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04 - Death by chocolate: India's new fight against cancer | Aniruddh Kulkarni
22 Plays12 days ago
Gerry grabs coffee with Aniruddh Kulkarni, cancer researcher at the Indian Institute of Science, to discuss some key public health issues of our times.
What's the impact of imported western lifestyles and dietary habits on non-western bodies? What is relative deprivation and how does it affect our mental health? What can we learn from the incredible progress our species has made against cancer and diabetes in the last few decades?
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Transcript
Collaboration in Cancer Research
00:00:07
Speaker
All right, so I am today, ah this week in Bangalore at the Indian Institute of Science as the guest of my collaborator, Dr. Anu Raghurajan, who is um a breast cancer a molecular biologist. um We've been working together for 11 years, thinking about emerging cancer cohorts and challenges for breast cancer patients who also have diabetes, which is very common in India.
00:00:36
Speaker
And we've had a very productive ah collaboration and have more to do in the future. And so it's an exciting time and I'm thrilled to be spending this week here.
Academic Path and Research Goals
00:00:46
Speaker
And today I'm talking with Anurut, who is a ah key um senior trainee with Dr. Rondarajan.
00:00:53
Speaker
And i was curious to get his opinions about the field, about the cancer spectrum in India, what is seen in the clinic, what the emerging questions are, what we should be worried about in the future, and questions of cancer disparities.
00:01:08
Speaker
And so thank you um for taking the time. definite We're delighted. Maybe you could introduce yourself a little bit, just tell a bit about your background. Yeah, so I'm Anirudh. I have completed my Bachelor of Pharmacy from University of Mumbai. Then I did my Master of Pharmacy from Manipal.
00:01:24
Speaker
And after completing my Master's, I wanted to get more experience in cancer biology and working on mammalian cell culture and animal models of breast cancer. So I was recommended to this lab by my supervisor and lamb was very generous to take me in. So I've been here since October 2023.
00:01:43
Speaker
And across like the last two years, we have worked on developing microfluidic device which can predict um the metastatic potential of patients in the clinic.
00:01:56
Speaker
we have We have been working on testing NPK inhibitors as a strategic therapeutic strategy for mitigating metastasis. And I've also been a part of the project to understand the influence of type 2 diabetes on breast cancer.
00:02:10
Speaker
So overall, ah in my experience here, I've worked on breast cancer in all three contexts to some degree or the other. So I'm happy to talk to you. Great. And where are you headed professionally? What will you be doing five years from now?
00:02:24
Speaker
So currently, I'm speaking, I'm still applying for PhD positions so here in India as well as abroad. I'm still looking out for positions that deal with cancer biology, maybe pharmacology, cancer therapeutics.
00:02:38
Speaker
ah And yeah, um it's an ongoing process. Let's see where where it goes. Hopefully, five years down the line, I'll have my PhD and maybe I'll be working as a translational scientist in some industry, pharmaceutical industry, where I can...
00:02:52
Speaker
join the link between basic research and pharmaceutical research and eventually the bench to bedside process. That's a lot of American graduate students think the same way. So where where am i
Personalized Cancer Treatment Strategies
00:03:06
Speaker
happiest? Is it in the lab?
00:03:08
Speaker
Is it in the clinic? Is it in a pharmaceutical company? is it conducting clinical trials? Is it with new device development? So there's lots of possibilities. And so why I've known students who feel like they wanted to be closer to benefiting patients. so So there's less of the basic research component and more farther down the pipeline where you really are developing a new drug or testing it in actual patients.
00:03:34
Speaker
What about you? Do you feel like there's a, where along that spectrum do you Yeah, i do agree that I'm also further down the line, maybe like working in a collaboration with the hospital where we can get patient samples immediately. We can run tests on them. We can characterize them.
00:03:50
Speaker
Maybe we can give feedback to the oncologist in a real time where They can make decisions, so they can personalize their treatment based on that. So that's there. But also on the there is one aspect of it where we can take these samples and see what why the patient didn't respond. Like what is going wrong with them or if anything is going wrong.
00:04:12
Speaker
And those who did respond, like why did they respond? We never look at that aspect of it. It's like the glass half full, and half empty conundrum. So those who responded, what...
00:04:23
Speaker
en enable them to respond to no treatment and what enables the others to not respond to treatment. So that involves an aspect of basic research also. I agree. um There's always a responder fraction of patients.
00:04:38
Speaker
And there's also a fraction of super responder patients. These patients are essentially cured and quickly, and we declare victory and send them home. We don't continue to study them, but they are in some ways the most interesting because we would love to know what What do you do? what What's the secret? and then What can we give that to everybody?
00:05:00
Speaker
How did you do so well? And conversely, there's the non-responders, there's the patients who don't respond to anything. yeah and try and try and try. Why? Why? they don't. why What is the problem? What should we be doing? And as researchers, we always focus on the non-responders because those who responded to the treatment, those who survived are not a scientific problem to us.
00:05:21
Speaker
That's achievement and we set it aside and we focus on the non-responders.
Breast Cancer Challenges in India
00:05:26
Speaker
oh We always tend to ask the question, what is different with the non-responders?
