OncoDaily Dialogues #5 – Sarkis Meterissian / Hosted by Roupen Odabashian

In our ongoing series called “OncoDaily Dialogues,” we consistently feature prominent individuals in the field of oncology. We showcase their achievements, obstacles they’ve overcome, and significant moments in their journey.

Today, we have the privilege of hosting Dr. Sarkis Meterissian, a renowned oncologist from McGill University, Professor of Surgery and Oncology, Past-President of the Canadian Society of Surgical Oncology and Past-President of the Breast Surgery International, as our distinguished guest.

Dr. Meterissian studied medicine at the MUHC, from which he graduated in 1985. By 1990, he had completed his residency in general surgery in the University’s teaching hospitals and completed a two-year research fellowship in surgical oncology at New England Deaconess Hospital in Boston. He went on to complete a second two-year fellowship in clinical surgical oncology at MD Anderson Cancer Center in Houston, Texas, under the supervision of Dr. Charles Balch. Along the way he obtained a Masters in Experimental Surgery.

In 1994, Dr. Meterissian returned to McGill University as Assistant Professor of Surgery and Oncology. From 1997 to 2001, he served as General Program Director in surgical oncology. In 2001, he was promoted to Associate Professor with tenure in addition to becoming Program Director of General Surgery, a position he held until 2007, when he took his current position as Associate Dean of Postgraduate Medical Education. In 2010, he was promoted to Full Professor.

He has been a member of the Centre for Medical Education since 2001 and was President of the Canadian Society of Surgical Oncology from 2007 to 2009. He was the Chair of the AFMC Standing Committee of Postgrad Deans, the President of the Quebec Postgrad Deans Group, as well as the President-Elect of the Canadian Association of University Surgeons and of Breast Surgery International. He currently serves on the Board of Directors of the Collège des Medecins du Quebec.

Named outstanding General Surgery Teacher in 2000 and 2001, as well as Outstanding Teacher in the Department of Surgery in 1996, he was also named in 2005 to the Faculty Honour List for Teaching. In 2007 he was awarded the Philip Wolfson Outstanding Teacher Award by the Association for Surgical Education, which comprises more than 190 North American institutions and medical schools. Finally, from 2007 to 2009 Dr. Meterissian was an International Medical Education Travelling Scholar in Utrecht and Stockholm (biography from https://mcpeaksirois.org/en/scientific-committee/dr-sarkis-meterissian/).

Dr. Meterissian is also a member of the Editorial Board of OncoDaily and is co-chairing the Breast Cancer Working Group of Immune Oncology Research Institute, sharing his expertise and educating oncologists from LMICs.

Our host is Dr. Roupen Odabashian, hematology/oncology fellow at Karmanos Cancer Institute in Detroit, USA. Beyond his clinical practice, Dr. Odabashian possesses an unwavering passion for delving into the intricacies of healthcare policy, regulations and Oncology. He understands the multifaceted nature of cancer as a medical condition and acknowledges the various stakeholders and regulatory bodies that influence the delivery and administration of cancer treatments. In alignment with this commitment, he has joined OncoDaily, where he plays a pivotal role in conducting interviews with Leaders of the Cancer world.

About OncoDaily 

OncoDaily was founded in 2023. It is a US-based oncology media platform, which features the latest news, insights, and patient stories from the world of oncology. Within a short period of time it became one of the leading oncology media platforms globally.

OncoDaily gathers content from various sources, including social media posts from renowned oncologists from all over the world, news from oncology societies and cancer centers, patient and survivor stories, and career-related information for professionals.

The mission of OncoDaily is to empower patients, survivors, and professionals with the knowledge and inspiration they need to fight cancer. The motto of OncoDaily is “Cancer doesn’t take a day off – neither do we”.

Previous series:

OncoDaily Dialogues #1 – Harout Semerjian / Hosted by Roupen Odabashian

OncoDaily Dialogues #2 – Piotr Wysocki / Hosted by Roupen Odabashian

OncoDaily Dialogues #3 – Andrés Wiernik / Hosted by Roupen Odabashian

OncoDaily Dialogues #4 – Therese Mulvey / Hosted by Roupen Odabashian

Follow the transcript below:

Roupen Odabashian: Alright, welcome Dr. Meterissian. Thank you so much for being here.

Sarkis Meterissian: Thank you, Roupen.

Roupen Odabashian: So, Dr. Meterissian, can you share with me your journey from your initial medical studies in Montreal to becoming a professor of surgery and oncology at McGill University? How have these roles shaped your approach to Surgical Oncology?

