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Features May 2007: Volume 4, Number 2

The Doctors
Photography By David Ahntholz and Jim Coit

The GQ M.D. By Debra Kain
And It's Only Tuesday By Jacqueline Carr

A Hip Doctor By Michelle BruBaker

Every day, the doctors of the UC San Diego Health Care system bring cutting-edge research to the treatment of their patients. We followed three of them on their daily rounds.

The real story here is not about me,” she says about the GQ accolade. “It’s the patient. Personalized care is the goal, so it’s all about the person, not just a new drug or molecular target.

Catriona Jamieson, M.D., Ph.D.

The GQ M.D. By Debra Kain

Last year, Catriona Jamieson, M.D., Ph.D., assistant professor of medicine and director of stem-cell research at UC San Diego Moores Cancer Center, was featured in the 2010 “Rock Star of Science” campaign in GQ magazine. But her biggest fans are no doubt a far tougher crowd than a stadium full of music fans. They are the cancer patients she treats, often using therapies that she and her research team have developed in her UCSD lab using adult stem cells.

“The real story here is not about me,” she says about the GQ accolade. “It’s the patient. Personalized care is the goal, so it’s all about the person, not just a new drug or molecular target.”

Jamieson specializes in treating patients with leukemia and other types of blood cancers called myeloproliferative disorders (MPDs)—a family of uncommon, but not rare, degenerative disorders in which the body overproduces blood cells that can cause many forms of blood clotting. MPDs can result in heart attack, stroke, deep venous thrombosis and pulmonary embolism, and may develop into acute myelogenous leukemia.

Although some effective treatments are available, they are laden with serious side effects and individuals can become resistant to the treatments.  Jamieson studies the mutant stem cells and progenitor cells that can give rise to cancer stem cells. Cancer stem cells may lie low to evade chemotherapy and then activate again later, causing the disease to progress and become resistant to treatment. Her goal is to find more selective, less toxic therapies.

In the past two years, Jamieson’s stem-cell research studies have taken a great leap: from identifying a promising treatment in the research laboratory to opening and completing one of the first-ever clinical trials to target cancer stem cells in humans. 

“We are very interested in what is called ‘personalized medicine’ which, in cancer care, means finding out who will respond to a particular therapy,” says Jamieson.  “What can we find out from a patient’s genetic information—in the profile or ‘signature’ of their particular blood cancer stem cell—that will help us treat that cancer aggressively and effectively?”

A recent week for Jamieson included a day of seeing patients—some new referrals, but most patients who she has been treating for months or even years—hosting a site visit by leaders of the California Institute for Regenerative Medicine (CIRM), which has funded Jamieson’s stem-cell research; and a flight to Washington, D.C. to appear before a congressional hearing on personalized medicine addressing complex issues such as who will pay for it. 

But this morning, Jamieson’s concern is personal. Her first patient has been seeing Jamieson for ongoing cancer treatment for more than three years and has had an excellent response to treatment.

“Dr.  Jamieson kicks butt,” he says cheerfully.  “I don’t know how she does it.  But together, we’re beating this.”  His wife adds, “Hers is not a dogmatic approach; it’s like we’re part of a family and our care here at Moores has been remarkable.”

Jamieson’s next patient is suffering from a condition that causes her body to create too many platelets, putting her at a risk for bleeding.  Jamieson listens as the woman talks about how she is feeling, her kids, and the stress she faces in her job as a prison counselor. “I really don’t know how you do it,” Jamieson tells her, “working full time, raising your kids and managing this disease.” They discuss possible clinical-trial options for her, dependent on how the patient’s platelets look under the microscope.

Jamieson always explains the disease from a scientific point of view, but not just because she is herself a researcher. “I don’t dumb it down. People understand far more than some doctors credit them for, and I know they often go home and look up terms they might not understand. If I don’t use the real medical terms for their condition, they won’t be as well-informed as they can and should be.”

And she includes patients and their family members in each step of the decision-making about their care. 

“We get to know the patients and their families and that means we have a real investment in their long-term health,” she says. 

That concern for each patient is also what drives Jamieson in her research lab. She is co-director of a stem-cell disease team at the Moores Cancer Center, which received a $20 million research grant from CIRM to develop novel drugs against leukemia stem cells. The goal is to move those drugs to clinical trials in the shortest possible time frame.

“Despite current therapies, a small number of leukemia stem cells remain in patients and they continue to grow, spread and kill normal cells,” says Jamieson. “Our preliminary results in the lab suggest that it will be possible to destroy these leukemia stem cells and destroy the cancer once and for all. That’s my goal.”

Jamieson described her approach to patient care and research: “First, I have to understand where the patient is coming from, so we both know where we’re going before we start. We have to work together as a team to help each other,” she says.  “Second, I need to pay attention to detail, like a detective, explaining every piece of data and think about what the patients aren’t telling me.”