00:05:32
Speaker
We never ask the other way around. What was different with the responders? Why did they respond? like It's easy to say that so hormone receptor positive patients respond better than TNBC2 treatment. of it's On the surface, it seems ah logical that they have receptors which we can target and they respond better.
00:05:50
Speaker
But that's not the only thing. why are Because ER positive cells in a tumor are like 2% or something, and the rest of the tumor also responded to a treatment. Like, why? and There's a lot of mysteries here. Yeah. yeah and Like, our clinicians have this pragmatic ah view on this thing that if a drug works, they go for it. They, unlike us researchers, they don't care or they don't want to know why it works. it As long as it works, it makes their patients healthier, they go for it.
00:06:22
Speaker
And there are a lot of stuff to be uncovered here. yeah I think that's very frustrating. If something works, I want to know why does it work? And will it work again? Yeah. I mean, sometimes it doesn't. doesn't. Which means that you are wrong. about why you think it works. yeah You try it again, a new patient, it doesn't work. So what's the problem with joe but this is an incorrect recommendation?
00:06:44
Speaker
True. And also we think to we we like to think that we know why patients don't respond. Like the principles of drug resistance are the same, whether you talk about cancer, or or infectious disease or whatever.
00:06:57
Speaker
But even then, despite knowing all those principles, we still have no idea why like, can we not target those problems? Like, can we not bypass those problems?
00:07:08
Speaker
And still, we don't have a good solution for that because cancer finds a way. And it's like, there's a lot of things to be uncovered, I think. yeah And so what about from your point of view as a young Indian investigator focused on breast cancer, what do you see as the urgent emerging problems that we should all be paying attention to, both in the Indian context and worldwide? what ah What's bothering you about disease patterns?
00:07:40
Speaker
Come on. Epidemiological standpoint, it's concerning that breast cancer patients in India, the incidence occurs at an early age. yeah The disease itself is more aggressive and the rates of TNBC are much higher in India as compared to the Western demographic.
00:07:57
Speaker
That is epidemiological and it could be attributed to like the environment risk factors, the pollution, the dietary lifestyle of our people.
00:08:08
Speaker
But when it comes to treatment of implementation in the clinic, that's where I'm really concerned because although there has been this substantial development in treatments, targeted therapies, antibody drug conjugates, it is still out of reach for most of the population because they can't afford it.
00:08:27
Speaker
But maybe they can afford it for a few cycles and after that they run out of money and their insurance won't cover it or they don't have an insurance in the first place. So there is this a disparity in not only the treatment strategies that are available, but also what person like what's of the society ah the patients end up surviving.
00:08:50
Speaker
ah People who are financially but in a better shape. they end up surviving maybe for a like few more years but people who are you know economically backward class they are not able to and this does bother me more as compared to epi epidemiological reasons because there is only very few things that we can do I believe um to prevent cancer because it's it's a very random thing to happen and
00:09:23
Speaker
We can maybe ask people to not smoke, not consume alcohol, maybe shift to a healthier diet. But at the end of the day, if it happens, we need to be ready to manage that disease. And that's where I am more concerned about.
00:09:37
Speaker
And also it has to do with my background from a pharmaceutical aspect that we need to be ready. Our industry needs to be ready to like face the challenge.
00:09:49
Speaker
So I think what you're also saying is that if the disparities in cancer access and treatment um are related to money, and it's the same everywhere. yeah So the poor get less, the
Healthcare System and Accessibility
00:10:04
Speaker
wealthy get more. yeah the wealthy have more access, more education, they're willing to argue for change in their treatment, whereas people who are perhaps the lower social classes yeah don't even question what their physician might say.
00:10:21
Speaker
And as we were discussing the other day, clinical visit could be five people in the room all at the same time. yeah So Americans are used to one-on-one visits with their oncologist But in some hospitals, like in some of the government or ah public hospitals, yeah that visit includes five or six other people at the same time um because it's efficient.
00:10:43
Speaker
And the case burden is so high yeah that that's the only way the oncologist can see those patients. So that's shocking to me. But but that's that's the reality of health care. right Unfortunately, yes. And...
00:10:57
Speaker
The problem is we can't really advise the clinicians to do a better job. We cannot fine tune government healthcare care system because they are at their breaking point. They are performing to their maximum catering to all this all the patient crowd.
00:11:14
Speaker
so To tell them to have a one-on-one patient counseling is counterproductive. They don't have the time for it. Neither do the patients because a lot of these people are daily wagers. So they can't take their time out every other day to come to the clinic for counseling with the doctor, some healthcare profession.
00:11:35
Speaker
So the problem, uh, it's, I am not sure if there is solution can give for this, but Maybe on a certain degree, if the government can intervene, ah maybe more healthcare care facilities, maybe hiring of more oncologists, training of more oncologists, that could be a starting point where the cascade begins and eventually we'll have a better healthcare care system for cancer patients. What do you think is our responsibility as scientists ah as we work to develop novel cures, really interesting new profiling techniques, fantastic new drugs?
00:12:14
Speaker
But if they cost a million rupees each, there's no point, right? They'll never be used. And it's the same in America. You can profile a lung cancer patient at the cost of $30,000 more.