Sarkis Meterissian: Thanks, Roupen. In medical school, if I go back to that time, I was always interested in surgery. The moment I started Anatomy, it interested me very much – the dissection, the human tissues. So that was the beginning of my interest in surgery that blossomed during medical school. And interestingly, during residency, as I was trying to figure out where I was going to go in terms of subspecialty, you’ll be intrigued to know that ironically, when I went to rounds with surgeons, medical oncologists, radiation oncologists, I noticed that the medical oncologists and radiation oncologists had a lot of knowledge of the biology, of the research, of the treatments available.

And the surgeons, of course, were very good surgically, but however, they were in many instances would do what the oncologists would tell them. And I asked myself, well, maybe I want to become a surgical oncologist so that I don’t want to be told what to do. I want to be part of that discussion. And so that was the interest that I had. And so then, then I also liked Surgical Oncology for the fact that it combines, as you know, the best of research and clinical and gives you unique opportunities to do both.

Roupen Odabashian: Yeah, I agree with you. It’s very, I think the field of cancer, of course, I haven’t done Surgical Oncology, but the field of cancer by itself is very unique. It’s different. It’s a different beast. It’s different medicine. Like, I think all the studies in medicine are on one hand, and oncology, medical, surgical, radiation, it’s completely different world. And I got exposed late to oncology, which is, unfortunately, that’s how Internal Medicine training is like. You get very small snippets, but I think it is actually one of the best fields out there.

Sarkis Meterissian: Agreed, agreed. And the link between the surgeon and his or her patient is a link that cannot be reproduced in any other branch of surgery. You know, whether you do a gallbladder, hernia, the patient comes and goes. The cancer patient stays with you for years, decades, and they follow you, and they see you once a year. It’s a special bond that I feel privileged to have had over my career.

Roupen Odabashian: Yeah, I completely agree. I just started my fellow clinic, and it’s nice. Like tomorrow, I know I’m going to see the same patient I saw a couple of weeks ago, and we’ll have some discussions about their kids, about their family. 

Right, so let’s shift gears about, let’s talk about New England and MD Anderson. You’ve done your fellowship there, so what were the key learnings that have influenced your career? This would be the first part of the question, and the second part I want to touch base on is like, you were in Canada, and I did my internal medicine residency in Canada, and the education there is great. What led you also to leave Canada and seek more education?

Sarkis Meterissian: Okay, well, first of all, you have to remember back in 1990 when I finished my surgical residency, we didn’t have very many fellowships in Canada. That’s number one. There was no Surgical Oncology fellowships in Toronto, Montreal, Calgary. Now they all have fellowships, and even more, there are even more cities with fellowships. So the second thing was, I wanted to go to a different place. I wanted to see how it’s done in a different place, to bring new knowledge, your new techniques back to McGill. And you’ll be surprised to know that I, being stubborn, I absolutely wanted to go to Sloan Kettering or MD Anderson.

When I applied to those institutions, I didn’t get in. Oh, I didn’t get in in 1990. So I wrote them. I wrote them. I said, you know, could you please tell me why I didn’t get in? And they told me, well, because your CV does not have enough publications. So that led me to say, okay, well, then we’re going to fix that. And, you know, Armenians, we don’t ever say we’re defeated. So I went, I went to Dana Farber, I went to the New England Deaconess, which was associated at the time with Dana Farber.

I worked with someone by the name of Dr. Glenn Steele, who was a liver surgeon. And so I didn’t do breast research. I did research on metastases to the liver, trying to understand their biology. Very successful two years, didn’t do any clinical work, didn’t touch a scalpel. Very scary for me, the first day at MD Anderson. So when I applied, I got in. And then I went from 1990 to 92, I was pure research at New England Deaconess, and then I went to MD Anderson. And I went into, like, as you know, Sloan Kettering, MD Anderson, the centers in the US that specialize in cancer, I call them Disney Worlds of cancer. Anything you want to do, they do. The trials, the research, the discussions, just the excitement of being at the leading edge of cancer treatment and research was so exciting for me. And then we came back in 1994 to have my practice at McGill.

Roupen Odabashian: Wow, that’s very inspiring. And I just want to touch base on one point you mentioned, that you spent almost two years studying the mets in the liver. In one of the previous episodes on OncoDaily, we met with Dr. Vierck, and we talked about this topic. I want to grasp your mind, grab your mind. How do you feel that different metastases behave in different organs?

