Advocate for yourself. This is simple and straightforward, but critical. Know yourself, know your body, know your needs, and listen to your gut. Whether it is a symptom or pain in your body that feels wrong, or if it is in a meeting with your oncologist about your care plans, you are your greatest advocate, and everyone should feel empowered to speak up for themselves.
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 Nicholas J. Robert.
Nicholas J. Robert, MD, is the Chief Medical Officer at Ontada. He is responsible for deepening Ontada’s clinical focus and expertise. He also collaborates across the organization to ensure studies, real-world data offerings, and educational programs maintain the highest scientific standards and clinical relevance. Board certified in Internal Medicine, Anatomic Pathology, Medical Oncology, and Hematology, Dr. Robert has spent much of his career as a practicing oncologist and serving as a leader in community oncology. He has authored more than 100 publications, serves as a reviewer for medical journals, and is a member of several industry organizations including the American Society of Clinical Oncology (ASCO).
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. What or who inspired you to pursue your career? We’d love to hear the story.
Growing up, my grandfather was a pharmacist, and my father wanted to be a doctor. I myself have loved science since I was young and wanted to find a way to use science to help people. Since science is core to medicine, and because the practice of providing medicine and care is human-centric- which I love- it was a perfect fit for me. I went into internal medicine for these reasons and went on to study pathology to learn about cancer and how to diagnose it. I enjoyed learning the biology of different cancers, and that brought me to oncology. Becoming an oncologist felt like a natural transition because it married my interests together — understanding the causes and effects of disease and having the ability to really help people and make a difference in their lives.
This is not easy work. What is your primary motivation and drive behind the work that you do?
I was directly involved with the delivery of patient care for a very long time, and I was an investigator for a lot of clinical trials throughout most of my career. With medicine, we’re always asking questions, finding answers, and asking more questions from these answers. Better care comes from this continual learning which has been accelerated with the advancement of real-world evidence (RWE). It’s exciting and extremely fulfilling to be involved in the discovery and application of new evidence which can lead to better care. What keeps me driven, motivated, and excited isn’t just the work itself, but the people I work with.
At Ontada, we all share the same kind of inquisitive nature and are constantly seeking answers that we hope translates into improved care for patients. We are invested in the intelligent use of RWD — from our own data sources like Ontada’s iKnowMedSM electronic health record (EHR) and other shared industry sources — and translating it into the insights that transform our battle against cancer. Together, as we continue to learn more about the makeup of different cancers, we’re getting better at providing informed, targeted treatments that improve patients’ quality of life. Being surrounded by individuals who are equally committed and passionate in this mission is inspiring and seeing the difference this work makes in the real lives of patients keeps us motivated to continue trying to make a difference.
What are some of the most interesting or exciting projects you are working on now? How do you think that might help people?
The first Ontada product I’m particularly excited about is the rollout of our RWD Enterprise product. Built to serve physicians and pharmaceutical companies, Ontada’s RWD Enterprise is an anonymized data product derived from structured and deeply curated EHR fields (unstructured data) to provide a comprehensive longitudinal patient view. The data is refreshed on a quarterly basis to ensure the latest insights are captured. The product provides clinical depth to power research and is linkable with other data assets such as claims and social determinants of health (SDoH) data for advanced research insights — empowering researchers to uncover learnings more easily, faster, and accurately. We’ve completed the dataset on melanoma, meaning it is now available, and are currently working on developing these datasets for non-small cell lung cancer (NSCLC), breast cancer, and multiple myeloma.
Additionally, Ontada’s RWD Enterprise product is different from other oncology data products because of its richness in early-stage data. While there is robust industry data on advanced and metastatic cancers, Ontada is able to capture extensive early-stage patient data, and this product will make more early-stage data available. This is key because we are seeing more interest in early-stage research as it can enable better identification and treatment of cancers for better outcomes and lower cost treatments, so this will be a tool to support that work. Secondly, we’re converting this data into what’s being called the common data model, which is a uniform way to translate information into an acceptable format. Unlike accessing one-off data, the common data model transcends different data sources, which is a big step moving forward to improve transparency and clarity. So, while this takes a lot of effort — once achieved — our product will provide the necessary foundation for conducting analyses in a way that’s more compliant for regulatory purposes, with the potential of building evidence for the Food and Drug Administration (FDA), for example.