00:12:26
Speaker
If that patient wants to pay for it, great. Or if it's a clinical trial, great. But that's never going to be the standard of care. Who has that kind of money? Just insurance doesn't cover it. yeah Private funds are only the thing that will pay.
00:12:39
Speaker
And so are we spending our time wrong coming up with novel, new, high technology tools if they will never be used, no matter how good they are? Right.
00:12:51
Speaker
No, I don't think we are spending our time wrong with that, developing newer testing methods or developing newer ways of targeting cancer cells.
00:13:03
Speaker
oh That is important because we need to expand the frontier way to do that research. um And in the beginning, every new technology costs a lot. That's true whether it's medicine or it's whether it's any aspect of engineering or anything that's there.
00:13:19
Speaker
I think beyond a certain point, the government needs to be intervene and maybe subsidize the costs of that because all these has implications eventually on public health spending.
00:13:31
Speaker
So if the government realizes that if they can subsidize the cost, they'll end up saving in the longer run. So for example, let's say there are antibody drug conjugates that costs like 10 or 100 times more than doxorobacin.
00:13:47
Speaker
If the government can subsidize that cost, they can maybe and um come to the realization that the patient may not relapse and then they'll save money on subsequent treatment cycles.
00:13:58
Speaker
So that cost benefit analysis, if governments undertake and they do find a advantage, then maybe we'll have some some breakthrough there.
00:14:14
Speaker
But as far as we are concerned, as scientists, as researchers, I think it's our duty to expand the frontier every opportunity that we get.
Diabetes and Cancer Treatment
00:14:23
Speaker
And since we are utilizing taxpayer money for our research, it's also a responsibility to convey to the public what we are doing, why we are doing it, and how is it going to benefit them in the end.
00:14:36
Speaker
And I think that's where we have to emphasize a little more and it hasn't been there. You mentioned an important barrier a few minutes ago about convincing our clinical colleagues to that our discoveries are change the way they treat their patients. And a great example is diabetes.
00:14:55
Speaker
And the current estimate is, what, 100 million Indian adults with diabetes? And your work and my work is showing they have different outcomes. It's a different disease. Diabetes much more serious, but never considered in the standard of care oncology. Oncologists don't think about diabetes at all. yeah And so what is our role then to help them be aware that this patient that they have who is diabetic is different from the clinical literature for how this patient should be treated. and You said they're very busy yeah and don't don't have time to. So what should what should we do?
00:15:33
Speaker
I think a more detailed conversation with the clinicians, which is difficult because they don't have the time. But if we do have a detailed conversation with them about what our findings are, what the consensus in the scientific community is about, why diabetic patients with cancer are different in biological years compared to those without diabetes.
00:15:53
Speaker
Maybe they'll come around and um look ah look at their prospective patients from that perspective. But then again, we are not going to convince them to change their way of prescribing their chemotherapy or radiotherapy. It's not going to change their medical training basics. That's going to be there forever.
00:16:14
Speaker
But if we are able to at least tell them that look at these patients from a different perspective, it might help the to cause a shift in the mindset that the oncologists have.
00:16:25
Speaker
And maybe they will involve an endocrinologist or like some other specialist who is not involved in oncology in their decision making. And hopefully one day, maybe other researchers will gather a body of evidence that is substantial enough to change that medical thinking. and Hopefully, yeah. So when we're saying diabetes, we're referring to the obesity-driven type 2 systemic disorder, and not type 1 diabetes, which is the deletion of beta cells in pancreas you see in children. So this is adult diabetes driven by
00:17:02
Speaker
changes in physical activity and diet, and they're driven by lifestyle and other factors. So in the United States, we often see among African-American or European or Latino women obesity associated with their diabetes.
00:17:18
Speaker
And if such a person develops breast cancer, I think that's a different disease, let's say estrogen receptor positive breast cancer. right In such a patient, that is a different disease from someone who is otherwise healthy metabolically a normal weight.
00:17:35
Speaker
So that's i'm I'm concerned that we're not treating these patients properly. And yet in India, the phenotype is different yet again. you talk about that? Yeah, so I'm not an expert in this to be honest, but the type 2 diabetics in India fall into the category of lean diabetics where their BMI is close to normal.
00:17:56
Speaker
They don't appear to be obese, but their glycemic index is off the charts. And I think you had mentioned it out a few days back that the fat, the adipose tissue is all in the wrong places, like in the pericardium, the peritoneum.
00:18:11
Speaker
So that's a problem because if an oncologist looks at a patient with cancer, breast cancer, and if not considering the glycemic index is a problem inherently, but if the patient appears to be not obese,
00:18:30
Speaker
If their BMI is normal, their high 10 rate ratios are normal, then the oncologist is not going to take that into factor when making the decision. And that's a problem because we don't know how these patients are going to respond.
00:18:44
Speaker
And as we said, we always think why this patient this cohort of patients didn't respond. Maybe this could be the answer. We don't know because that kind of data is not maintained.
00:18:55
Speaker
so
00:18:57
Speaker
I'm not. um So would you agree that this is yet another kind of breast cancer? It's a different disease in someone who is lean and diabetic. We will speculate. I would speculate that know the cancer would respond differently to whether it's radiotherapy or chemotherapy, of but like how aggressive the disease is. I would speculate that it would be different than a person who is who suffering from obesity-related diabetes.
