Cancer Genome Sequence, we've brought this to the tribal communities of the American Southwest in New Mexico, Arizona.

And we have actually sequenced almost 500 American Indians with cancer who have not been studied before.

And we're finding a number of mutations that we think will be targetable with new therapies in their cancer.

So this scale-up is coverage by insurance companies for cancer genome sequencing for any cancer patient.

And it's about access to this kind of testing where we can bring people hope.

- Is the sequencing very expensive?

- It's actually gone way down.

So it used to be when I started, back when this little boy from Colorado was sequenced.

If we'd had to pay for that, we had a federal grant to cover it, it would've been $10,000.

Today I can do that sequencing for about $1,000.

And sometimes $300 if I wanna do a smaller test.

- Can you talk a little bit about your background, please, Dr.

Willman?

The road that brought you to where you are now?

- I was a little Midwestern kid born in Southern Indiana.

Born to a normal rural family in Central Indiana.

I had a grandmother who was very powerful, who really pushed all of us grandkids to go to college and go to school.

She was amazing.

She was a teacher, but she had a degree in mathematics and linguistics, so she was pretty powerful.

So I went off to college and school, and I loved it.

And just at the time I started college in the Midwest at St.

Olaf, the genome studies began.

And it just intrigued me.

And I was fortunate enough to get accepted to Mayo Medical School.

And in my third year of medical school, they allowed me to take what's called a physician-scientist training fellowship at the National Institutes of Health.

So I went off from in between my second and third years of medical school, and was able to train at the National Cancer Institute.

One of my mentors was Tony Fauci, by the way.

And another individual doing genomics at that time.

And it just started my career.

So my career has always been a blend of medicine.

It's been a blend of very advanced science like genomics and targeted therapies.

But where I come from and where I've been, I don't like to leave people behind.

So I built a cancer center in New Mexico where I went after I finished my training at Mayo and at the Fred Hutchinson Cancer Center in Leukemia.

And 25% of our patients were uninsured at that time 20 years ago, and about 40% were Hispanic or American Indian.

But we found a way to bring cancer care to all of those patients.

So when I came to Mayo, I came back to Mayo, it was interesting.

I remember speaking with Dr.

Gianrico Farrugia, our CEO, and I was having trouble leaving New Mexico to return to Mayo Clinic.

You may think that sounds crazy, but I thought, what am I gonna do at Mayo Clinic?

That's, you know, the premier healthcare institution in the world.

Who gets access to that?

And Gianrico said to me, "Cheryl, I'll give you the resources and tools to where you can build what you've done at New Mexico for everyone."

And he meant it.

And that's where we've developed the Care Beyond Walls, the Trials Beyond Walls, and bringing all of our AI, virtual digital technology to bring what we're talking about to anyone in the world.

That's really our goal.

- So Dr.

Willman, we've got about 30 seconds left here.

I wonder if you could just sort of encapsulate for us, can we imagine a future where cancer is cured or at least reduced to chronic disease status?

- Jim, I believe we absolutely can.

I believe we absolutely are ready to a place where we have the tools for early detection and for therapeutic intervention, and for much more targeted, less toxic therapies for the majority of cancer patients.

We have a very, very hopeful future.

- Dr.

Cheryl L. Willman, thank you so much for spending some time with us.

That is all the time we have this week.

If you wanna know more about "Story in the Public Square," you can find us on social media, or visit salve.edu/pellcenter where you can always catch up on previous episodes.

For G. Wayne Miller, I'm Jim Ludes asking to join us again next time for more "Story in the Public Square."

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