The second product rolling out soon that I would like to mention is Ontada’s Clinico-genomics product. With this, we have an opportunity to provide deeply curated genomic data beyond what oncologists would normally be able to use to identify targeted, personalized treatments for a patient. The product will provide de-identified genomic data from tissue and liquid biopsies linked to structured, EHR-derived clinical data per record. Here, a key differentiator is the combination of clinical and genomic information through multiple lenses from various labs, providing a diversity of data. This product will serve researchers, notably those in translational medicine and drug development. To have both the genomic and clinical data in one product is a great opportunity for oncologists and researchers to explore potential new biomarkers and potentially develop new treatments.
It is also very important to us at Ontada to work closely with practicing community oncologists and their teams when it comes to upgrading and improving iKnowMed. This close collaboration helps us continually improve our EHR and support the oncologist clinical workflow while ensuring new guidelines are incorporated in a timely fashion. We are invested in oncology-specific functionality and information timeliness. Whenever the National Comprehensive Cancer Network (NCCN) makes a new treatment recommendation, for example, our EHR is updated to reflect that change within one week’s–time — updating oncologists in near real time. Additionally, given the growing emphasis and action being taken regarding Social Determinants of Health (SDoH) for patients, we’ve recently redesigned our EHR to better capture information relating to a patient’s social determinants. Specifically, we’ve embedded the NCCN’s distress thermometer into our EHR for oncology practices to use and into our patient portal, Ontada Health, which will be rolling out soon, to give patients the opportunity to share SDoH-related factors. This functionality will improve the opportunity to have SDoH-related information to be completed and documented between both the provider and patients, which drives more informed care and support. There are many reasons why this data is important for physicians to have. A clinical study, for example, is used to inform the approval of these products in a controlled environment. So, understanding how medicines perform outside of the controlled environment where patients may or may not be receiving the same level of guidance or follow up as they would in a trial, is significant as it tells us more about the effectiveness and safety of the medicines in the real-world setting.
Lastly, we recently announced that Ontada was awarded a contract with the FDA to advance the use of real-world data in the U.S. community oncology setting. The research aims to strengthen the scientific understanding of the natural history of rare cancers by leveraging Ontada’s community oncology footprint, unique RWD, and experience in real-world research. The goal of the study is to enhance understanding of how patients with rare cancers present and are treated in order to inform drug development for sponsors and the FDA. We look forward to working with the FDA on such an important initiative and further our contribution to advancing the fight against cancer through greater understanding.
For the benefit of our readers, can you briefly let us know why you are an authority about the topic of Cancer?
I’ve been very fortunate to be able to dedicate my career to medicine and more specifically, oncology, and as a result have garnered decades of expertise. Before joining Ontada a few years ago, I spent much of my career as a practicing oncologist, including my roles as medical director of the research program at Virginia Cancer Specialists and clinical director of medical oncology at Tufts Medical Center. I received my medical degree from McGill Medical School and completed residencies at Royal Victoria Hospital and Massachusetts General Hospital and fellowships at the Brigham and Women’s Hospital and Dana Farber Cancer Institute. I was also a fellow at Harvard Medical School. I have a long history in academic and community oncology and with cancer research, during which time I’ve participated as an author of over 150 publications. I’m a member of the American Society of Clinical Oncology (ASCO) and Professional Society of Health Economics and Outcomes Research (ISPOR), and serve as a reviewer for multiple medical journals, including the Journal of Clinical Oncology-Clinical Cancer Informatics.
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?