00:19:24
Speaker
So in my view, the clinical trials for breast cancer that were conducted in you know wealthy white women in Massachusetts or California, It's completely wrong for lean diabetic women in India with the same kind of breast cancer because they will respond likely completely differently. And you're saying it's more aggressive.
00:19:45
Speaker
And younger women. Yes. And so I think we're actually doing harm to these patients to use medical guidelines that were developed in a completely different population.
00:19:56
Speaker
True. oh That is of a problem and yeah inherently, but also a Even within India, we have we are such a diverse population.
00:20:09
Speaker
They different dietary lifestyle, differenting they come from different backgrounds, different lifestyle, alcohol consumption, smoking, and all that. And diabetes is just one confounding factor that we take into consideration because our labs work on that aspect.
00:20:26
Speaker
But we also have to consider other aspects like the stress levels, the cortisol levels in these patients. I would think that the cortisol, average cortisol level ah of a patient in India versus maybe in Boston would be different. And again, that would influence their treatment and the diets are different.
00:20:44
Speaker
So To and adopt a guideline developed in another country where the clinical trial was done in a different demographic. I wouldn't say it's completely wrong. It could be counterproductive in some aspects and yeah we have to do more work to better understand these disparities in race or ethnicity when and and we are addressing such problems.
00:21:10
Speaker
you made another interesting observation which is that people who have this lean diabetes phenotype often don't know no because they're lean so they look perfectly normal and yet their glycemic index is sky high yeah so what does that suggest is it there's a large number of undiagnosed yeah diabetic adults Unfortunately in India, the ah thinking is that if you don't eat a lot of sweets, you're not going to get diabetes. And that's not true.
00:21:39
Speaker
And if a person is lean, they think I am not going to have any metabolic disorders or any obesity related disorders. And again, that's wrong. That's one factor that the awareness is not there.
00:21:52
Speaker
Second, people who do know about diabetes, who are aware about it, they also understand that the medication for diabetes is a lifelong um medication. They have take it throughout their life.
00:22:04
Speaker
And then they're worried about the costs, the potential spending on that. So they don't want don't want to get tested. because of that fear. If they don't know, they don't have to buy the medication.
00:22:15
Speaker
So, in our study, in our um study on diabetes and breast cancer, what has happened repeatedly is that the patient did not know that they were diabetic. They appeared to be healthy.
00:22:26
Speaker
When they reported to the cancer hospital for their initial diagnosis, that's when they came to know that they were diabetic and they were When they were asked about it, dinner like I didn't know. like I was not taking any medication for it.
00:22:41
Speaker
and The oncologist there again, as you said, they don't take this into consideration. They just, they are concerned with the random blood sugar because they want to perform a surgery.
00:22:51
Speaker
And once that is done, the patient leaves the hospital, maybe comes back for chemo. And that's it. That aspect of diabetes is there only for that fraction of time where they consider it prior to surgery.
00:23:04
Speaker
And that's it, that's lost. So this problem of undiagnosed diabetes, hi clouds the data a lot when it comes to our studies.
Medication Concerns and Social Media Impact
00:23:15
Speaker
So one of the major new therapeutic innovations in the West is these GLP-1 agonist drugs. So things like Losempic and Wagovi for weight loss. And they work.
00:23:27
Speaker
You definitely lose weight on these drugs. And um that often resolves diabetes in patients who were obese and then they took the drug and they have to stay on it for the rest of their lives but it works. yeah And yet with this lean diabetic phenotype, some of these patients are even underweight. You know, they're they're below normal weight.
00:23:52
Speaker
And if the standard of care is to prescribe a weight loss drug, what do you do with someone who's already underweight? yeah I mean, is it it's probably a bad idea. yeah I think it's counterproductive. It's not going to work.
00:24:05
Speaker
look Or it might work from a diabetes standpoint, like a glycemic index standpoint, but i love It will have adverse effects on their weight for sure. And like the way Ozempek or Terzempetide is getting adopted into modern society, it's too rapid and frankly I'm a little concerned like what are its implications, especially in Indian context.
00:24:28
Speaker
Because those have been tested in the West and I have read that in the United States it has moved wonders. Some have been calling it as a miracle drug for weight loss.
00:24:40
Speaker
But when the same drug comes to India and we have people in India and undergoing that therapy, I am concerned about its implications. so because We don't know. We don't know. And the doctor might look at the clinical reports, clinical trial reports that were conducted in the West and he or she might be completely correct in the decision to prescribe that to the patients.
00:25:03
Speaker
But the patients are under the influence of their social media or whatever to... lose their weight really fast. And that bothers me, frankly. Well, the social media problem is a real one because there are lots of Americans who are not obese who are taking Ozempic and everything because they want to be even more beautiful.
00:25:27
Speaker
Which is very funny. like i mean Like they want to be Hollywood starlets and and Instagram influencers who want to be even leaner and prettier. You're like, really?
00:25:39
Speaker
you're You're committing to this for the rest of your life. True. And I mean, social media is a different problem on its own, but I'm also worried like are we leaner?
