From MMA Fighter to Radiation Oncologist: Combating Prostate Cancer

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Dr. Simon: Hello everyone. My name is Dr. Daniel Simon. I'm your host of the Inaugural Science at UH Podcast, sponsored by the University Hospitals Research & Education Institute. This podcast series will feature University Hospitals, cutting-edge research and innovations in each of the episodes, I will invite UH physicians and scientists to share their scientific discoveries. It is my honor to introduce our first episode guest, Dr. Daniel Spratt, Chairman of Radiation Oncology at University Hospitals and Professor and Chair of Radiation Oncology at Case Western Reserve University School of Medicine. Welcome Dan.

Dr. Spratt: Thank you so much. It's a great pleasure to be here, Dr. Simon.

Dr. Simon: So your journey, to becoming a doctor is really quite unique prior to becoming a physician you were a bodybuilder, an MMA fighter and a personal trainer. Tell me what inspires you to go to medical school and choose a physician-scientist as your career?

Dr. Spratt: Well, again, thank you. It's a true honor to speak on this and be part of this with you for UH, but I think that many great leaders that I've spoken to throughout my journey, actually many have very unique stories. And so I think mine is just one of many. Often, people start to pause and question when they hear these things because they are somewhat atypical, but I'm a product like everyone else of their environment. I have no physicians or academicians in my family and I was always engaged in physical activities sports throughout my childhood.

And starting at a young age, I think like many parents, they enrolled me into karate and then that progressed year over year into multiple martial arts and then eventually into bodybuilding, andnd eventually, that was my passion rather than school. And I needed a job after high school and started as a personal trainer. And so, I think that I had a lot of the same types of themes; thematic drives… that I think many leaders and many physicians use, consistency, drive, questioning… things… to you know discovery.

But I didn't have, I would say the ideal outlet. And so I was very fortunate that two of my clients, they were physicians that I was training, burst the small bubble I was in, and exposed me to science and medicine. And I would say, a very long story short, was sort of a catalyst to pivot that drive into something that really has limitless potential. And, many years later, I'm here today talking with you.

Dr. Simon: Well, it sounds like I could really use your help since I was on a three-mile run this weekend and pulled my calf muscle. So, maybe we can do some personal training later. So, it's interesting you picked a career in radiation oncology as your specialty and prostate cancer as your research focus. How did you get to radiation oncology?

Dr. Spratt: Yeah, radiation oncology it's, even my parents still call me a radiologist. So, very few really know what a radiation oncologist is, and I was very just serendipitous in that I actually went into medical school and planned to be a neurosurgeon. I did my first-year research at Vanderbilt… you gotta pick your summer project and I worked with neurosurgeons and it was pretty much a dead set till the end of the third year. And it just didn't click with me, the patient connection aspect to it. Obviously, it's a very rewarding specialty, but I found radiation oncology as many of the patients with brain tumors end up needing radiation.And I just really connected with it's a hyper academic evidence-based field. There's immense patient interaction and it's a very technologically advanced specialty where you can cure, you can palliate. And so I was just very fortunate to find it early on.

Dr. Simon: That's really a great story. I'm touched personally by prostate cancer because my father had prostate cancer and unfortunately, developed a secondary malignancy, acute promyelocytic leukemia, likely as a consequence of his radiation treatment. So, I also, really appreciate the complexities of the disease and the treatment options and decisions that patients go through.

So, I'm a cardiologist and really don't understand all those. Can you tell me a little bit about prostate cancer, what's cutting edge right now? And some of the challenges that patients, clinicians, and scientists are facing right now?