According to the National Cancer Institute (NIH), the definition of cancer is as follows:
“Cancer is a disease in which some of the body’s cells grow uncontrollably and spread to other parts of the body. Cancer can start almost anywhere in the human body, which is made up of trillions of cells. Normally, human cells grow and multiply (through a process called cell division) to form new cells as the body needs them. When cells grow old or become damaged, they die, and new cells take their place. Sometimes this orderly process breaks down, and abnormal or damaged cells grow and multiply when they shouldn’t. These cells may form tumors, which are lumps of tissue. Tumors can be cancerous or not cancerous (benign). Cancerous tumors spread into, or invade, nearby tissues and can travel to distant places in the body to form new tumors (a process called metastasis). Cancerous tumors may also be called malignant tumors. Many cancers form solid tumors, but cancers of the blood, such as leukemias, generally do not.”
What causes cancer?
That’s a loaded question. I’ll refer to the National Cancer Institute’s explanation of how cancer develops: “Cancer is a genetic disease — that is, it is caused by changes to genes that control the way our cells function, especially how they grow and divide. Genetic changes that cause cancer can happen because of errors that occur as cells divide, because of damage to DNA caused by harmful substances in the environment like chemicals in tobacco smoke and ultraviolet rays from the sun or because they were inherited from our parents. The body normally eliminates cells with damaged DNA before they turn cancerous. But the body’s ability to do so goes down as we age. This is part of the reason why there is a higher risk of cancer later in life.”
It’s usually not possible to know for certain exactly why one person gets cancer and why one doesn’t. Cancer isn’t a singular disease but rather a group of related diseases, and a lot of factors such as our genes, lifestyle, and environment may increase or decrease our risk of getting cancer. Research is telling us a lot about genetics and risk factors, and our understanding of cancer is constantly evolving.
What is the difference between the different forms of cancer?
There are scores of different kinds of cancer, and they are either named based on the kind of tissue from which they originate or according to the location in the body where they first developed. For example, breast cancer starts in the breast, and lung cancer starts in the lung. According to Stanford Medicine, there are five broad classifications of cancer:
- Carcinoma, which accounts for 80–90% of all cancer cases, is a cancer found in body tissues that cover or line the surfaces of organs, glands, or body structures.
- Sarcoma is a malignant tumor growing from connective tissues, such as cartilage, fat, muscle, tendons, and bones.
- Lymphoma refers to a cancer that originates in the lymphatic system, e.g., lymph nodes, and are classified into two categories: Hodgkin’s lymphoma and non-Hodgkin’s lymphoma.
- Leukemia, also known as blood cancer, is a cancer of the bone marrow that keeps the marrow from producing normal red and white blood cells and platelets.
- Myeloma grows in the plasma cells of bone marrow. Myeloma cells can collect in one bone and form a single tumor, or they can collect in many bones, forming many bone tumors.
I know that the next few questions are huge topics, but we’d love to hear your thoughts regardless. How can cancer be prevented?
Being diagnosed with cancer is never 100% preventable, but there are certain measures you can take to lower your risk for common cancers. Living a healthier lifestyle, for example, includes weight management and maintaining a healthy diet, being physically active, not smoking, avoiding or limiting alcohol consumption, and protecting your skin. Additionally, taking preventative measures offered by healthcare providers is valuable, including keeping up with routine care, doing screening tests regularly to find breast, cervical, colorectal, and lung cancers, and getting vaccines that prevent certain cancers, such as the HPV vaccine and hepatitis B vaccine. It’s also important to be aware of your family history and discuss any history of cancer with your doctor. If a genetically predisposed type of cancer runs in your family, your doctor may recommend screenings earlier or more frequently than what is standard.
How can one detect the main forms of cancer?
If you have symptoms that are not typical or easily explained, such as blood in your urine, sudden weight loss, body aches, or other persistent symptoms that do not go away, it’s best to see your doctor as soon as possible to have it checked out. The best way to catch cancer early is through screenings such as mammograms, colonoscopies, and routine skin checks. For evaluating symptoms, there may be a role for image studies such as computerized tomography (CT) scans, bone scans, magnetic resonance imaging (MRI), positron emission tomography (PET) scans, ultrasounds, and X-rays. Even though they are not fun, they do save lives, and it is important to schedule those screenings when appropriate.
Cancer used to almost be a death sentence, but it seems that it has changed today. What are the odds of surviving cancer today?