00:25:51
Speaker
All this rapid adoption of Ozympic and other drugs, GLP-1 agonists, are causing a rise in allurensics in our generation? Hopefully not because... Do we know they have more anorexia? I'm not sure. I'll have to look at it. I've not read about it, but hopefully, I hope not. Yeah.
00:26:08
Speaker
but What do you see among the culture of people in Bangalore your age? Is there... they're There are way more gyms than I remember being. When I was last here, the gym culture, yeah the physical fitness culture, the bodybuilding culture was almost non-existent.
00:26:24
Speaker
That seems changed. Well, first of all, in Bangalore, everybody wants to be smart and strong and beautiful and wealthy and yeah it's all of it. So that's strongly influencing this culture.
00:26:35
Speaker
There's hundreds of thousands of young adults in Bangalore who want to be movie stars and drive sports cars. Do you see that changing? Do you see that as a strong influence on the physical fitness culture?
00:26:49
Speaker
um I do see that among my peers there has been an awareness on unfair like the importance of physical health. So they do try to go to a gym or they at least go for a swim or a jog or something.
00:27:02
Speaker
So that awareness which I appreciate is there right now more than ever I think historically. It's playing a good role in keeping people healthy in that aspect that they work out and they take care of their bodies.
00:27:17
Speaker
But also on the other hand, I've seen people go to the gym like three hours a day, two hours a day, maybe take supplements for bodybuilding. Could be anabolic steroids, I'm not sure, by they do it to but they do take protein supplements for that.
00:27:32
Speaker
And that's where, again, I try to i get concerned. like What's the boundary where we say, okay, this is taking care of your own health and this is overdoing it.
00:27:43
Speaker
Yeah. Or when does it become an addiction? yeah An addiction to, i don't know, steroids or bodybuilding or gym time? or And when does it associate with depression?
00:27:54
Speaker
Because I think the online, the Instagram culture promotes depression. know body dysmorphia yeah and depression and isolation and you know my friends will return my text because I'm not pretty enough. yeah you know like i'm not I'm not the cool kid any longer. I need to lose more weight or something.
00:28:14
Speaker
Really a dangerous psychological loop. i It's like a negative feedback loop, I would say. People see other people doing it. They try to emulate it. Then someone else sees this group of people. goes online.
00:28:29
Speaker
what i don't What people don't realize maybe is that what they are seeing online is a very, very, very filtered version of what the reality is. And I hope people keep off social media as much as possible. They hopefully don't use a lot of social media or at least don't don't try to compare their lives with those of others on social media because if it's going to be counterproductive. To me, that sounds even harder than convincing clinicians they should pay attention to our research. i't I don't see happening.
00:28:58
Speaker
so Especially very young people, yeah you know, people who are in early grade school, yeah they're from a very early age, people are learning. There are certain standards for beauty and certain standards for wealth. And like you should aspire to this.
00:29:13
Speaker
Yeah, body dysmorphia is there. You have anxiety because of you think other people are leading a better life than you are. i know that other people are doing better things than you are. And yeah, there's a book called ah An Anxious Generation. I think it's called An Anxious Generation about how social media is rewiring the next generation of kids.
00:29:32
Speaker
And when they become adults, how are, how is it going to impact the society? And yeah, it concerns me a lot. So personally, I'm not on any social media apart from WhatsApp. So yeah, I'm sure.
00:29:44
Speaker
there's ah There's a literature in sociology on this called relative deprivation, which is exactly this. You compare yourself to other people and ask, am I doing better? Am I doing worse? What about them?
00:29:56
Speaker
yeah And an interesting observation was that just before the French Revolution, the price of bread went higher and higher and higher and nobody could afford bread. Everyone was hungry and angry. And it's when the price of bread slightly improved, began to drop.
00:30:12
Speaker
That's when all the riots happened. Because people realized, oh, we've been suffering all this time and we didn't need to. and so it's curiously, it's when the price of bread improved that all of the ferment happened.
00:30:26
Speaker
So it's about this comparison to others. today You don't really know who you are on this long slide to fame and wealth. But you only have your imagination. So what do you how do you locate yourself with your peers?
00:30:42
Speaker
I like to think that we all are living our own unique lives. And social media is not going to be an accurate portrayal of what other people's lives are.
00:30:53
Speaker
what's happening in their lives. Like if um I were to travel to let's say France today, obviously I'll put that on my Instagram because that's something exciting. But if I were to get up on from my bed and travel to work, go back at the end of the day, it's not Instagram worthy.
00:31:11
Speaker
So- Like your morning coffee is not Instagram story. Yeah, but what people see is that trip to France and they think, oh, that person is, a lot of things are happening in that person's life. It is not happening in my and life.
00:31:23
Speaker
and change reaction of comparison start and... Well, so let's dig a little deeper there. Why would you post a trip to France on Instagram? I personally wouldn't because... You wouldn't? No. Because... Why?
00:31:36
Speaker
Because that's a personal trip. It's a personal thing. Maybe for safety reasons, if I want to let someone know, I will text them and let them know personally that if you want to reach me out, you can just text me or whatever. I'll be at this hotel.
00:31:49
Speaker
But I won't post it on my Instagram or Facebook because right because it's not ah not ah anyone's business. Posting to the public, oh, look, I'm in France on vacation and you're not. That's a different thing. Yeah.