When assessing individuals for enrollment in a clinical trial, she looks for what she calls “the spunk factor”—are they invested in getting better?  Will they stick to the treatment regimen and do they have the necessary family support?

“Patients often ask me what drug or treatment I would recommend if someone in my family had their type of cancer,” Jamieson says. “Instead, I have to ask: what would I take myself? My patients are the reason I need to get back into the lab at the end of the day; to figure out new therapies and better tests so we can aggressively and successfully treat their specific cancer.”

William Sandborn, M.D.

And It's Only Tuesday By Jacqueline Carr

Two hours into his day, William Sandborn, M.D., chief of the division of gastroenterology at UC San Diego Health System is finally back at his desk, iPhone in one hand, an empty Starbucks cup in the other. It is 9 a.m. and his morning started with a grand-rounds presentation that began at 7 a.m. "If the data is censored, there will be no insight," he says into the phone. "If we remain open-minded, the analysis will lead to a path that best divines the truth."

Sandborn is challenging the findings of a medical officer whose company has developed a novel therapy for inflammatory bowel disease (IBD).

As he listens to the pharmaceutical company's medical officer, a bus stops outside his office window, wrapped in advertising that reads, "Health Care Shouldn't Be a Pain. Choose UC San Diego Health System." Students from the School of Medicine emerge, temporarily filling his window.

Serum pharmacokinetic parameters indicate the amount of drug in the blood. When levels are too low, patients do not respond to treatment. In the case of biotechnology drugs, if the concentrations dip to undetectable levels, patients may become immune, allergic or lose response to the drug. Sandborn advocates for using factors such as body weight, gender and inflammation measures to predict the drug level needed for relief.

"To induce remission, the required concentration of drug varies substantially between patients," says Sandborn. "Once symptoms disappear, then we need to think about how much drug we administer during the maintenance phase of the disease. Do we give more up front and less in long term?"

In Sandborn's experience, close to 60 percent of his patients experience remission with monoclonal antibodies that provide a welcome respite from the severe bloody diarrhea and abdominal pain caused by ulcerative colitis.

Sandborn fixates on customizing drug doses for individual patients. He knows that many companies try to identify a single dose that will be effective across a range of diseases like rheumatoid arthritis, psoriasis, Crohn's disease and ulcerative colitis. While this strategy simplifies FDA and insurance approvals, these "average doses" may not be the "right dose" for an individual patient.

"We have to look at the big picture of the risks of being on the drug versus the safety benefit of getting off steroids and being in remission," Sandborn says to the drug company's medical officer. "Let's publish the science as it is, and then we can work out the logical implications for patients."

Concluding the call, he begins a rapid-fire team meeting to plan a regional IBD conference for gastroenterologists and surgeons, reviews budgets of 10 open clinical-trial contracts and schedules several red-eye flights to national conferences. His iPhone vibrates throughout. There are 14 new patients scheduled for his Monday clinic.

He conducts a "walking" meeting across campus with earphone buds in place. By all appearances he is talking to himself. In reality, he is "meeting" with a basic-science researcher in his department, wasting no time before clinic.

Sandborn came to UC San Diego from Rochester, Minn., where he headed up the Inflammatory Bowel Disease Center at the Mayo Clinic. He has replicated his successful model of care in San Diego, which attracts patients locally and globally. Approximately 40 percent of his new patients come from outside California. He has seen patients from 14 U.S. states, and countries such as the Netherlands, Mexico and Kuwait.

Arriving at UC San Diego's Thornton Hospital, located on the La Jolla campus, he pockets his phone and places a stethoscope around his neck. Patients ranging in age from 28 to 76 wait for him. What they have in common is IBD combined with conditions such as diabetes and cardiovascular disease. Each room is outfitted with blood pressure cuffs and "upside-down hats" in case the patient can't make it to the bathroom in time.

His first patient is a young woman who suddenly developed Crohn's in her 20s. She goes to the bathroom urgently four to five times per day, planning each day around the location of the nearest restroom. In addition to prescriptions, she asks Sandborn to approve flexible family leave to protect her employment.

"I just can't predictably do my job when I am having a flare-up of Crohn's," says the patient. "Unless you experience it, it's hard to describe the overwhelming impact it can have on your life."

A stream of other patients share stories of hospitalizations involving painful bowel obstructions and profuse bleeding. They are all familiar with classes of drugs that must be injected or infused through veins. Sandborn answers their questions without regard to time. For one patient, he sits on a footrest to be at eye-level as she speaks.

"The diversity of our patients is incredible. They are high-functioning individuals, leading lives as microbiologists and stay-at-home moms, all very active," says Julie Bosia, R.N., research nurse. "It is satisfying to offer them a medical option that may heal their bowel and improve their quality of life."