Different cancers have different survival rates, some better than others. Glioblastoma multiforme, for example, is the most common type of primary malignant brain tumor found in adults — with less than 1% of all patients living for more than ten years. For cancers that are difficult to catch early, such as pancreatic cancer, and cancers that have metastasized, the 5-year survival rate remains low. In metastatic cancers, there can be rare exceptions, such as with melanoma, but once cancer metastasizes from the primary site, it is difficult to stop. We’ve made great progress to help more people live longer and with a better quality of life, but the chance of being cured is still very low.
For early colorectal cancer, breast cancer, or lung cancer — those cure rates have gone up through a combination of appropriate surgery, radiation therapy, and systemic therapy — including immunotherapy in some cases. The key is early diagnosis when and wherever possible. We’re in a much better place than we were 25 years ago, and we are getting better every day.
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?
We should all feel good about the fact that there have been a lot of advances in cancer research and treatment, with more advances happening all the time. Here, I’ll talk about what are potentially the most significant breakthroughs in three different areas or types.
The first significant breakthrough is the discovery of just how badly the immune system was being exploited by cancers so that cancers were invisible to the immune system and were able to grow unchecked. It’s understood that there was a way to get around that with checkpoint inhibitors, a type of immunotherapy that blocks proteins that stop the immune system from attacking cancer cells. As a result, the immune system can actually go to work to fight and kill cancer cells. This treatment has had varying degrees of success. For melanoma, even metastatic melanoma, we now see a higher cure rate, and for individuals where a cure isn’t achievable, we are seeing these individuals live longer, which is so meaningful. Immunotherapy offers potential new treatments across 20+ cancers. In addition to being used across cancers that have metastasized, immunotherapies also have the potential to be used in early-stage cancers — including breast and lung cancers — which could potentially lead to an increased cure rate over time.
Targeted therapy, or a deeper understanding of cancer biomarkers, is also leading to more precise treatments. The poster child for targeted therapy is chronic myelogenous leukemia, which has been around for many years, but this type of therapy has expanded to include many more cancers now, such as lung cancer, which can have a huge impact. In the metastatic setting, it usually doesn’t lead to a cure, but it does lead to a longer life living with cancer and usually with a toxicity profile more favorable than standard chemotherapy. In lung cancer, specifically, targeted therapies have the potential to one day lead to an increased possibility for a cure.
Chimeric antigen receptor therapy known as CAR-T is a treatment that uses immune cells called T cells which are taken from a patient and genetically altered in a lab to enable them to locate and destroy cancer cells more effectively. The excitement has been mostly around hematological malignancies, but there is potential for this therapy to be applied outside of the hematological space.
I should also mention antibody-drug conjugates (ADCs). This is a very cool concept because the tumor has a certain profile that you can target. You use an antibody to target that specific biomarker, and the antibody is coupled to a very effective chemotherapy agent. The Trojan horse phenomenon is a good way to think about this therapy — the antibody-drug conjugate is taken into the cell, and once in the cell, the antibody breaks away from the chemotherapy agent, and the chemotherapy agent kills the cancer cell. The concept has been around for a while, but in recent years it has really taken hold in many areas like breast cancer. This therapy has been used in HER2-positive breast cancer, but a new category called HER2 low has been identified as one that stands to really benefit from this treatment as well. Again, this is in the metastatic setting, but we’re going to see a migration of this approach into early disease. ADCs are also showing promise in patients with triple-negative breast cancer, which accounts for approximately 10–15% of all breast cancers. Traditionally, these patients only had chemotherapy as a viable treatment option. However, a majority of triple-negative breast cancer patients fall into the HER2 low category, so ADCs have the potential to be an alternative treatment option for these patients as well.
Healing usually takes place between doctor visits. What have you found to be most beneficial to assist a patient to heal?