00:32:03
Speaker
There might be people, as influencers who might be doing that. They post a very small part of their lives which is not even accurate and people look up to those people. Yeah.
00:32:14
Speaker
It's unfortunate. Well, let's let's take a ah slightly bigger picture here. where Where is all of this headed in terms of public health in India? You had mentioned earlier about um you know complex patient treatments and drug resistant bacteria that are really common and people self-medicating using antibiotics or ordinary infections all the time in a context where cancer is also rising.
00:32:44
Speaker
where Where is this headed and what should we most worry about in India?
Infectious Diseases and Cancer
00:32:54
Speaker
so theyve club I only ask you easy questions. odd Because I come from a pharmaceutical background and I studied all sorts of drugs and what kind of disease they are used in, I worry from all fronts. So from cancer perspective, I think we have to worry about what people are consuming because that ends up being a risk factor for their cancer incidence later in life.
00:33:20
Speaker
but I worry most about people having some sort of infectious disease and cancer because then the treatments are not exactly contrary to each other.
00:33:35
Speaker
But if you wipe up but wipe wipe out an immune system of a person by chemotherapy, then your antibiotics are not going to work to the same degree. And then you have something opportunistic going to happen in that patient to which you have to taper down your chemotherapy. Again, the cancer comes back because of that.
00:33:52
Speaker
I worry about that kind of patients especially. It's the immune compromised patients. Immune compromised patients. And also in a government hospitals where um there is such a crowding of patients.
00:34:06
Speaker
Again, it's not the patients to be blamed. this We are a very populated country in that regard.
00:34:14
Speaker
Like the chances of something spreading infectious disease in a cancer hospital, I think that's what I'm most worried about. Every time I visit our collaborative hospital anywhere. yeah like this is This could be something waiting to go wrong.
00:34:30
Speaker
Hopefully it never happens that way, but it could happen. So that's one thing. and so Before you move on there, so what what was the experience of India's cancer hospitals during COVID?
00:34:42
Speaker
ah I'm not sure because I was associated with this lab when that COVID pandemic happened, but I'm not sure i have to ask someone else. But I think there were it was a lot of i think we' put them in lot of confusion problems because we had to not only maintain social distancing, I would expect that doctors could see very few patients every day because they were limited by the number of patients they could see or the crowding that could occur in the hospital.
00:35:13
Speaker
So I think that could have been like like everything would have gone haywire during the pandemic. One of the things we saw in Boston was that ah elective surgeries, even cancer surgeries, were sometimes postponed or delayed or canceled because of that capacity problem of social distancing.
00:35:32
Speaker
And so then people's tumors reg progressed. Time passed, things got worse, possibly metastatic. They moved from stage two to stage three or stage three to stage four while they're waiting for slot to open up for surgery. And so there was more death, more cancer death.
00:35:49
Speaker
because people had to wait for their treatment. And so the delay caused by this whole infectious disease problem increased cancer death. Right. And also I would expect there to be some implications because the logistics broke down during pandemic. The shipping industry was like, you know, like... ah had some problems. So I would expect that people had issues getting their treatments because the drugs just weren't available. ah Whether we're talking about chemotherapy or whether we're talking about any year any treatment for any disease, I would expect that that would have resulted in few deaths.
00:36:23
Speaker
Not a few being an understatement, but deaths in India or in every country, I would expect that would have happened. That's the kind of confounding factor that does concern me, infectious disease. Because cancer, of it's difficult to manage as it is, but when you have a factor of infectious disease, when you have a factor of diabetes, when you have logistics breaking down, that kind of things do bother me more than it should, unfortunately.
00:36:55
Speaker
And the cancer burden is high, continues to be high, and it's all also driven by the built
Environmental and Optimistic Outlook
00:37:01
Speaker
environment. So nobody chooses to live next to a well that's contaminated with arsenic yeah or where there are organic toxins or pollution nearby. And yet people have to live in those neighborhoods. They would rather move, but they can't. yeah And so their cancer exposures are going to stay high and the burden will stay high.
00:37:19
Speaker
on And as you say, your worry about infectious diseases and cancer is going to continue to be a problem, possibly worse, with drug-resistant bugs everywhere.
00:37:31
Speaker
um But is are there signs for optimism? what if So for the next five or ten years in public health, what makes you optimistic? What what are your sources of hope for cancer treatment and public health?
00:37:44
Speaker
um So my personal ah source of optimism is that in the last 100 years, so let's say the discovery of penicillin is where modern modern medicine starts, let's say.
00:37:56
Speaker
We haven't even reached 100 years of discovery of penicillin. Its clinical implementation would come a decade or so later, but in that 100 years, we have gone from not being able to treat staphylococcal infections to now where we can easily manage tuberculosis, except for the extremely drug resistant cases.
00:38:16
Speaker
We can manage HIV cases where drugs like acetothymidine or lenacapha, we can keep the HIV levels below detectable levels.
00:38:27
Speaker
We can manage stage 3 cancers, except in very aggressive disease. So in and not all that progress happened in the last hundred eighty years or so and cancer chemotherapy compared to entire human timeline, it's like really new. It's been there for like 70 years.