Sarkis Meterissian: Well, you know, we have progressed a lot in cancer, in understanding of cancer biology, but the seed-soil hypothesis was come, they came up with that many, many decades ago, and it still holds truth. And now we’re understanding why that is the case. So colon cancer going to liver, sarcomas going to lung, you know, uveal melanomas going to the eye, going to the liver, and so, you know, and certain types of breast cancer like triple-negative going to the brain, and then others going to bone.

So it’s very interesting, and we’re beginning to understand more and more as we’re getting into the genomic analysis of tumors and their metastases. So I think it’s fascinating, and we have made such progress. When I was a resident, we didn’t, even the cure rate of breast cancer was in the 60s, 70s, now we’re in the 90s. And the cure rate of liver metastases was barely 25%, and now colon cancer with the true newer treatments and new surgical approaches exceeds 50%. So it’s really amazing.

Roupen Odabashian: Yeah, I agree. It’s very fascinating. And I think now with the technology is like getting faster and faster, we are learning more about our genomes. For example, like companies like 23andMe have like tons of genomic data, and we have the large language models. So the combination of both is very fascinating and exciting. I think this is the best time to be an oncologist, surgical oncologist, medical oncologist, or radiation oncologist.

Sarkis Meterissian: I agree very much. Although, like, anytime, in 30, 40 years, people look back and say, “I can’t believe they were operating on breast cancer,” because then they’re going to, because of the genomic analysis and newer treatments, maybe we will do biopsies and then we’ll treat the cancers by intravenous treatments or maybe by local injections or radiotherapeutic approaches. So I think the, it’s amazing even in my career how cancer knowledge and treatment has evolved, and if it changes, and breast cancer is one that changes almost monthly, let alone yearly.

Roupen Odabashian: Yeah. Before we started the episode, you were talking about your students, and it’s very inspiring to see that despite everything you’ve achieved, you are still heavily involved in mentorship and education. And I want to shift gears toward my next question. So you’ve been recognized for your educational excellence, including being on a mill faculty honor list and receiving the Association of Surgical Education Outstanding Teacher Award. What drives you? What’s going on in your mind that motivates you so much to give back to your students?

Sarkis Meterissian: You know, Roupen, I love research, I love clinical work, but early in my career, I realized that I can make a real impact on young people. I can influence them. Even if they don’t become surgeons, even though they don’t become oncologists, I can try to influence them to be caring doctors, good doctors. And you know, a good teacher, and I’m sure you’re the same, you, if I told you, if I asked you who are your mentors, you’ll remember them. And those mentors, you never forget.

So I said to myself, you know, I’m going to make an impact on these young people. And even if, you know, you and I are doing very well in our careers, but you know, the Nobel prizes, it hit me that, you know, the Nobel Prize is fantastic, and, you know, an Armenian won one recently, as you know, but if I challenged you and asked you who won the Nobel Prize in medicine in 1987, you know, but if I told you, give me your mentor in medical school, you will say it in a second. And who is your mentor in residency, you will give me the name. And so that’s why I said, you know, I want to make a mark for myself, one student at a time.

Roupen Odabashian: That’s very inspiring, actually. That’s very deep. Because like, literally, because I, I don’t know who got the Nobel Prize in 1970, but I remember very well one of my best mentors in residency. Like, he, despite he was an accomplished researcher, and for me, being accomplished means like publishing a New England Journal of Medicine or one of those names. Despite that, like, he used to meet with me every two weeks, and I remember him very well. And before leaving Ottawa, like, I went there, I hugged him, brought him a gift, because like, he made a huge difference in my life.

Sarkis Meterissian: You brought him a gift, like that is special. So he influenced you, and that’s something that a New England Journal paper is fantastic, but if he influences 20 people like you, he’s made a difference.

Roupen Odabashian: Yeah, yeah. Now I want to talk more about your research. Could you share some insights on your current research, especially about breast cancer and melanoma, and how do you see your current research topics are contributing to the general field of oncology? I’m very excited to hear what you’re working on.

Sarkis Meterissian: So, I, all of my research is in the area of breast cancer. I do clinical work in melanoma, but my research is breast. And my research in breast cancer can be divided into two parts. I work on the wellness, kind of the non-medical treatments of our patients, and I’ll explain that to you in a second. And then I also work on translational research. So on the non-medical, I’m very interested in how to improve patients’ lives after a diagnosis of breast cancer.

And I’m not talking about chemotherapy, radiation, surgery, all those things. We’ve done tremendous advances, we’re curing disease, but you know, we have a human being behind the disease. So we say, wow, fantastic, we’re so good, we cured the cancer, but did we heal the patient? And they’re sometimes broken. They have trouble going back to work, their marriage breaks apart, they have trouble concentrating, chemo brain, difficult relations to their loved ones. And those are things that we in medicine haven’t paid enough attention to.