Dr. Spratt: Prostate cancer, and there may be more parallels than I realize with heart disease in the center. Prostate cancer is the most common cancer in men in the world. There are over 3 million men in the U.S, right now, walking around with prostate cancer. But it's exceedingly, we call it heterogeneous, meaning that some men it's not gonna harm them. They don't even need treatment. But it's still the second leading cause of cancer death in men. So, it's not something to just ignore, and it's the most common, Ii's called treatment-associated or cancer-associated disability from prostate cancer, because a lot of these men will live for many years, they may have surgery, there are side effects they have from radiation, there are potential side effects, hormone therapy, chemotherapy. So, it's this dichotomy where a lot of biomarkers or ways to personalize treatment to avoid overtreatment and avoid undertreatment, is just paramount because if you just go ahead… and this goes back to sort of the PSA screening controversies back in the day, they were sort of recommending against PSA screening because every guy would just go get biopsied and get treated. Now there's a lot more selectivity of who gets treated. So, the recommendations have become stronger.

So, that's sort of one big arena, with all of that, prostate cancer also has the greatest healthcare disparity by race in terms of incidents and mortality, and this is very complex in nature. Some of it is definitely related to structural racism and social determinants of health and a lot of the modern writings…actually, one of the new faculty here, Randy Vince, you helped with his recruitment. There's a lot of parallels that the world of cardiology actually looked into this decades ago. Chronic stress, diet, things that are very clearly linked. And now we're finding those same things being linked to prostate cancer and these types of disparities.

Dr. Simon: So, tell me a little bit more about the work that you and your research team have led using artificial intelligence or AI to personalize the treatment of prostate cancer.

Dr. Spratt: So, this is probably one of the most exciting and talked about things going on. I think in at least a localized prostate cancer setting. I would even say in the world right now. What advanced computational power and technology has enabled, is myself with a large group, through NRG Oncology, it's a national clinical trials group, and some AI scientists I collaborate with through a company called Artera. We have gained access to five phase three randomized trials that were conducted decades ago that saved all of their tissue.

And that tissue was scanned into images, and using deep learning...sort of a component of artificial intelligence...we were able to generate what's called a prognostic biomarker. Meaning, that just by scanning the slide it can tell us - is a patient less or more likely to develop recurrence or die from their prostate cancer. But, really the biggest discovery...and we've presented this and this will be submitted soon, hopefully, be published in a very high-impact journal...is that we created and validated the first ever what's called a predictive biomarker that actually selectively identifies the men who benefit from adding hormone therapy.

For those unfamiliar, hormone therapy is chemical castration. It's menopause for a man. And, so it's not something men look forward to - hot flashes, decrease libido, weight gain, muscle loss, some bone issues, cardiovascular issues. So, it's definitely something that, yes, if it can help improve their survival, men will definitely take it. But, if there's no benefit...and we found it's about two-thirds of men that right now national guidelines would recommend hormone therapy for...could safely omit it. And, so we validated this on a dedicated randomized trial, this pathology-based biomarker...and what's really exciting is UH Seidman Cancer Center will be one of the first sites in the country, really the world, that'll be part of their early access program - given our collaboration with everyone.

Dr. Simon: Well, that is really exciting. And, I think about all the complex treatment decisions that my father faced, probably close to a decade ago. And obviously, we had none of these tools. And, so it was all I would say, recommendations of physicians with best standard of care but clearly not this degree of precision. So, that's really, really good news.

So, recently there were dozens of news articles about a consortium UH Seidman and your team leads called MARCAP. What is this?

Dr. Spratt: Like many scientific efforts, groups, it's gotta have a fancy acronym. And, this stands for the meta-analysis of randomized trials and cancers of the prostate. And, this really parallels an effort in breast cancer that was successful and started decades ago. The acronym is not quite as catchy, but it's the EBCTCG, it’s the early breast cancer trials group. And, what they did was by having all the different trialists in the groups agree to share the individual patient data, they were able to make sort of discoveries as how best to personalize treatment when any one randomized trial and even in breast and prostate cancer there are often thousands of patients,they're not tens of thousands of patients. So, by pooling the individual patient datacan lead to a lot more discovery and personalization. This had never been successfully done in prostate cancer. Everyone kind of lived in their silos. And, so really through a lot of persuasion, and a lot of collaboration, and really being creative of how the sort of contracts and data sharing agreements worked, we started with a small number and that grew and grew. We now have the vast majority of every single randomized trial in localized prostate cancer with patients through radiation. t's now reached over 20 phase three randomized trials, over 20,000 patients. We've published now four high-impact papers off this work. The first one, the seminal paper was just published in Lancet Oncology, really addressing three important questions that were not as well validated and clarified to who benefits from these different types of hormone therapy intensification methods that have been tested. And UH Seidman Cancer Center, as well as UCLA, are the data repositories for this international consortium.

