Today I'm speaking with Dr. Ash Tewari, the Ronald P. Lynch Professor of Urologic Oncology at Weill Cornell and director of the LeFrak Center for Robotic Surgery. He's now the founding director of the new Center for Prostate Cancer. Dr. Tewari is a renowned urologist, a surgeon and a prostate cancer researcher who is at the leading edge of translational research.
LAURIE H. GLIMCHER: Ash, it's really a pleasure to be talking with you today.
How prevalent is prostate cancer, and what do you think it's going to take to find a cure?
ASH TEWARI: Thanks for giving me an opportunity to be part of your elite group. Prostate cancer is one of the commonest cancers. Every year we are finding about 200-plus thousand men with prostate cancer. And, as to what it will take, if you as a dean and [Weill] Cornell as an institution, and me as a surgeon, and someone as a basic scientist, put together a resolve that we need to find out why this is happening, I think we can do it.
GLIMCHER: I agree. What does robotic technology allow us to do that we couldn't do before?
TEWARI: Laurie, prostate is in a very delicately-located structure. And this organ is within millimeters from very delicate nerves and walls which control urination. The robot gives this magnification with more precision and also a lower amount of bleeding.
GLIMCHER: What's the future of robotic surgery? There must be so many advances on the horizon.
TEWARI: I think the future is what we will make out of it. For the first time, there is a computer between surgeons' minds and hands and patients' bodies. So, that allows it to integrate data from the different sources and superimpose them onto the surgical field. So when, as a surgeon, I see my hand, I see the skin, I can appreciate where the bones are, but I cannot see the nerves. But supposing I have another layer between my eyes and the hand which allows me to bring in the real-time MRI images on my hand, and then if I'm doing surgery, I can see where the nerves are and I cut a little different[ly].
GLIMCHER: When you get questions from your patients, which I'm sure you do, how do they inform your own research?
TEWARI: These are the connections which drive the research, which give me ideas.
GLIMCHER: You have so many grateful patients. I cannot begin to tell you how many grateful patients have talked about you to me. Do you find that they inspire you?
TEWARI: So, the patients drive my quest [for] whatever I'm doing. And I can tell you one confession: Grateful patients inspire me, but the patients who didn't do perfect, they inspire me even more because those are the ones where I couldn't deliver, sometimes because of the limitations of the technology or limitations of the disease itself. If I got to a cancer a little late and the cancer is already going into a sphincter or into a nerve, then I have to balance the competing interests. Can I get all the cancer out? So, those patients have given me more motivation and they are the reason for my resolve that we need to make a difference.
GLIMCHER: Was there a particular question you can think of that was devised by one of your patients that led you to generate a particular hypothesis?
TEWARI: More than once. One of the areas which I'm very excited about is real-time decision-making. As I surgeon, I operate today — I did two surgeries today. Seven days later, I'll find out if I could take all the cancer out or not. Patients always question, 'Why don't [you] know about that right when you were doing the surgery because at that time you could have gone and removed more than seven days later telling me: Oops, I couldn't get all the cancer out.' A patient comes to me and he says, 'Now, doc, in every other specialty they have a mammogram for the breast cancer; they have a CT scan for the pancreatic cancer. Why don't you have real imaging for prostate cancer?' This was happening in 2005 and '06. There was no real imaging for prostate cancer, so what I started doing was to talk to my radiologist colleagues and we started experimenting with a different kind of MRI. We started trying different variables in that MRI and combining that with what was happening in Ithaca. In Ithaca, there is a very senior National Academy of Sciences member Watt Webb, and Watt Webb was working on a specialized laser that he could bombard onto a tissue without damaging it. So, we started getting a real-time imaging of a tissue doing microscopy level without need for the specimen coming out of the body. Imaging with an MRI and multiphoton is one of my real passions right now.
GLIMCHER: It's a huge advance, and I love the way you teamed up with our parent university up in Ithaca. So, how important do you think it is to identify those patients whose prostate cancer is aggressive and is going to require surgery and distinguish them from those whose prostate cancer is indolent and you don't really need to do anything about?
TEWARI: This is that $1 million question, which the field of urology is dealing with. We may be a little ahead of most programs. So, I recently analyzed my data as to what kind of patients I operated on. For the last eight years, I've operated on close to 4,000 patients. I looked at how many of those were so-called indolent cancers, what you call a Gleason 6. And in my program, in the last few years, the indolent cancers have been less than 15 percent. And most of these patients were in their 50s, meaning very young patients and which you cannot ignore — 40-65 percent of the patients in other programs with Gleason 6, while in mine they are 15-20 percent.
GLIMCHER: You've recently been named the director of the Prostate Cancer Center. What issues are you going tackle?
TEWARI: What I see my role to be is like a conductor. I want to create a symphony, which is best fitted with the best musician of a different kind. I want to have people with an expertise in medical oncology, in genomics, in imaging and focal therapy, in surgery, in post-op recovery, in the basic research, targeted therapies, and if I can put it all together, this is what I define success.
GLIMCHER: The U.S. Preventative Task Force recommended in May that healthy men should not be screened for prostate cancer using the PSA [prostate-specific antigen test] because the resulting diagnosis could do more harm than good. What's your reaction?
TEWARI: I mean, I think they went through a similar kind of recommendation for breast cancer, also. From my perspective, people still need to know about prostate cancer. Even if PSA is not a perfect test, it's a great alarm. What we need to do as urologists is to use that information in a more careful way. Not every abnormal PSA needs downstream testing, needs downstream invasive testing and definitely doesn't need a treatment. So, if we combine the prudent use of clinical exams, other markers like PCA3 [a gene used as a prostate tumor marker], other biomarkers are on the horizon, imaging — I really am a big believer of imaging — and combining all of that with patients' own unique profile in terms of the history, other medical problems, we can make better decisions.
GLIMCHER: Where do you think your enormous, astonishing surgical skills come from?
TEWARI: I think I'm still learning. I was more of an outdoor-ish person. I used to play Cricket. I have been known more for my Cricket in my earlier life than for medical school.
GLIMCHER: What inspired you to pursue a career in medicine?
TEWARI: For me, the loss of some very important people in my life, and maybe my father not being able to go to medical school even though he got into [it].
GLIMCHER: It's been really wonderful talking to you, Ash, and I'll say again how delighted I am that you are leading this new center.
TEWARI: Thank you.