So I have a grant, I have two grants, one from, two, both from the Quebec Breast Cancer Foundation. One looking at the influence of a life coach in the integration of a breast cancer patient after treatment, randomized between having a coach and not having a coach. And, you know, looking at their adaptation to life, looking at their coping skills, anxiety, trying to see how we can decrease that. Because as you know, well, you can treat a patient today, cure them in six months, and you say, and in five years, we call them cured.

But have they really been able to reintegrate? That’s the question. Now, I just recently got a grant looking at nurse navigator because we have a rapid diagnostic clinic, trying to ask the question, does a nurse navigator decrease the anxiety, stress, and improve coping skills of our patients as they come in for biopsies? Because many patients come in and they don’t know what’s going to happen. First of all, they may not have cancer, but if they do, they don’t even know what biopsy they’re going to get. So we’re trying to look at how to make the journey easier for the patient. So that’s a lot of the work that I’m doing in breast cancer.

We also have, I’m involved in a clinical trials group in Quebec called Q-CROC, that brings together 11 hospitals and universities together. And in that area, I was lucky enough that I got inspired by the Canadian Kidney Database, kidney cancer database. So I decided to see if we could start a metastatic breast cancer database. There isn’t one in Canada. There is one in BC, cancer agency has put one in BC, there’s Princess Margaret, but province-wide, no. And so now with pharmaceutical companies and the Canadian Cancer Society, we were, I was able to establish a breast metastasis registry that we have over 600 patients, trying to look at the real-world evidence.

Because as you know, a lot of metastatic patients are treated on a compassionate basis. They get medications that are not on trial, and nobody really studies these results. Now we’re going to be able to study the results, and that’s why the pharmas are so interested, and they’re throwing money at us because they want more and more patients, and they want to study patients and the effectiveness of the treatments. Now, in the translational side, I’m very interested in better understanding two areas.

I’m involved with a very bright young researcher looking at circulating DNA, and with the breast metastasis registry, trying to ask the question, can we use circulating DNA as a marker of response to therapy in metastatic breast cancer and as a predictor of recurrence? So we have a grant from a private family here that we made an application to, to get preliminary data using our metastasis registry, combining that with the basic science of circulating DNA and sequencing the tumor that belongs to that patient because we have, in order to see if there’s a correlation with the circulating DNA.

And then, of course, the last area that I have a grant, we just got a grant as well on DCIS progression to invasive cancer. What influences it, what’s the molecular biology of it? Because I’m convinced that we overtreat a lot of patients with ductal carcinoma in situ, that we give them radiation, we give them anti-hormone pills, as you know. And some of these patients are never going to have a problem with their DCIS. So which DCIS should we treat, which one should we not treat? We really don’t know the answer. Right now, we treat everybody the same. A lot of studies are being done to try to determine if you can deescalate the treatment, but we’re trying to understand the molecular biology of DCIS.

Roupen Odabashian: Dr. Meterissian, you touched on many, many points that are very fascinating, and I just want to circle back. You mentioned, and I want to grab your mind. I think one of the things that you brought up, and it’s something I see in my clinic, my patients, every day, we discuss lots of trials. This treatment, treatment X was better than treatment Y by, for example, 4%, and improved survival by four months. So it got approved because there is nothing else available. But none of these trials are taking into account the patient’s quality of life on treatment X and treatment Y. And you brought a very important point. Like, those patients get broken up financially, emotionally, from the family side. How is your experience, and how you discuss those? How can you discuss this with your patient beyond the numbers that clinical trials give you? How can you talk to them about, how is your quality of life going to be on treatment X versus treatment Y?

Sarkis Meterissian: Well, you know, it’s a difficult discussion. But, and sometimes, the discussion comes from areas of uncertainty because we really don’t know if in this particular patient, one of those treatments may be even the 5% to 10% or 20% of patients that will respond and may be a long-term survivor. So my discussions usually center around the fact that, as you said, sometimes we don’t have many choices. Why don’t we try to put you on the trial? But if you become severely symptomatic or disease progression, then we should take a step back.

And then we should say, okay, we tried. And maybe now, when we have a better idea of whether the patient has a limited lifespan or is curable, then we make a decision, either we go palliative, or we continue being aggressive. So I think all my career, I’ve tried to balance what are the life expectancies versus the treatment side effects. And when a patient is curable, we have to be even more careful because we don’t want to, for example, operate and do a full axillary dissection and find all the lymph nodes are negative. And then they get lymphedema, which they have to live with for life.

