Expert Opinions: Dr. Robert L. Ferris, 

Professor, Department of Otolaryngology, of Immunology, and of Radiation Oncology,

Hillman Professor of Oncology

Director, Hillman Cancer Center,

Co-Director, Tumor Microenvironment Center

Associate Vice Chancellor for Cancer Research

University of Pittsburgh Medical Center (UPMC)

School of Medicine, University of Pittsburgh

Pittsburgh, PA, USA

 

Dr. Ferris is a world-renowned Otolaryngologist-Head and Neck Surgeon and Immunologist. He earned his MD and PhD degrees from Johns Hopkins and trained in Otolaryngology and Head and Neck Surgical Oncology at the same institution. He is a pioneer in head and neck cancer immunology and immunotherapy and has numerous contributions in the field of head and neck cancer. His research in head and neck cancer immunity and tumor microenvironment played a substantial role in the development of the field, the development of novel therapeutic approaches the implementation of which, resulted in significant improvements in patient survival. He is one of the most cited academic surgeons in the globe with >36.000 citations and an h-index=93.

 

 

1.       Dr. Ferris, why did you choose to specialize in Otolaryngology? What attracted you in the field then, and what attracts you know?

You know, at my advanced age its hard to remember what I did last week, not to mention what I was thinking 25 years ago. But if I can recall, my decision to enter Otolaryngology was primarily driven by head and neck cancer. I knew I wanted to be a surgeon, I actually got my PhD in immunology in an HIV immunology lab in the early 90s -before we had drugs for HIV- so I was trained as a translational immunology & immunotherapy person before I made my clinical decisions, much like many MD-PhDs. Then I went back to the wards I had thought about GI & transplant surgery, and how I could link immunology with my clinical activity. Simultaneously to choosing what that clinical effort would be, I had the feeling that head and neck cancer surgery could left some potential time available, to actually run a laboratory. And what I saw by doing rotations in GI & transplant surgery, cardiac surgery and a number of other potential options at the time was that there was really very little time, whereas the ENT/Head and Neck folks seemed to have a little bit more of a balance. Then I thought that there was a chance that I could actually do both and the combination of inpatient and outpatient management, really seemed to me to be the best opportunity to marry my passion for immunology & immunotherapy with head and neck cancer. Of course, the only problem was that it didn't work at that time! So I went into it completely naive to the fact that it would work in my lifetime. We haven't solved or cured the disease, but it's only been a pleasant surprise that it actually come together to benefit patients in some way, over the couple of decades.

 

2.       Thank you! I’d actually like to stay a little bit longer on this- you are one of the most acknowledged surgeon-scientists in the head and neck. How do you find the balance between the clinic and the laboratory? You mentioned that you tried to find a balance but how did it end up? how was it in the end?

Yeah, it's a good question and I think there is no simple formula true that. Before I became a Cancer Center Director, people would ask me how my week is like, I’d say 75% clinical and 75% lab, and that was probably true for me but the issue there is that not everybody can have a balance like that, and one has to be very efficient very good at time management. Recently a colleague who runs a lab and has a bright MD PhD student coming up, asked me to meet with her student and explain “how I do it”. The first thing I told her was for three to four years of your residency you have to ignore the science, ignore the academics and become the very best clinician that you can, because you don't get a chance to get back and learn all the anatomy, all the physiology, you don't get a chance to get back and learn how to be an otolaryngologist-head and neck surgeon.

When I came back on my 4th and 5th year and sort of restarted, the field had moved on. PCR was discovered and got a Nobel Prize and so I came back, and the field was different. Nobody was reading the journals anymore, they went to the computer and read them online. A lot had happened. I mean the field changes. At the same time if you've got the appropriate PhD training you can still do it. You know there is a little bit of a re-entry - imagine being in an orbit in space and you get a re-entry- you get the gravitational fields, you get the same heat generates, it's very tough but I would still recommend ensuring very early that your clinical competence it is beyond reproach, because it gets because it is very hard to be a surgeon-scientist, so you want to make sure that you are a good diagnostician, a very competent and safe surgeon and a relatively fast one.

