Surgeon Laura Esserman raised questions last fall about the effectiveness of mammograms for women under 50. Now she is coordinating a national research effort to match the right drug to the right cancer patients more quickly. Only collaboration makes this kind of medicine possible, says this innovative physician/scientist.
by Deborah Franklin
Source: Stanford Business Magazine, Summer 2010
Photo by Anne Hamersky
The waiting room of the San Francisco breast cancer clinic designed by Laura Esserman, MD, MBA looks more like a spa than a medical office. Comfy chairs, natural light, warm woods, and muted colors set a soothing tone. During a busy February afternoon, patients helped themselves to herbal tea while they waited to see doctors; soft bossa nova played in the background.
Only the large ceramic tiles that cover one wall—botanical prints individually inscribed with encouraging words from one cadre of cancer patients to the next—speak to the deadly seriousness of the battle at hand. As one tile reads:
"The chairs are soft, there's cool water and hot tea, but there is nothing comfortable about waiting for your first appointment with an oncologist. Take a deep breath. Summon your tigers. And walk through the door."
On the other side of the door, Esserman, a 53-year-old breast surgeon and chief of the clinic, prowls the halls in a long brown skirt, loose sweater, and low-heeled boots. She checks the chart of a new patient who has invasive cancer, consults with another doctor, then stops to advise a young intern who is racing to finish a grant application.
"When are you headed to the airport?" Esserman asks the intern. "Now your day is like mine. Lunch at 5 p.m. Perfect!" She laughs and turns to an assistant to ask about another colleague. "Does he know the grant's been delayed?" she asks. "Please call and let him know; he's probably working like a madman."
Esserman steps into "the hub," a small conference room in the clinic equipped with half a dozen computer terminals, and sits down to log on to the medical records of the patient she has just seen. Within a few months, the plan is to have every aspect of the patient's medical history and care—chemo treatments, scans, and multiple reports from radiology, pathology, oncology, nutritional interventions, and certain genetic tests—immediately accessible online to those on her medical team who need to know.
"Hospitals are known for their turf wars," Esserman says. "Taking one piece of the problem—the disease, the patient—and trying to control that piece. It doesn't work so well for the patient who gets shuffled off from one specialist to the next—and it doesn't save money."
So, instead of asking patients to schlep records across town for needed scans and lab work, Esserman made sure specialists such as radiologists and geneticists were based next to exam rooms. The design of the Carol Franc Buck Breast Care Center at the University of California, San Francisco, makes quick hallway consultations between doctors from different disciplines easier and more frequent, and that alone improves the coordination of patient care, Esserman says.
Teamwork is the future of medicine and medical research, she believes, though "being a team player is really something I didn't learn how to do until business school. Science and medical training in the United States is all about rewarding individual behavior. It's not about rewarding team players."
Esserman's vision of how collaboration can improve cancer care is about to get its biggest test. She's one of the prime movers behind two huge multicenter studies being launched this year. One, set to begin this summer, will "unite the breast cancer programs of all five University of California campuses," she says, "enabling doctors and researchers to share their data, analyses, and treatment plans. We'll be able to track the long-term outcomes of patients all across the state."
The second study, just beginning, unites nearly 20 major cancer research centers across the United States and aims to characterize different types of breast cancer using telltale molecular markers, then quickly screen the most promising new drugs against them. The ultimate goal is to give each patient a drug that is more individually tailored to her specific tumor—the better to wipe it out and prevent recurrences. The study design makes it easy to drop a drug that's ineffective and give more women quick access to new experimental drugs that seem to work.
Both projects rely heavily on the field of "bioinformatics," a research approach that pools and analyzes layer upon layer of data about individual patients and their breast tumors in a hunt for meaningful patterns as to why some cancers aggressively spread and others don't, and why some patients respond better to certain treatments than others.
"These are very complex projects with a lot of moving parts," says Anna Barker, deputy director of the National Cancer Institute, who worked closely with Esserman in setting up the national study. "It's not unlike running a big company."
Esserman "is a force of nature," Barker says, with exactly the set of scientific and business skills needed to keep the landmark collaboration among scientists, government, business, and philanthropic foundations on track.