And they die at 89, their arm is, and they’ve had a terrible life because they’ve had to deal with an arm which is four times the size of their normal arm. And we give them antihormone pills that give them hot flashes and bone pains that are far exceeding, as you say, the percentage. One thing I do do, Roupen, is I’m very careful to explain to them the absolute survival advantage. For example, if it’s 3% on 10%, I never will say 30%. I will always say, you know, I will try to explain to them that there’s 10% survival or recurrence, and if you take the pill, it’ll be 7%. So that they understand that the true advantage is 3%. So then I, and I explain to them, is 3% important to you? And I’m very careful because, as you know, one patient, they want everything. 1%, give it to me. The other patient will say, no, no, no, 10% is my cutoff. And so I’m very careful to kind of match the treatments with the patient’s character and give them factual data.

Roupen Odabashian: Gotta also, you mentioned that you were able to fund your research by a grant from a family. I think one of the things that researchers always struggle with is having enough a grant. But this is one of the few times that I’ve heard like creative way of financing or funding your research. Can you be, if that’s okay, like, expand more on your experience? How were you able to work with this family who were able to grant this or fund this research to help answer important questions?

Sarkis Meterissian: Sure. I’ll tell you two stories, in fact. One that you’ll find fascinating, but maybe you already found that story on the internet, but I’ll tell you the second story first. For the family, breast cancer, we’re lucky. You know, we’re not an orphan disease. We’re not like melanoma, pancreatic cancer. You know, breast cancer has a lot of people. A lot of people have breast cancer, a lot of people with means will contact us and say, you know, we like to make a donation.

And, “Is that, but we like to make it to a specific project.” And that’s when we get together in our, with, you know, whether it’s a clinical project or we get together, as I said, with this basic scientist who, looking on circulating DNA, and say, hey, there’s a family, in this case, the family was wanting to give 200,000. There’s a family who wants to donate 200,000.

I think we could use this money to do research in the area of metastatic breast cancer with your expertise of circulating DNA and my breast metastasis registry. Why don’t we put that together? And we come up with a proposal which the family liked. The second thing I, the second thing I was going to talk to you about is in 2021, in the middle of COVID, every year, we have fundraisers for breast cancer. We have a gala dinner. We raise usually between 150 and 200. We use that money for everything from equipment to funding trainees or fellows or to do fund research.

But during COVID, we couldn’t do any of these events. So the foundation said, you know, Dr. Meterissian, how about if you shave your head for breast cancer? So I said, initially, my initial response was, are you crazy? But then my wife encouraged me. So for one year, from October 2020 to October 2021, I did not cut my hair. And if you look on the internet, you’ll see, when you look under images, it’s easy to find me with very long hair. Then two days before, I dyed my hair pink, on October 20th, 2022. And then I shaved my head bald, and I raised, anD now hold on to your seat there, Roupen, I raised $347,000.

Roupen Odabashian: Oh, wow. This is unbelievable.

Roupen Odabashian: And when I started, they said, how much will it take for you to cut your hair? I said, if I raise 50, I will cut my hair. And I was thinking, who’s going to get 50? But, but we, first of all, the company Pfizer gave 25, Gilead gave 12, AstraZeneca gave 15, Avon matched every dollar up to 200,000. So, and the patients gave the rest. So we finished with $347,000. So that was another way to fund projects. And not, not a way, I mean, guys like you can do it, Roupen, you have a lot of hair.

But not easy way to raise money. But, you know, I was on the front page of the newspaper, “Doctor shaves his head for breast cancer.” So it was, I was really happy. And the patients were so understanding and so happy that I was doing that. The patients had lost their hair during chemo, and one of them gave me even a hat. They said, “You’re going to be cold when you’re bald.” And they were right. I was cold because I cut my hair in October, and it took months, like three, four months for it to grow. But I’m doing well.

Roupen Odabashian: You’re doing amazing. That is very inspiring story. That is very inspiring story. And like, I’m speechless. It’s fantastic. Like in my mind, because like the only way to fund your research is like go to different organizations and apply. But like, you became so creative in finding ways to answer questions.

Sarkis Meterissian: Yeah, I was. But anyway, make me happy after this phone call, and also for people who view this, just Google me and Google the images. You’ll see what I mean. You’ll see pictures of me with pink hair and bald head.

Roupen Odabashian: Alright. So before shifting gears and talking about the Surgical Oncology in Canada, I want to ask you, um, specific questions to yourself. What advice would you to give your younger self 10, 15, 20, 30 years ago? What would you, if you are now talking to yourself, what would you say?