As I said to one of my trainees, who is now on the faculty of a major institution in the US, we were doing a case and she was taking a little bit longer and I said “you can't take an hour and a half case and make it at three-hour case and expect to be a surgeon-scientist. You have to take a three-hour case and make it a two-hour case, or there is just not enough time in the day! Because we all have families and may want to have a family and a spouse, and activities outside. So, the clinical training is absolutely paramount to allow you to be a clinical academic surgeon with a laboratory or a clinical trials portfolio. That's generally my recommendation.

And as far as how I balance, I think I'm good at multitasking. Some people are and some people aren’t and that's why as I said in the beginning, there is no real formula. I can tell you my formula, but it's contoured to my skillset. I couldn't have told you what my skillset is 25 years ago, but to do this job you should be pretty good at keeping a lot of stuff going at once.

The last little piece to it is that when I started here in Pittsburgh in 2001, I collaborated with a number of people. I started to do the same mouse preclinical immunology of head and neck cancer that some of my colleagues were doing, and then I realized that due to my clinical days, one or two days per week, I would just fall behind, because my colleagues in the lab were their full time. And so I began to design projects that uniquely harnessed those one to two clinical days. I created datasets and biospecimens, and I asked questions that were unique to my specific practice. A good example is that I began studying Cetuximab back in 2005-6 and designed a neo-adjuvant clinical trial so that my colleagues could do a mouse model, or someone could do in-vitro work, but they were never going to reproduce those 40 patients who took a month of cetuximab. I had specimens -blood and tumor- before and after treatment.

At that time, I used to lose sleep at night – you could wake up in the morning and pick up a journal to find out that you had gotten scooped. Somebody had just put in more time in it, while you were at the clinic! So, I designed projects like this. I would think of 10 projects, and I would discard nine of them because they didn't fit this uniqueness. Also, I would just turn the projects away if I thought that somebody else could do it and that's why I got into the neoadjuvant clinical trials and became less and less of a mouse immunologist.

That’s fascinating- I mean the way you combined your skillset with you plans is really impressive and very interesting to hear.

3.       Moving on to the next one, I really wanted to ask you about residency. What are you looking for in a resident? I know that your department has previously considered and accepted ΙMGs before so I wanted to ask you about that as well.

I am not a department Chair, but I participated for years in the residency selection and interviews -a little bit less now as a Director of the Cancer Center, which is a bit of a separate entity at the University of Pittsburgh, and we oversee all Medical Oncology, Radiation Oncology and Surgical Oncology. I think that the folks who have made it into our program as IMGs have spent some time here, and people knew them. Some came through my lab; some came through other labs or other divisions but there was a comfort level with the person.

Even though an individual may come from a major other country, the primary city or the top ranked place, I think there is some difference with the US system, so it does help to have spent time in the US with people we know. Also, there is frequently an international graduate working at a US institution, we get their application, and their PI says that they’re fantastic and the feeling then is “so why aren't you taking them?”. We tend to feel that if the people come here and we see them firsthand and collaborate and they can do some projects with us, we sort of de-risk it.

Even so it's a tough road because it's so competitive for the US graduates. Somebody always brings up in the committee meeting that we have after interviews, that “he/she seems great and maybe they even did a sub-internship with us, but we have our pick” and we're fortunate that in Pittsburgh -as other top programs- we don't go low on the match list, so why should we do this if there is some risk in it?! We always try to de-risk it and of course, it always depends on how much their mentor knows them and can articulate this.

And then it's the productivity- if you come and you are a really great guy or gal but there are really no publications, no presentations etc. it's harder. But if you have a body of work, I think you have a shot at a number of Centers. Cherie-Ann Nathan, a good friend of mine who recently gave an invited lecture and told her story, was picked by UCSD when she came from India. She spent some time at Hopkins and maybe some time at UCSD, and people got to know her and realized that she's obviously world class – today she's the outgoing President of the American Head and Neck Society. So I think that the programs need to see into the future, see into this person's soul and say “is this person really going to be a high performer?” and we have had some phenomenal residents trained outside the US before they came to our program!