Support, love, care, empathy, and so many other things contribute to the broad notion of healing and can come from friends, family, healthcare providers, and even strangers. Healing, through my experiences as an oncologist, is to take that journey with patients and to be there for them in the ways they need. Even In the situation where cure is not possible, there will be good times when the cancer is under control. It is like riding a wave of enthusiasm and hope knowing that, at some point, that wave may crash, and the cancer will progress. In this circumstance, healing really looks like understanding the situation, addressing and acknowledging it, and accepting it. It’s a difficult but important role.
A big part of it is also simple genuine human interaction and support from their team. In addition to oncologists, we have palliative care physicians, advanced care providers, nurses, social workers, navigators — a lot of people who take that emotional journey with the patient and support different moments and needs. Healing looks different for everyone. It is done internally by yourself and with the support of people around you. Healing is work and a lot of the time it comes from openness, communication, honesty, and care, and an effective care team needs to be ready to help patients through their experiences in whatever way they need.
From your experience, what are a few of the best ways to support a loved one, friend, or colleague who is impacted by cancer?
The role of caregiver or supporter can’t be emphasized enough. When someone you love has been diagnosed with cancer, it’s important to understand that you’ve been invited to be on their support team and to learn what is needed from you in that supporting role. Because no two people are the same, good communication is essential in determining someone’s needs as they navigate a cancer diagnosis. Oftentimes, patients I saw came in with someone, usually their significant other or close friend, and some patients do all the talking while their supporter is just there to listen, ask questions, take notes, or simply hold their hand. All of these supportive roles are important and comforting to the patient. Cancer is a team sport — both on the provider side and on the patient side — and it benefits patients to have a strong support system. In our patient portal, Ontada Health, we have an option for the patient to add people to their team as caregivers, as well as to define the extent of that individual’s role on the team, what they can access, etc. It may just be a friend who drives them to their appointments, or it may be someone very close to them who they want to have access to all of their information — but either way, it ensures patients’ loved ones are looped into the process in all the ways they need.
Lastly, as a general rule for anyone in healthcare, there’s no such thing as a stupid question. A patient — or their caregiver — should never feel they cannot ask a question. If you think it, just ask it. The anxiety of worrying about something that may not exist is a genuine concern, and the best way to alleviate that anxiety is to just ask the question.
What are a few of the biggest misconceptions and myths out there about fighting cancer that you would like to dispel?
Well, it’s not always a death sentence. I’ve cared for a lot of patients with breast cancer in my career, and for the majority of them, it wasn’t a death sentence because they were diagnosed early and the chances of being cured were very good.
Another myth is that people who enter into a clinical trial are given a placebo — that’s very uncommon. In an oncology clinical trial, you’re always going to get at least standard therapy. An individual would only be given a placebo if there was no standard therapy. On that note, very few people, relatively speaking, actually enroll and participate in clinical trials for a variety of reasons but mainly because of a lack of access or knowledge of available trials. Clinical trials have been instrumental in the progress we’ve made in the oncological field, and they will continue to play a key role in further progress for both adult and pediatric cancers. We should shed a brighter light on their availability to patients and encourage more participation when appropriate.
While it’s not so much a myth and more of a concern — I would be cautious when it comes to recommending treatments or suggesting expectations that are not grounded in facts, no matter the setting or level of informality through which it is being presented. The progress we’ve made in oncology has been based on science, and even scientists can come up with what they think is a great idea, but even a rational, sound hypothesis can ultimately be proven wrong through the scientific method. We’ve made progress in oncology by understanding the biology of cancer better, and it’s important to remember and stay true to the fact that the advancement of oncology has been from the application of scientific principles. We know there is a gap between what we understand and learn, and how we can actually implement that knowledge to improve care — it’s a process that can take years. That can be very frustrating because patients with cancer don’t have all those years to see these developments realized. And sometimes for patients, an opportunity for a new cancer cure may sound too good to be true and one should be cautious in those situations. So, I say all this because oncology is science-based, and when combined with human-centric experiences between provider and patient, it’s important to make clear what is science-backed versus what’s rooted in pure hope. We should be wary of pushing hope where there is no data.
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.