00:38:48
Speaker
So in that time, we have moved from nitrogen mustards targeted therapies and now to antibody drug conjugates. So this precedent that is set by the by pharmaceutical companies in coalition with governments who were able to bring all this to the public makes me optimistic that no, we are on the right trend.
00:39:12
Speaker
While it is frustrating for us as researchers that every time we open up some literature paper, we see like the breast cancer is the leading mortality, for example, in women.
00:39:23
Speaker
That is indeed frustrating and you tend to have a pessimistic outlook after reading something like that. But that was the mortality was 100% before 1940. And today we worry about metastatic cases. We don't worry about non-metastatic cases because that is something manageable.
00:39:41
Speaker
So again, it's like people look at the situation as they look only at the glass half empty aspect of it. They don't look at the glass that is half full. So if we are on the right trend, I believe, and hopefully someday, maybe 10 years from now, we'll have better therapeutics, better way of diagnosing, better way of targeting these cancers, not only cancers, but also infectious disease, metabolic disorders, everything.
00:40:08
Speaker
And I hope we'll, I know we'll find a way. When is a good question. Yeah, your point about cancer mortality, you know, especially breast cancer mortality being 100%.
00:40:19
Speaker
hundred percent Like around the time that penicillin was discovered in 1948, breast cancer mortality was 100%. Everybody died of it. And now survival 80%. we're...
00:40:33
Speaker
try to improve on that. But that's a huge change. That's huge achievement. And we don't congratulate ourselves. We tend to look at the 20% and like we are bothered by that. Which is fair enough because as scientists, we like ah tend to look at what's the problem.
00:40:47
Speaker
But It's like we have traveled so far to go to the place where the rainbow touches the earth, but we we don't look back to see how far we have traveled. And that's, I think, what's happening with cancer treatment. that We have come a long, long way.
00:41:02
Speaker
If you would ask a person who suffered from CML, maybe before 2000, and after 2000, there's a difference in how they ended up managing the disease. Yeah. so Well, and the first use of methotrexate, right? The first chemotherapy for childhood cancers.
00:41:20
Speaker
That was five years before I was born. Exactly. That's in Boston, the first use. That's essentially within my lifetime. Exactly. Is chemotherapy yeah began. Yeah.
00:41:30
Speaker
So you're right, but look how far we've come. and it's The progress is exponentially increasing, yeah the speed with which yeah new drugs are coming online. Actually, I would encourage all the people to think about the milestones in terms of people who were born around that time or were around that time or got married, something like that.
00:41:51
Speaker
Because then you realize, oh, it wasn't a long time ago. Like, i am my grandmother, who is right now 95, she was born before penicillin was clinically available.
00:42:03
Speaker
And so in her lifetime, we have gone from penicillin to algomycin to linozoloid and now all kinds of antibiotics are available. And unfortunately in India, they are available over the counter.
00:42:15
Speaker
i we I think we often take modern medicine for granted. We don't realize how like it's ah how much of a luxury it is, but do we take it for granted because if I get a cut today while working in the lab, I can go and apply sofromycin or streptomycin ointment on that cut if it were to get infected.
00:42:37
Speaker
That was not a... opportunity or whatever thing that is available. You won't die of tetanus. Yeah, right. Even that's something that we take for granted. I can go to the health center, get a tetanus shot of a preventive measure and yeah.
00:42:52
Speaker
And no side effects. No side effects. You don't even know. I'll never look at that cut again for the rest of the day. I'll carry on with my work. Yeah. again We are lucky, I think. We are much luckier than most of human history. We have different set of problems. I'm not ah neglecting that.
00:43:10
Speaker
But when it comes to medicine, I don't think we are any worse. We are way way better off as compared to most of humans ever. o i mean i'm not sure that it's that I'm not aware of any numbers for this, but I would expect the average lifespan has definitely increased in last century. Just because of antibiotics.
00:43:32
Speaker
You take into account insulin, you take into account chemotherapy, you take into account other drugs for other diseases. And seat belts and clean water. yeah right Right there, public dislo public soap sewage systems.
00:43:44
Speaker
And road signs, stop signs on the road. exactly Safety, right? That saves so many lives. And all these all this happens so incrementally for a person to monitor that they take it for granted.
00:43:58
Speaker
But if we look back the last 100 years, I guess I mean, if someone were to get a cut and you know it's what if it was infected with staphylococci, I'm not sure what a patient in 1995 would do.
00:44:14
Speaker
But today, don't worry about it. We just carry on with our work. If it something happens, and look ah like I'll do whatever I can at that point. But we don't spare a second thought for it. so Well, kind of like your perspective.
00:44:30
Speaker
ah Thank you for your candid ideas. And it's but such a pleasure to talk to you about this, really. But I think in scientific literature, in editorials, maybe if people realize how far we have come, maybe there will be a little less pessimistic hint.
00:44:51
Speaker
hint and while they were writing the introduction part of the research papers. Like, yes, we understand breast cancer mortality is high. We understand how bad of a disease it is. Same applies for diabetes, same applies for tuberculosis.
00:45:05
Speaker
But we have come a long way. And so we are on the right trend. The trend is in a positive direction. It's just that we have taken modern medicines for so granted that we expect a cure at every corner.
