Only 4% of the federal funding for cancer research goes toward pediatric cancers, and that is all pediatric cancers combined. Only a fraction of that 4% goes toward a rare cancer like osteosarcoma. This makes private funding of pediatric cancer research from foundations like St. Baldrick’s, Alex’s Lemonade Stand, the National Pediatric Cancer Foundation and MIB Agents essential to support research in understanding these cancers and finding new treatments for them.
Cancer is a horrible and terrifying disease. There is so much great information out there, but sometimes it is very difficult to filter out the noise. What causes cancer? Can it be prevented? How do you detect it? What are the odds of survival today? What are the different forms of cancer? What are the best treatments? And what is the best way to support someone impacted by cancer?
In this interview series called, “5 Things Everyone Needs To Know About Cancer” we are talking to experts about cancer such as oncologists, researchers, and medical directors to address these questions. As a part of this interview series, I had the pleasure of interviewing Dr. Matteo Trucco.
Dr. Trucco graduated from the Lewis Katz School of Medicine At Temple University in 2006. Dr. Trucco works in Cleveland, OH and specializes in Pediatrician.
Thank you so much for joining us in this interview series! Before we dive into the main focus of our interview, our readers would love to “get to know you” a bit better. Can you tell us a bit about your childhood backstory?
Iwas born in Torino, Italy. We lived in Switzerland for about a year and then we moved to the United States. I grew up mostly in Philadelphia and Pittsburgh with my parents and two sisters (I’m in the middle) and I went back to Philly for College and Medical School. Never really thought about going into Medicine, being interested in every else from engineering to religion to photography, but eventually settled upon it in college and never looked back. My medical training and work bounced me around after that to Cleveland, Baltimore, Houston, Miami and eventually back to Cleveland where I am now.
What or who inspired you to pursue your career? We’d love to hear the story.
Kind of hard to say. I come from a family of doctors; I’m the 11th “Dr. Trucco” in the family and both my parents are physicians, along with my older sister and my younger sister who is a clinical psychologist. I certainly remember accompanying my father to his lab when he had to get an experiment done or take care of some piece of equipment. I also remember him asking me to read over some papers or listen to a presentation to make sure the English made sense since he never spoke a word of English until he was nearly thirty. In retrospect, I now know he was explaining some cutting- edge techniques and concepts that now, 20 or 30 years later, are common practice, but were revolutionary at the time. Despite all this, medicine wasn’t really something I considered for me. My older sister was the one who was always going to be “the doctor”. I tended to get a bit squeamish around people suffering, so figured it wasn’t a good fit. It was a conversation with my dad where he mentioned something along the lines of “everybody gets uncomfortable caring for sick people, especially early on and when you don’t know what to. It probably means you care. Once you make it your job to know what to do and you focus on getting the patient better, that uneasy feeling goes away”. This opened my eyes to the possibility of going into medicine. I then had the chance to work in the lab with some truly inspiring researchers,volunteered in the ER and worked with some great nurses that further showed me what a difference you can make in peoples’ lives by working in various aspects of medicine. Once I got into medical school, everything “clicked” and I knew I was where I was meant to be. Pursuing Pediatrics and Pediatric Oncology seemed the natural fit as I was again fortunate to work with doctors and nurses who were the type of caregivers I wanted to be like “when I grew up.”
This is not easy work. What is your primary motivation and drive behind the work that you do?
It may sound like a cliché, but it all comes back to the patients. Perhaps it goes back to that uneasiness with seeing people suffer, but the thought that there is something I can do or something I can say to directly help the patient in their journey with cancer, regardless of the outcome, motivates me to be there and do this. I do realize it is not easy work and somedays I may have to have upwards of half a dozen gut-wrenching conversations with different patients and families in a row. Similarly, when I worked in the lab, or now trying to push through a bunch of bureaucracy to get a clinical trial open, or do things like help organize a conference, tumor board or grant review, they are all motivated by wanting to make a difference in patients’ lives.I hate the thought of some of these projects or programs not happening simply because no one would put in the effort to make them happen.
What are some of the most interesting or exciting projects you are working on now? How do you think that might help people?
My work mostly focuses on trying to tackle cancers, specifically pediatric bone and muscle tumors (sarcomas) like osteosarcoma, in a “different” way. I realize “different” is rather vague and generic, but I’ll elaborate. The way most chemotherapy works is by killing cells that divide quickly. Cancer cells typically divide quickly, so that is how chemo works. Hair, blood cells and the cells lining the gut also divide quickly, which is why we see many of the side effects from chemo that we do.