And so again, as we keep expanding this with pharma and with other trials ongoing, it again really speaks to multidisciplinary and, as well as the excellence that the UH Seidman Cancer Center brings to the table here.

Dr. Simon: Wow, that's really, it's very, very impressive. And, thank you so much for your leadership. Putting together national/international consortium are not easy. And so, kudos to you

So, I saw recently that your GU team was named as the first Hydrogel SpaceOAR Center of Excellence in the world. This is really amazing. Tell me more about this new technology.

Dr. Spratt: We have an amazing multidisciplinary GU team, the urology and uro oncologist with Dr. Yoni Shoag, Adam Calaway, Lee Ponsky, and many others. Now, Randy Vince, we mentioned. Our medical oncology team, Dr. Jorge Garcia, Prateek Mendiratta, Jason Brown, and some new recruits, Pedro Barata joining. And, then in the radiation oncology space really...expanding with new recruits Dr. Zaorsky, Dr. Jia, Dr. Zuhour and others. We really felt it was paramount that we set up a true multidisciplinary Center of Excellence that focused on the patient, not the treatmentmeaning that we wanted to give the best treatment to each patient. And, also going back to what we talked about earlier, minimizing these side effects that many of these men will not die from prostate cancer. And so, keeping a good quality of life is critical for them. And so, by working collaboratively, it doesn't become about trying to persuade them to get one treatment versus the other. And so, by partnering myself specifically with Dr. Yoni Shoag and our excellent nurses here, there's a procedure called the Hydrogel SpaceOAR, which people call it a rectal spacing gel.

And, it's a gel that got FDA approved around 2015… and actually UH was the first center to place it after the FDA approval. And, by building this multidisciplinary program, standardizing our workflow, very high volume use of this spacer gel, it protects men's rectum from the radiation...to now it's nearly 0% of men will ever have rectal bleeding. Which, 20 years ago, it was over 10%. And so, this is a huge game changer and it enables us to also use commonly a very convenient type of radiation called SBRT or just five treatments. So, each session, door to door is 45 minutes.

The beam is on for about six minutes. So, you're talking about five easy outpatient appointments and they have this one procedure with Dr. Shoag that takes about 10 minutes for him to do. And like surgery...I mean, it's something you need to gain technical skill at...and so, he's really been amazing. And so, they recognized Boston Scientific who makes the product. They started to create these centers of excellence and due to our high volume and our outcomes, we were named as the very first Center of Excellence in the world for use of this Hydrogel SpaceOAR.

And, there'll be a couple more programs to probably follow, but again, a big accomplishment I think for this relatively new team, that's really, I think, brought experts from around the country and really the world here.

Dr. Simon: Wow, you should be very proud. You're at the center of building this team together, along with Dr. Ponsky. And, it's great that you and Dr. Shoag are taking the lead here. Well, listen, Dan, I wanna thank you so much for taking the time to speak with us today. It's been really inspiring to me, to listen to you. I helped recruit you here to be the Chair of Radiation Oncology and boy, am I glad I did that. I'm learning a lot from you and it's just great to see you soaring here in your first year and a half or so.

So, for our listeners interested in learning more about research at University Hospitals, please visit UHhospitals.org for more information and stay tuned to our future podcasts. Thanks for joining us.

Dr. Spratt: Thank you so much.