"There's a tsunami of data coming in, and it takes a team of people to analyze and manage all that information," Barker says. "The person in charge also needs social skills -- the ability to bring disparate groups together, to inspire them and get them to believe in her vision. That's leadership. And that's what Laura brings, too. She's a visionary and is able to translate that vision to other people."
Esserman, center, operates on a breast cancer patient at UCSF Medical Center at Mount Zion. Although she has reduced her medical case load as her management workload has increased, Esserman says, seeing patients adds urgency to her other tasks. Photo by June-Ho Kim
Before she started shaping the future of medicine, Esserman studied the past. As an undergrad studying history of science at Harvard College in the 1970s, Esserman was fascinated by the context of scientific discovery -- the way some of science's boldest ideas are initially discarded, sometimes for centuries, until culture catches up. Copernicus needed Galileo to test and popularize his theories about the true nature of Earth's orbit. Ignaz Semmelweis needed Louis Pasteur and Joseph Lister to confirm that microbes, not bad air, are behind infectious disease and festering wounds.
The lesson Esserman took away then, and has faced time and again: "Being passionate and sure of yourself and wanting to get things right is a great thing, but at the end of the day, honestly, that's not enough to get the job done." You also have to get skeptics onboard.
She chose Stanford for medical school, she says, because it's on a university campus, where she could continue to take interdisciplinary courses. She thinks her strength is not as a specialist but as a "change agent" and "integrator," always looking for fresh ideas that can improve the practice of medicine. Though she sometimes ruffles feathers, Esserman says she's not a diva. "When other people have good ideas I'm just as excited to try to make them happen too."
Esserman worked her way through med school as a research assistant for mathematician and surgeon David Eddy, who was then at Stanford. In his lab she learned of "evidence-based medicine" and saw how mathematical models of disease biology could improve cancer screening. A postgraduate fellowship in medical oncology/immunology with Stanford's Ronald Levy, a champion of personalized medicine, spurred her to look outside the box for solutions to some of biology's biggest problems, she says. Levy and his team were exploring new ways to harness the immune system to squelch lymphoma without the toxicity of chemotherapy.
Esserman stayed on at Stanford for her surgical residency and was chief resident in 1991 when, during grand rounds one day, she talked about the future of medicine -- and her own future -- with Stanford health care economist and managed care pioneer Alain Enthoven, another mentor who recruited her to enroll at the business school.
"Laura came to me and said she loved research, loved academic medicine and didn't want to leave surgery," remembers Enthoven, the Marriner S. Eccles Professor of Public and Private Management, Emeritus, at the business school. "But she wanted to learn how to make decisions—good decisions—in big organizations." Business school could teach her that, he told her. And once she learned to read a balance sheet, he said, it would be harder for guys holding the purse strings to dismiss her ambitious projects out of hand.
Still, the young surgeon took some convincing.
Esserman speaks at a March news conference launching a novel clinical trial for breast cancer patients. With her at the National Press Club is Dr. Janet Woodcock, director of the FDA Center for Drug Evaluation and Research. Photo by B. Vartan Boyajian
"Hardly anybody was for it," she says. "Even my mother said, 'Don't you ever want to get out of school?'" Esserman and her husband, political consultant Michael Endicott, were expecting the first of their two children, and Esserman had just finished eight years of surgical training. It was the early 1990s; at the time, surgery had few women leaders.
"A lot of people were just waiting for you to make a misstep," she remembers.
One advisor warned her that if she went to biz school, she'd never get a job in surgery again. "It was very hard to hear that," she says. "But it's also just the sort of thing that pisses me off."
So that fall Esserman signed up for a full load of business school classes while continuing to take surgical calls at the hospital. "You can still practice surgery," Enthoven told her. "This will be like work-study." It was never that easy.
"She was 20 or 30 minutes late to my class every day," says Professor Jeffrey Pfeffer, who teaches Paths to Power, one of Esserman's favorite classes. "When she finally got there on time—it was the last day of class—the rest of the students gave her a standing ovation. The thing is, she was perpetually late because she was coming from the hospital, seeing patients, and I think that gave her an interesting perspective, some insight, that other students didn't have."