While this blunt tool works relatively well for some cancers, we have suspected for some time that there are subsets of sarcoma cells that don’t respond to chemo like the rest of the tumors, possibly because they don’t actually divide quickly and sort of lay dormant, until one day, for unclear reasons, they start growing and dividing and lead to relapses. We are trying to focus on strategies to get rid of these cells that are resistant to conventional chemo. We are doing this by trying to repurpose drugs that can sensitize these cells to chemotherapy. We are also trying to repeatedly change the schedule, combinations and intensity of chemo to keep the cancer “off guard” and prevent it from developing resistance.
For the benefit of our readers, can you briefly let us know why you are an authority about the topic of Cancer?
Beyond the regular training (4 years of Med school, 3 years of Pediatrics training, 3 years of Pediatric Hematology/Oncology training) for the past 10 years I’ve been focusing almost exclusively on treating sarcomas and other rare tumors. I’ve also been involved since my training in the study and development of new treatments and clinical trials in sarcomas. I’m also the Principal Investigator for several clinical trials focusing on sarcomas, and I’m the Co-chair for the National Pediatric Cancer Foundation’s Sunshine Project Consortium, a group of 30+ pediatric cancer centers that develops and runs innovative clinical trials with a focus on sarcomas. I’ve furthermore been fortunate to partner with MIB Agents to help organize and run the annual FACTOR conference on osteosarcoma, I chair MIB Agents’ Scientific Advisory Board, oversee their Outsmarting Osteosarcoma grant program, and moderate their International Virtual Osteosarcoma Tumor Board called TURBO.
Ok, thank you for all of that. Let’s now shift to the main focus of our interview. Let’s start with some basic definitions so that we are all on the same page. What is exactly cancer? What causes cancer?
We don’t know exactly, but in broad terms, there is damage to the coding of cells that causes them to divide uncontrollably. This is what cancer is: cells dividing outside of the normal programmed way that they should in the human body. In adults, the damage tends to be due to a lifetime of small mutations in the cell’s coding caused by errors in copying the code, which happens every time the cell divides, and/or damage from exposure to toxins such as smoking, sunburns, certain infections, or excessive unhealthy diets and lifestyles. If enough damage and errors occur in a cell, it can start dividing uncontrollably. In children, and in certain specific cancers in adults, it isn’t an accumulation of damage and errors, but an error or damage in a specific part of the cell’s code that is critical enough to drive the cell to turn into a cancer.
What is the difference between the different forms of cancer?
The original cell that mutated to turn into a cancer, and the specific mutation that drove the cell to turn into a cancer dictates what cancer develops. As described above, some cancers, like the ones more typically seen in adults, are due to accumulation of lots of little mutations, while others, like the ones we more typically see in kids, are due to mutations in specific critical areas that drive the cell to become cancer.
I know that the next few questions are huge topics, but we’d love to hear your thoughts regardless. How can cancer be prevented?
Unfortunately, you can do everything right, and nothing wrong, and still develop cancer. However, you can tip the odds in your favor by living as healthy a lifestyle as you can. Things like avoiding smoking, using sunscreen, maintaining a healthy weight, exercising, eating a healthy balanced diet all help minimize the damage caused to your body’s cells and decrease the chance of developing cancer, and other medical issues.
How can one detect the main forms of cancer?
There are specific guidelines for the more common forms of cancer to try to detect them early, because the earlier they are detected the easier they are to treat. This includes colonoscopies and mammograms. We are working on a blood test to help screen for cancers and catch them early, but we aren’t quite there yet.
Cancer used to almost be a death sentence, but it seems that it has changed today. What are the odds of surviving cancer today?
Depends on the cancer. If caught early, where it is still localized in one place and can be completely removed or it is a type that responds well to treatment, the prognosis can be great. Once the cancer has spread throughout the body, or certain specific cancers that just don’t seem to respond to the treatments we have available, unfortunately carry a worse prognosis. In pediatrics, for example, we cure over 85% of kids with cancer. There are some pediatric cancers, like Acute Lymphoblastic Leukemia, certain Lymphomas, and certain eye, kidney and liver tumors that we cure over 90% of patients. However, there are other pediatric cancers like metastatic sarcomas, high-risk Neuroblastoma and many cancers if they relapse that carry much poorer prognoses despite very intensive therapies. There is also one pediatric brain tumor, Diffuse Intrinsic Pontine Glioma, that is essentially still considered incurable despite all the advances we have made in cancer therapy.
Can you share some of the new cutting-edge treatments for cancer that have recently emerged? What new cancer treatment innovations are you most excited to see come to fruition in the near future?