00:45:21
Speaker
No, and that's not going to happen. It will happen eventually, but it will take time. Give us time. Give us time. Give us money and give us time. That's true. but again trust us trust Trust us. look what Look at our track record. yeah Trust us, please.
00:45:36
Speaker
Again, that's something again on us to deliver to the public. like We have come a long way. And that's because of the scientific community working in collaboration with the pharmaceutical industry and the clinicians and the government.
00:45:48
Speaker
We have come this long. If you continue to do that, give us like, give us like taxpayer money and fund our grants. Yeah, exactly. Keep us employed. Keep us employed.
00:46:00
Speaker
It's going to go in the right direction. I don't see why but progress would like decline. I don't see any reason for it. Yeah. And I'm not. I am very optimistic about cancer treatment.
00:46:13
Speaker
Maybe more than infectious disease for that matter. Because we'll find a way for it. Because that's how human nature is. We always find a way. I like that. We'll find a way. True. mean...
00:46:25
Speaker
What I always look back as a comparison is when Kennedy said we'll go to the moon by the end of the decade. They found a way to do it and it's not easy. It wasn't easy in back in night the 1960s to develop everything from scratch, go to the moon, come back.
00:46:39
Speaker
So why can't we look for cancer? Well, you know what made that work? A deadline. A deadline. He gave a deadline. By the end of the decade. And it's 1969, so it's a deadline. right Give us a deadline. yeah It's a deadline. Also, geopolitics, if you are competing with someone you don't like, you will end up being more competitive.
00:47:02
Speaker
yeah And also, look at all the implications of that program. for the program I mean, I'm not read much into that, but NASA got expanded, they found Johnson Space Center which wasn't there, it came to existence.
00:47:19
Speaker
I mean, I don't know, all the technologies that came out of NASA. A million things. Yeah. A million things. I mean, they had to develop, I think, pretty much everything from scratch. Yeah. And not an easy thing to do back in the 1960s when computing power was barely anything compared to today.
00:47:37
Speaker
So, well, somehow I don't think Mars is going to be the inspirational target that the moon was.
00:47:44
Speaker
and I don't think Mars is a different problem on its own because. But in terms of thinking about an aspirational goal and a agenda, yeah Mars is not it. I think it's also because we live in a different era right now.
00:47:58
Speaker
Back then it was all about competing with the Soviets. Americans had to do that. Right now, who are you competing against to go to Mars? No one. And the common public would be like, why are you not spending that thing on like eradicating diseases or other problems?
00:48:13
Speaker
They don't, again, they may not realize that all that money is not actually going to Mars. It's going to come to the public, boil down to the public. So... The same applies for research also.
00:48:24
Speaker
It's not like we are going to keep it with us and like stash it somewhere else. It's going to the public eventually. And it's all about the long-term benefits of it. We don't see that.
00:48:36
Speaker
Well, thank you for your thoughts. um I actually had one point to bring up. There was this paper that spoke about the similarities between tuberculosis and cancer because they behave in very similar ways, although they are different diseases inherently.
00:48:53
Speaker
Granulomas can be compared to primary tumors, then they shed off, they both are the organs. The causative agents are dormant cells which are drug resistant and they persist for a long, long time and they come back like at any time.
00:49:07
Speaker
So what are your thoughts on studying one disease and then applying the lessons learned from it to the other? It's always a good idea. It's a good idea. Always. Yeah. because some diseases provide rules and insights and interpretation. would never occur to you yeah if you stay narrowly focused on one disease or one condition. yeah But sometimes you see, how does an infectious disease solve this problem? Amazing, right?
00:49:31
Speaker
So HIV is a great example. yeah So reverse transcriptase of the triple drug combination is inhibitable in a way that two drugs don't work. yeah And this informs cancer therapy, right? we never hit a patient with one chemotherapy. We give a whole spectrum of different drugs that act on different targets yeah and those work.
00:49:50
Speaker
So it's the same idea. And so that kind of thinking across discipline is very important. And outside of your box, think about how do other people think about this problem? It's such an interdisciplinary way of thinking, i did because infectious disease and cancer, some would say they don't intersect, or circles don't intersect. No, but they do. Yeah, they do. At least, maybe not mechanistically, but at least in kind concept, they can. And you can apply the lessons learned from one in treating the other and vice versa. Especially resistance. and so So antibiotic resistance is so parallel yeah to chemotherapy resistance in cancer.
00:50:23
Speaker
It's very parallel. And so maybe in the lessons that we learned in targeting cancer cells, maybe the people who work on tuberculosis can use it to target a mycobacterium.
00:50:34
Speaker
The lessons can go both ways. agree. Eventually, I think but that kind of crosstalk between the scientists who work on two different things will help in progress for everyone.
00:50:49
Speaker
Thank you again. Thank you for having Such a pleasure. It was very interesting. We should talk again in a year. Sure. See if our answers change. I hope not. At least not for the optimistic side of it. I will still be optimistic, but let's see where it goes. Let's talk again in a year. I'll be curious to see if your opinion is the same. Oh, no problem. All right. Thanks for having me. Thank you very much.
00:51:12
Speaker
Thank you.