Sarkis Meterissian: I would say, enjoy the journey more than the destination. It’s easy to say that at my age, and maybe less so for you, but you know, you know, in life, in academia, and I hope one day, Roupen, I guess you’re going to come back to Canada, and I will, and but you know, it’s natural, and you know, all of us, Armenian trait is, we’re push, you know, we push, we, our parents always pushed us, right? And, you know, assistant professor, associate professor, full professor, tenure, research, publish, grants. Let’s take a deep breath. And I would say to myself, what happens will happen.

Work hard, I’m not denying it, but take time. And I was very careful, and I could have probably done more. I have three kids, now I have two grandchildren, but, oh, and you have to ask my kids to get the truth. I personally think that I tried my best to spend as much time with them as possible. But anybody listening, I think, especially the young folks who are up-and-coming generation like who will replace all of us, enjoy the journey. Don’t forget to take care of yourself, and you will be very famous in your area, in your institution, and you’ll be proud of yourself, I am sure. But you can never forget your own health as well as the health and love of your loved ones. So take, I would say, take your time to appreciate the good things in life as you’re moving up the ladder.

Roupen Odabashian: Can I ask you one more questions on that? Because I’m still struggling with it. How do you find you could balance academia, research, and personal life?

Sarkis Meterissian: The only way, at least you can try. Like I said to you, in order to get the true answer, you have to ask my children. You say, did Dr. Meterissian spend time with you like he’s saying? But the only way you can do it is to always remind yourself that I have to go home. I can’t stay until 7 every night. I’m not saying that you have a grand deadline tomorrow, you have to stay, but you can’t stay till 7, 7:30. Your daughter or your son has a concert, you have to go.

So I think as much as you push yourself, you say, tonight I’m going to interview Dr. Meterissian, tomorrow I’m going to finish my paper, next week I’m going to prepare my talk, you have to say the same things to yourself about your daughter’s concert, your son’s baseball game, and so on. You know, next week, I got to go to, no, I can’t, no, sorry, I can’t do the interview, or sorry, I can’t be at the meeting. And if you, it’s a, it’s an effort. It takes a lot of effort.

But because it’s natural for you to go to the meeting, to write the paper, to have the deadline. But, and the family will always say, it’s okay, it’s okay. But deep down, it’s not okay. And I think if you make the time, you will be very happy when you’re 55, 60 years old, and you look back at your life.

Roupen Odabashian: Yeah, I think that’s, this is very important. I, I do fall into those mistakes where, like, I think like any other young oncologist, you push yourself harder and harder and harder. But I think it’s very important to stop and-

Sarkis Meterissian: Yeah, take a deep breath. And look, you’re at a time of your life, Roupen, that like, I was at MD Anderson, you’re now doing your fellowship. You know, but a time will come when the fellowship is done, and now you have life plus your career. And I think it’s finding the balance is a daily reminder to yourself. Stop, take time for yourself.

Roupen Odabashian: Alright, I will try to do that more often. Now let’s talk about the Surgical Oncology in Canada. In every episode in OncoDaily, we talk about the practice of oncology in different countries. How do you think the Canadian healthcare system, with its unique features, influence the practice of Surgical Oncology, especially I want to understand your perspective about patient access to care and to treatment?

Sarkis Meterissian: So first of all, Surgical Oncology has evolved by leaps and bounds since I was a resident. There were no fellowships in Canada, whether it’s Surgical Oncology, medical or radiation. I mean, there was much more medical and radiation, of course. But so that’s number one. Number two is that the access to care doesn’t compare to the US in the sense that I love being at MD Anderson. But I always felt very uneasy with, I remember we had a service where we ran the service, and we had to sign our invoices.

I know, $5,000 for this, $3,000 for that. And I remember even when my wife delivered, our second child was born in Houston, there was a sign at the desk saying, if you do not have insurance, please go to another hospital. So I think that I’m privileged, and you will be, to work in a place where you don’t have to ask yourself, is this person insured for me to treat them? That’s amazing. Now you can then say, oh yeah, okay, but the US, they have more access to clinical trials. I’d say, no, I would tell you no. Whether you’re in Toronto, Calgary, Vancouver, any city, and now the smaller ones, Ontario with their different cancer centers, in Quebec as well, I don’t think there’s a problem with access to trials.