Esserman says that although she's had to cut back on her own medical practice through the years as her management workload has increased, seeing patients still undergirds and gives life to her other tasks.
"That connection is really important," she says. "It's about urgency. When you are in a room with administrators, they don't have that urgency. It's really easy to forget if you don't see patients."
Today Pfeffer counts Esserman a close friend and invites her back regularly to offer some of those insights to his current students. She even consented to be one of his case studies—to have her management decisions sliced, diced, and analyzed by the class. They can be tough on her—accusing Esserman of taking on too much, of not delegating enough, of not staying on message. Esserman winces a little at the critique, but listens, takes mental notes, and says she finds the criticism useful. Pfeffer says resilience in the face of criticism is one of her strengths.
Esserman talks to Professor Jeffrey Pfeffer while visiting his classroom for an exercise in which MBA students critiqued her leadership style. Pfeffer, who taught Esserman when she was a student, says resilience in the face of criticism is one of her strengths. Photo by Steve Gladfelter
"Many people, when they are told no, feel rejected, like it's an attack to their ego," he says. "They give up. The world is full of people who give up. But Laura's great gifts are her persistence, resilience, and ability to work on multiple fronts. Early on, when she was having trouble getting something done within the structure of her department at the local level, she built national alliances and continued to be very effective. If you're blocked in one direction, go another."
Esserman tells Pfeffer's students that she learned that persistence from a scientist—Judah Folkman, a Harvard surgeon and medical innovator who died in 2008. Starting in the late 1960s, Folkman theorized that tumors need to recruit their own blood supply. Finding a drug to shrivel that blood vessel network and block a new one from forming, he reasoned, might be a way to stop some cancers cold. Folkman's revolutionary theory was ignored, even ridiculed, for many years. But he persisted, eventually founding a field—anti-angiogenesis—that already has led to promising, revolutionary new drugs and today engages an estimated 1,000 or more laboratories worldwide.
"Judah Folkman said that when postdocs would come in complaining to him about getting two grant rejections," Esserman says, "or feeling depressed because they weren't where they thought they should be in their career or their research, he'd tell them, 'Well, come back when you've got 10 grant rejections.'
"Particularly if you are trying to change something that is very fundamental, you must be persistent," Esserman says. "You have to be determined and persistent and clever."
Many women and some doctors took umbrage last fall when her work and that of others suggested that the standard guidelines for who should be screened with mammograms and how often needed updating. Esserman wasn't surprised.
For the record, she is not against annual mammogram screenings. She thinks that mammograms are a valuable tool and that most women between ages 50 and 70 should get them regularly. But women in other age groups could follow a more nuanced schedule, she
suggests, shaped by the combination of other risk factors they have.
For example, the common practice of prescribing screening mammograms for all women in their 40s (beyond simply those with a strong family history of breast cancer, or a genetic mutation such as BRCA-1 or BRCA-2, or other factor that puts them at high risk) has led to a lot of unnecessary testing and rarely picks up the most aggressive tumors, Esserman says. And no good evidence exists to show that women older than age 70 or 75 benefit from screening mammograms, she adds. The cancerous tumors picked up in such tests of elderly women are generally the slow-growing, non-lethal type.
Though Esserman has taken some heat for that stance from some organizations, such as the American Cancer Society and the American College of Radiology, many other doctors and researchers looking at the data agree with her, including the influential U.S. Preventive Services Task Force, an independent group of experts charged with setting testing guidelines.
Fears that the new guidelines are motivated by a desire to ration health care are misguided, Esserman says. Instead, they are based on the evidence, accumulated through two decades, of when mammograms are useful and when they aren't. "Why should standards that were developed 20 years ago be set in stone?" she asks. "We've learned a lot since then. If you walked into a computer store and they tried to sell you a 20-year-old machine, you'd be outraged.
"Mammogram screenings have a useful place, but you can't ask them to be better than they are," she says. "The point isn't to argue about mammograms. Women should be clamoring for better methods of detecting cancer."
Sure, change can feel risky, Esserman admits. "But it's risky—even riskier—to stand still. If the current standard of care for breast cancer were so great, women wouldn't still be dying of this disease—about 45,000 in the United States each year. That's too many. We have to do better. We can."