Immunotherapy, meaning harnessing the body’s own defenses to treat cancer, has revolutionized the treatment of certain cancers, like some leukemias, lymphomas and melanomas, in recent years. Unfortunately, it hasn’t worked as well for many other tumors. I think the most exciting things coming in the near future is changing our thinking on how we approach cancers. We used to think a cancer was a bunch of cells that were all exactly the same and you just had to keep hitting them with strong chemo to kill them all off. We are realizing that, while that strategy may work for some cancers, it doesn’t work for many. Cancers are composed of cells that, while they are all cancerous, they have different mutations and different behaviors. The location of the cells with relation to blood vessels also, for example, is important, as are the normal cells near and interspersed among the cancer cells in how they actually support and protect the cancer cells. By better understanding the complexity of cancer, we are developing better strategies for treating the cancers and better tools for evaluating them and trying to stay ahead of them.
Healing usually takes place between doctor visits. What have you found to be most beneficial to assist a patient to heal?
Keeping a positive attitude is important. It is easy to get overwhelmed and feel defeated. While the disease is terrible and the treatments often aren’t much better, focusing on what is going ok can help immensely. Also, little things like going for a walk, being in nature, engaging in hobbies, even light exercise if patients are up for it are all helpful. I would also add that keeping open and clear communication with the medical team is vital. The team can’t help the patient if they don’t know about side effects or challenges the patient is facing. Often medications can be adjusted, or other help and support can be found. Even just talking frankly about how much everything associated with cancer sucks can be healing.
From your experience, what are a few of the best ways to support a loved one, friend, or colleague who is impacted by cancer?
I actually went through my mother having terminal cancer last year and it was a tough experience. I don’t know that I handled it perfectly, but what I tried to do was be present and make myself available. It’s a balance of wanting to be supportive and help, but also not imposing your help on them. At the same time sometimes patients and caregivers are so overwhelmed that they don’t even know or see that they need help, so you sometimes have to just step in an say “I’m going to step in and you are going to go take a nap since you haven’t slept in three days”. Similarly, you don’t want to force difficult conversations because if someone isn’t ready, that isn’t going to help, but at the same time you want to create the opportunity to talk about difficult and unpleasant things because it can ultimately be very therapeutic. The same goes for the family members and caregivers. They often suffer, in their own way, as they see their loved one suffer. Tell them they are doing a great job.
What are a few of the biggest misconceptions and myths out there about fighting cancer that you would like to dispel?
Let’s start with the whole notion of “fighting cancer”. It is certainly a useful analogy of going to battle against this enemy we call cancer, but we also run the risk of insinuating that if a patient struggles or if the outcome isn’t what we hoped, that somehow they didn’t fight hard enough or they gave up. The longer I’ve been in this field, and certainly impacted by my patients and family experience, I view it more as a journey. It’s a bit harder to ‘rally the troops’ and ‘bang the war drum’ for a journey, but I think it fits better. Our job as the medical team, and friends and family, is to accompany them and help guide them through it, regardless of where the road may lead.
Thank you so much for all of that. Here is the main question of our interview. Based on your experiences and knowledge, what are your “5 Things Everyone Needs To Know About Cancer? Please share a story or example for each.
I’m going to focus on Pediatric cancer and the specific cancer osteosarcoma.
- Only 4% of the federal funding for cancer research goes toward pediatric cancers, and that is all pediatric cancers combined. Only a fraction of that 4% goes toward a rare cancer like osteosarcoma. This makes private funding of pediatric cancer research from foundations like St. Baldrick’s, Alex’s Lemonade Stand, the National Pediatric Cancer Foundation and MIB Agents essential to support research in understanding these cancers and finding new treatments for them.
- The current treatment for a cancer like osteosarcoma was developed in the 80’s, making it about 40 years old. It is extremely toxic and about half the patients have long-term side effects after they finish treatment. These patients have to undergo massive surgeries to remove the tumors and replace the affected bones with metal rods and artificial joints, and sometimes we still have to use amputations to try to cure these children. With this treatment, about 70% of patients who have osteosarcoma only in one part of their body (localized) will be cured. Unfortunately, we have no idea who the 70% that will be cured are nor the 30% that won’t be cured. For patients where osteosarcoma has already spread throughout their body, cure rates are less than 30%.
- Before the incorporation of chemotherapy in treatment, patients with localized osteosarcoma, for example, only in their leg, would undergo amputation and be considered ‘cured’. About 80% of these patients would have the cancer come back in their lungs and/or other bones. The addition of chemotherapy to surgical removal of the cancer has resulted in about 70% of patients being disease free for over 5 years. That means 20% of patients would be cured just with surgery, and 30% of patients are not cured even with chemotherapy and surgery. Unfortunately, we can’t tell who is going to be cured with surgery alone, who will be cured with surgery and chemotherapy and for whom surgery and chemotherapy is not enough. These are the statistics for osteosarcoma when it is only in one part of the body (localized). When it has already spread throughout the body, what we call “metastasized”, there is an over 70% chance of the cancer coming back despite chemotherapy and surgery removing all the cancer we see. When osteosarcoma comes back (relapse) there is less than a 20% chance of being cured regardless of what treatment we use, and that number gets lower and lower every time the osteosarcoma relapses.