Now, you could argue, in the smaller towns in Ontario or Quebec, a woman with breast cancer won’t have the same access, I would give it. But I’m not sure that the woman in the small town in Texas or Michigan may have the same problem. And especially if the insurance company doesn’t pay for her to go to the university center. So I think that the access to clinical trials is amazing. The access to medications and our knowledge and our ability to implement the latest in the trials is comparable to anyone else. And as you know, and you may know, is that when it came to clinical trials, NP, for example, Canada was the leader, even better than the US. When they were doing the trials of total mastectomy versus partial, they were doing the trials of different chemotherapeutic regimens. Always the Canadian centers were entering patients much more quickly than the American centers. So I think that the care is very comparable, and you don’t have to be rich to get the care.

Roupen Odabashian: Yeah, I completely agree with you. Like, I also went through that cultural shock between Canada and the US. In Canada, I never thought about, like, what, who should, chemo authorization is not a thing. Medication authorization is not a thing. Like, if the medication is appropriate, you can order it. But in the US, like, I’ve been going through this as well. Like, it’s like you have to make sure there’s chemo OD, and then if the treatment is refused, you have to justify that. You have to mention the note. Although we pay more taxes, relatively speaking, that’s what I’ve been told, in Canada, but I don’t mind. My dad had open heart surgery last year, or two years ago, in the Heart Institute, and I paid nothing. Nothing. Like, open heart surgery. I, I prefer to pay taxes, extra taxes, finding an insurance that might or might not cover some options.

Sarkis Meterissian: No, so I really enjoy, I mean, look, I, whether you’re in your hospital, if you stay there, which we don’t want you to stay there, we want you to come back to Canada, but if you stay there, I’m no doubt that Roupen Odabashian CV may be a bit richer than he would be if we came back to Ottawa, because he would be throwing resources. But at the same time, back to the, your life work balance, let me tell you, if I stayed at MD Anderson, I would be forced to work 7 p.m. most nights and push, push, push.

Roupen Odabashian: Yeah, yeah, yeah. I agree. I want to go back to the past couple of years, you know, like that pandemic everyone heard about, the COVID-19, and there was lots of surgical slowdown. How did the COVID-19 pandemic, and how did the surgical slowdown, impact cancer care in Quebec and in Canada, and what lessons did you learn when you went through this, and especially when it comes to managing healthcare resources?

Sarkis Meterissian: Well, I can tell you that we’re feeling the repercussions of the slowdown now, at least in Quebec. Before, in my own hospital, before COVID, we used to see 450 breast cancers a year. Now we’re touching 700. And it’s because women were not going for screening mammograms during COVID. So we’re getting the regular patients, plus we’re getting all these other patients who, unfortunately, are coming with locally advanced disease. So I think that we kind of were so preoccupied, I mean, I’m not talking about me or you, but the governments were so preoccupied with COVID that nothing else mattered. And I could never understand that. And I remember, like, cancer patients, you know, were waiting.

And I published a paper where we published it in Surgery, where we were giving patients aromatase inhibitors, because the patients were on average waiting three or four months for their surgery. So we’re giving them AIs to ER/PR positive tumors because they were only allowing us to operate on triple-negative or HER2. But those patients were getting neoadjuvant chemo, thank God. But the other ones, they would not let us operate unless they were big tumors. And so we were putting them all on aromatase inhibitors, and we showed in that paper, luckily, that the tumors did not grow in those four months. But that’s not the way to practice medicine.

So I agree with you that cancer was neglected, as were other diseases during COVID. And now we’re paying the price, and now we have so many cancers. It is really, that’s one difference, you know, you asked me before, the difference in the US would be, if I had a long waitlist, they would call me and give me more OR time. At my institution now, I don’t know if the same in Ottawa or Toronto, there’s a, there’s not enough nursing or not enough anesthesia to, even if they want to give me extra OR time, there’s no, there aren’t the resources. So now the patients are back to waiting about eight weeks for their surgery. So that’s, that’s the big difference now. Will it make a difference? It won’t for 95% of people.

But I always worry about that patient who may have a problem biologically waiting eight weeks. So I must say that that’s the only one I’ll give you is that if tomorrow we need extra resources for even chemo, we’re waiting now four weeks. If I give them a, before, I used to call them and say, you know, can you start chemo because the patient was a borderline indication. And now, well, they tell me, well, whether you operate in eight weeks or I give chemo in six weeks. So there’s, that’s the major difference, I’ll give you, Roupen. It’s not our knowledge, not the trials, not the chemos, it’s the resources in Canada compared to the US. And it’s gotten worse post-COVID.

Roupen Odabashian: Alright. Talking about the challenges that we face, but also challenges always come with opportunities. Now we talked about the past, I want to focus a bit about the future. What do you see the most significant challenge and opportunity in the field of Surgical Oncology, in your opinion?