- Take measures to prevent or decrease risk the best you can or detect it early. The best thing for all of us would be to not get cancer, of course. So, it’s important to know and implement the things in our daily lives that give us the best chance of not getting cancer or catching it early. I discussed preventative measures earlier in my interview, but as a reminder, a few examples include not smoking, avoiding or limiting alcohol, protecting your skin, and maintaining a healthy weight and active lifestyle. And for early detection, I suggest knowing your family history and genetic disposition, attending regular routine care visits, doing screenings, and self-checks.
- A more positive notion that incurable cancer can now be converted to more of a chronic disease. This may be a concept you’ve heard before. I’ll be the first to admit it’s a little disingenuous because if anyone had a choice between getting diabetes, for example, or metastatic lung cancer, we would choose diabetes. But there is truth in that some metastatic cancer patients can live for years, as treatment is the best it has ever been and improving constantly. If you don’t have cancer or haven’t experienced it through a loved one, this probably doesn’t sound too good to you. And I understand that. But for people with cancer, the hopeful notion that they could live longer and spend another year or few with their loved ones is significant because more time, sometimes, is all we can ask for.
- The practice of oncology is team-based. Oncology consists of a robust care team, and every member of the team is critically important. While the oncologist could be considered as the captain of the team, it would be impossible to adequately care for patients without these specialists. An oncology care team can include, but isn’t limited to, oncology nurses, advanced practice providers like oncology nurse practitioners (NPs) and oncology physician assistants (PAs), patient navigators, palliative care doctors and nurses, social workers, genetic counselors, pathologists, specialized pharmacists, diagnostic radiologists, rehabilitation therapists, and mental health professionals. It is important for patients and their loved ones to know who is on their team, who does what, and that the full team has their back, that they are covered. Furthermore, the patient and their support system are part of this team, too. For optimal experiences and outcomes, we must always behave and function like a team. This includes operationally and from a workflow standpoint, but also from a personal standpoint. It’s important that patients feel comfortable and confident in their oncology care team, as it allows for important questions, candid conversations, greater support, and a better experience for patients physically, mentally, and emotionally. Know your team, trust in your team, and lean on your team.
- Advocate for yourself. This is simple and straightforward, but critical. Know yourself, know your body, know your needs, and listen to your gut. Whether it is a symptom or pain in your body that feels wrong, or if it is in a meeting with your oncologist about your care plans, you are your greatest advocate, and everyone should feel empowered to speak up for themselves.
- Oncology is advancing, and significantly. There has never been more support, investment, momentum, or progress in the field of oncology than there is today. There has never been and will never be a good time to get cancer, but 20 years ago was a worse time to get cancer. The availability of real-world data and research is supporting science in oncology and making progress in transforming the fight against cancer more than ever before. Through better access of real-world data (RWD) and with the subsequent generation of real-world evidence (RWE), Ontada and the vast ecosystem of oncology innovators are devoted to bettering oncology. Trusted data and research have never been so available and actionable for life sciences. These stakeholders have access to high-quality, timely information through oncology EHRs, claims, and other data sources and are uncovering real-world insights that inform key decisions and provide evidence to bring advancements to market faster, like clinical research, trials, drug development, and commercialization. Additionally, trusted oncology practice technology, built with and for oncology specifically, is being optimally used by oncology providers at the point of care, enabling the delivery of evidence-based care, optimal personalized treatment plans, and constant information sharing across the space. The use of RWD and RWE is advancing, and it is making a difference in the cancer fight — that’s something to be hopeful about.
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. 🙂
I would say, when it comes to medicine, I encourage a culture of curiosity, openness, inclusivity, and the constant asking and answering of questions. In medicine, and in all things really, we will benefit from bringing more seats to the table and hearing more voices on the matter. Medicine is a science that is based on evidence, and it needs be rigorous and disciplined, but it is also human-intensive, and we need to maintain and evoke the human element in all areas where we can.
How can our readers further follow your work online?
- Dr. Robert on LinkedIn: https://www.linkedin.com/in/nicholas-robert/
- Ontada’s website: https://www.ontada.com/
- Ontada on LinkedIn: https://www.linkedin.com/company/ontada/
- Ontada on Twitter: https://twitter.com/ontadaoncology
Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.