- One of the most important things I tell my patients when we first learn they have a cancer like osteosarcoma is that it is not their fault. Especially in childhood cancer there is a lot of guilt in the parents, and also in the kids, that they did something, or didn’t do something, which led to the child getting cancer. I incorporate mentioning that it is not anyone’s fault whenever I have the talk with parents and children telling them they have cancer. About a year ago, I was having such a talk and I had a medical student working with me that day. She was present for the entire talk, and I did mention that it wasn’t anyone’s fault, and after we left the room, the student shared with me that she had cancer as a child and had lived with the feeling that she was somehow responsible for having cancer. This was the first time she heard a doctor verbalize that it wasn’t anyone’s fault and it was eye-opening for her as it related to her own history with cancer.
- We are working on itand changing our thinking and approach to cancers like osteosarcoma. When I was training about 10 years ago,we wrote a paper talking about a subpopulation of cells in pediatric sarcomas that don’t act like the cells that make up the bulk of the cancer. We called these cells “cancer stem cells” because they kind of behaved like stem cells that help regenerate organs or repair tissues in the body. Similarly, these cancer stem cells, seem to lay low, are not affected or eliminated by chemotherapy, but at some point they give rise to relapses. I remember telling a colleague about this theory and she basically laughed at it stating that it went against everything we KNOW about cancer. Nowadays, the principle of quiescent cells, resistant to therapy that give rise to relapses is commonly accepted and efforts are being made to identify these cells and find ways to eliminate them.
Similarly, there are efforts to change our strategy for treating cancers like osteosarcoma. Current treatment for osteosarcoma, developed over 40 years ago, involves combining surgery with giving the same 3 chemotherapy drugs over and over and over again pushing the limit of how much we can give before causing irreparable damage to the heart and kidney. This seems to get rid of all the cancer, but we know the cancer very often comes back, especially for patients with metastatic disease. Instead of blindly giving the same drugs over and over, we are exploring strategies of anticipating when the cancer might become resistant to the chemotherapy and changing the drugs or therapies we use before that happens. These approaches are still in their infancy, but they hold promise that we won’t be using the same approach for the next 40 years.
You are a person of great influence. If you could start a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
As it relates to cancer, pediatric cancer and a specific cancer like osteosarcoma, I think the change that would bring the biggest good would be a revamp of how we test and approve new therapies. In general, currently drugs or other treatments are tested in a petri dish to see if they can kill cells derived from a cancer. Then they are typically tested in a mouse model of the cancer, though the accuracy and quality of those mouse models vary, to show that the drug can either kill or delay growth of the cancer in a living entity. There is much variability on how many such experiments or evidence there needs to be to support then testing the drugs in people, but ultimately clinical trials are performed. The first phase (Phase 1) of testing is identifying the safety, tolerability and often the “maximum tolerated dose” of a drug in human beings. After that trial is completed to identify the dose and safety of the drug, a Phase 2 trial is conducted to demonstrate that the drug actually has an “effect” on a specific cancer, this may be testing the drug alone or with a “backbone” of established treatment. What qualifies as an “effect” can be somewhat variable. Finally, if it is felt that the drug is safe and effective against a specific cancer, a Phase 3 trial is conducted to compare the current standard therapy, which is often different than the backbone tested in the Phase 2 trial, to the new drug, either alone or testing whether the addition of the new drug to the standard improves outcomes.
While conceptually, testing new treatments in petri dishes, and animal models and establishing the safety and dosing first, and its efficacy and comparing it to the current standard all makes sense, had we used this approach to develop many of the therapies that have been success stories in the history of cancer, we would not have been able to. Testing one drug at a time, figuring the more drug you give the better, and trying to see if adding one drug to the standard will significantly change outcomes are fraught with us missing drugs that can improve outcomes, and potentially pushing drugs forward that are destined to fail.
Furthermore, the current clinical trial process is optimized for more common cancers, and not for the rare cancers with very few numbers. The bureaucracy required for clinical trial approval and oversight borders on the oppressive. While the intention of maximizing safety and accuracy is sound and noble, in practice, much time is consumed with forms, committees, approvals, re-approvals, hang-ups over clinically inconsequential details. While an ungoverned “wild west” approach to cancer treatment development would be irresponsible and dangerous, the current method feels as though it gets in the way of progress instead of encouraging and guiding it. A happy medium, assuring safety and integrity and at the same time ensuring speed and efficiency, should be possible.
How can our readers further follow your work online?
A few sites and links of my work:
Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.