 

4.       In research we frequently face the dilemma of quality vs. quantity. I know you are receiving hundreds or maybe even thousands of applications so my question is can you/do you evaluate the quality of applicants’ research, or is it just about the number of publications?

It's an interesting question but I don't have a great answer to it. It's not just numbers, it's what they do, what the people who worked with them have to say. Did the person take initiative? Did they organize the team? Were they reliable? Did they do their writing- because you know the ability to communicate in oral and written forms is a key to a career. So I think it becomes holistic and it's always highly individualized. We have people that look fantastic on paper, but they trained at another institution, and we just said, “Hey that place should take them - we don't know them”. When they've done that work before residency in Pittsburgh, we generally have taken them.

 

5.       Thank you! I’d like to go back to immunotherapy and head and neck cancer. So, we've had some major breakthroughs in targeted therapies and cancer care in general, and in the head and neck in particular -partly thanks to you of course. My question is, where do you see surgery in the future of cancer care? Are we going for debulking surgeries with targeted therapies being in the forefront? Will surgery retain its position in cancer care, what do you think?

I lived through the organ preservation era in the ‘90s and we thought that there would be no role for the head and neck surgeon, because as Arlene Forastiere liked to present, chemoradiation was curing all of larynx cancer. Certainly, it is advantageous that the patients didn't have to lose their larynx, but there is still plenty of laryngeal surgery going on.  Also, I would remind you -which I'm sure you know- that we are the first person to perform the diagnosis, we are the first person the patient meets, we deliver the news in many cases and we do the staging endoscopy to stage the patient and describe their risk stratification. So as long as that doesn't change, I believe the surgeon will be on the driver's seat.

I think surgeons do need to obtain high quality data for the treatments they offer and the decisions that we propagate and advocate at the tumor conference. As you recall in the 2009 TORS became FDA approved and we began to perform what we thought would be a fantastic surgery: R0 resection. We’d bring the patient to the tumor conference, with a couple of positive notes and some other feature and they would still want to give him chemoradiation and they’d say, “you don't have any data, you just have a device”. So, I found that frustrating and tried to fix the problem, at least in that setting.

We still need much more data; we need surgeons to run clinical trials -and it's not so hard actually! But I think that as long as the surgeon is the first person the patient meets and as long as the surgeons learn to run some clinical trials and participate in clinical trials, that we will have data showing that surgical therapy is a highly effective treatment, not only a staging procedure to identify the best biomarkers we currently have (which is pathological biomarkers). Surgeons can show tremendous quality of life improvement and great functional outcomes. I've seen that first-hand, it's not just because I'm a surgeon! We need to have good data and I think surgeons need to be aggressive about that in order to hold our position in the tumor conference. And it benefits our patients too.

 

6.       Thank you, I agree 100%. Speaking of clinical trials, I noticed this discussion that took place on ASTRO2021 about the ORATOR-2 trial. The TORS arm had unexpectedly more deaths compared to other trials like ECOG.

I don’t know if the ORATOR-2 is the best example- nobody understands what’s going on with that or why they’ve had those deaths. It was only two deaths I believe, but has not yet been reported. We don't really know. I mean doing TORS in Canada is a little different, because it's not approved, so you can only get it at a trial in particular institutions, its just not translatable across the field! I don’t know what to make of it, nor does the rest of the surgical field. However in over 500 cases in ECOG 3311, and thousands and thousands since its FDA approval in 2009, it is clearly a safe procedure. Chemoradiation also has a treatment-related mortality of 1-2%.  I think in general we need more clinical trials led by surgeons. Stephen Lai has a sentinel node trial; John De Almeida is opening up a SPECT-CT trial. These are surgeons running clinical trials! We need more surgeons leading more trials and asking surgical questions and non-surgical questions.