Sarkis Meterissian: Well, the biggest challenge, well, you know, the, I, there’s the challenge, is the Canadian challenge, which is resources. But if I have to look at a worldwide challenge of Surgical Oncology, it’s going to be both a challenge and an opportunity, is how to deescalate our surgery. And the opportunity, I’m going to throw it, is the genetic knowledge of cancer. In the sense that when I gave the presidential address for Breast Surgery International, I argued, and it wasn’t well received, that by the time I retire, or by 2035, we’re not going to do breast surgery for cancer anymore, because we’re gonna do genomics, and we will do biopsies, but Surgical Oncology will be mainly prophylactic surgery because we’re going to learn more about genetic mutations and we’re going to understand more specifics about it, and more patients are going to go for prophylactic mastectomy.

So I think the opportunity is in better understanding of the molecular biology of cancer, which will help the surgical oncologist better understand their tumor and better treat the tumor. Yes, it’s going to cause less surgery, and as we advance in the medical treatments, but that’s, that’s what’s going to happen. But we’re going to be in the, you know, whether it’s taking out a pancreas, taking out a stomach, taking out a breast, because they have genetic predisposition to cancer, I think that’s what’s going to happen by the time, well, I don’t know, I don’t know it’s going to happen in the next 30 years.

And of course, I’ll just throw in there the huge influence that AI is going to have, so that when we have tumor board, if I’m with you, you’re going to tell me about a trial, I’m going to tell you about a trial. But if we have AI, AI will tell us about a trial that we didn’t even read about from China or from Japan or from Australia that we may have missed. So the knowledge that AI is going to bring to the table will revolutionize, I think, our ability to select treatments for patients in an appropriate fashion, select the right treatment for the patient that we may, and knowledge is expanding so rapidly that it’s impossible for you and I to keep up with the knowledge, and we’ll need AI. As AI evolves and becomes a more, I guess, tangible, useful thing for us, I think it’s going to come in next year, two years, three years, that when you have tumor board, you’re going to have an AI helping you make sure that you haven’t missed a trial or missed a treatment option.

Roupen Odabashian: I completely agree. I completely agree. AI is actually one of my research projects. That’s my research focus, AI. And I’m currently working with a company in California that are trying to bring AI to oncology. And that’s, I just published a paper about using ChatGPT, testing ASCO guidelines on ChatGPT, and then ask a question bank on ChatGPT. And then I’m launching another way about real-life clinical cases on ChatGPT. So it’s very fascinating. It’s very fascinating.

Sarkis Meterissian: I’m going to PubMed you then, Odabashian. Look up, okay? Because I’m very interested. You know, because very fascinating, because Watson, you know, Watson, you know, the IBM Watson?

Roupen Odabashian: Yes, I know.

Sarkis Meterissian: MD Anderson had a contract with them. It failed. But I think we’re at the stage where it’s almost like Atari. I don’t know, you’re too young to know about Atari.

Roupen Odabashian: No, I know Atari. I used Atari.

Sarkis Meterissian: Atari was a video game, but that was the, and now we’ve gotten to the virtual reality video games. So, and I think the same thing is going to happen with AI. We’re at the beginnings of AI, and then now, in four, five years, or earlier, maybe two years, we’re going to have AI 3.1, then 5.2, and it’s going to be amazing.

Roupen Odabashian: I completely agree. I completely agree with that. And what happened with IBM, in my opinion, it was like the right technology about the wrong time. In the startup world or when you start something, like you have to have the right technology in the right time. For example, Uber, as an idea, wouldn’t succeed if you didn’t have mobile phone with a military accuracy GPS device. So the technology had to be there. And I think right now the technology is there, so we need companies to step up and take the initiative to bring that technology to healthcare. And unfortunately, healthcare is a bit slow to adapt to technology when compared to other fields. But if you demonstrate its utility, that we didn’t get initially, I think we will see-

Sarkis Meterissian: If the companies demonstrate how it can help us, I think it’ll be adopted.

Roupen Odabashian: I agree. I agree. Alright, that brings us to the end of the episode. Thank you so much. That was a very fun conversation. I really enjoy any moment of it. It was very fun.

Sarkis Meterissian: It was very fun, and I think you’re doing a great job with this OncoDaily. I think it’s a fantastic initiative, and I wish you all the best with it. And thank you for having me.

Roupen Odabashian: Thank you so much. It means a lot coming from you. And thank you, everyone, for tuning in to this episode of OncoDaily Dialogues. If you found this conversation insightful, please make sure to subscribe and share with your colleagues and friends in the oncology community. Stay tuned for more enlightening discussions with leaders in the field of oncology. Until next time, take care and keep advancing the fight against cancer.