The patients return to their jobs and homes, and their outward appearances give no indication of their debilitating medical conditions.

Some of the patients have lost response to all current medications. Clinical trials are their last treatment option before surgical removal of the colon.

"Since May 2011, Dr. Sandborn has submitted 10 clinical-trial applications for review and approval," says Michael Caliguiri, Ph.D., professor of psychiatry and director of UC San Diego's Clinical Research Protections Program. "If he keeps this pace over the next year, his research program will be among the institution's top five active clinical trial programs."

Sandborn's iPhone vibrates again. Tomorrow at 7:30 a.m. he heads to the endoscopy suite to perform 16 consecutive procedures ranging from flexible sigmoidoscopy, upper endoscopy and pouchoscopy to colonoscopy.

After clinic he edits research articles that are being prepared for submission to medical journals, including several for the New England Journal of Medicine.

His cell phone vibrates again. A patient calls for advice.

It's only Tuesday.

Scott Ball, M.D.

A Hip Doctor By Michelle BruBaker

As Scott Ball, M.D., walks into the exam room, he immediately puts patient David Jackson at ease. He pulls up a chair, shakes his patient's hand, flashes him a friendly smile and introduces himself. He not only asks Jackson the reason for his visit, but he asks him about his family, career and activities.

"It's important I get to know my patients and their lifestyle as an orthopedic surgeon. I perform hip and knee replacement, hip resurfacing and revisions of failed hips and knees," says Ball. "I think we get the most challenging cases at UC San Diego Health System compared to other hospitals, and I salvage quite a few disasters. My goal is to help patients get back to their active lifestyle as much as possible."

Ball had started his day walking his daughter and son to school for "National Walk Your Kids to School Day." "I have clinic all day and a department meeting tonight at 6 p.m.," he says. "I work a lot between clinics, research and surgeries, but my family is my priority, and I try every day to balance my professional life with my personal one."

It's obvious in spending just five minutes with Ball that his family means the world to him, and they are a focal point in conversations with patients who are also parents.

Jackson is in the office to talk about the difference between resurfacing (reshaping the damaged surface of the femoral ball and then covering it with a round metal cap), and total hip replacement (removing the entire femoral ball). An avid cyclist, Jackson has dealt with hip pain for about 10 years.

He is worried that he waited too long to come see the doctor and that surgery won't help. He also reveals he is nervous to go under, especially being a father.

"I completely understand," says Ball to Jackson. "But this fear shouldn't be a reason to not have the procedure done if it will improve your quality of life. After surgery, most of my patients wonder why they didn't do it sooner—I've even had patients finish triathlons post-surgery."

Ball scrutinizes Jackson's X-rays and tells his patient that his hip is basically bone on bone. After a short physical exam, he concludes that it is as stiff as it can get. Ball now sits and lays out the data on the different procedures, addressing Jackson's concern about metal hip replacements, which have recently sparked controversy with a recall and complications.

About 300,000 hip replacements are performed each year in the United States, and in the last decade, up to 25 percent of those have been using metal against metal as the bearing-surface articulation. A small percentage of those were performed with the implant that has been recalled. And Ball is in the middle of research on screening tools to help diagnose patients who are at risk with metal hip replacements—many of whom may be subjected to a hip replacement revision.

"There is no need for panic among patients. However, they should be aware and have regular follow-up with their orthopedic surgeon to assess the status of their implants," says Ball.

Ball has always been drawn to the research side of medicine and how it impacts patients and surgeons nationwide. Currently, he spends about 80 percent of his time in patient care and 20 percent in research.

He explains to Jackson that the results and recovery time of both resurfacing and a total hip replacement follow the rule of twos—the surgery is two hours, he will spend two days in the hospital and two weeks on crutches. Jackson should be back on his bike in about a month or two.

"I really want you to take your time to think about your options and contact me during your decision process if you have any questions," Ball says to Jackson, as he hands him his business card.

"It's very important to me that patients have direct access to their physicians. I want them to be treated like I would want my family treated," says Ball.

This connection is clear as you look at the pictures and cards that line his office wall from former patients crossing the finish line of a marathon or a thank you card to express their appreciation to the man they say changed their lives.

Being an orthopedic surgeon is part of Ball's family tree. His father was an orthopedic surgeon and fixed Ball's broken arm when he was seven-years-old.

"Although that was impressive, I didn't know I wanted to be a doctor until I spent a summer in college shadowing my dad," says Ball. "Seeing how he changed lives and 'fixed' people made me realize that is what I wanted to do."

After meeting Jackson, Ball goes over his case with physician assistant Dustyn Severns. "We are a team," says Ball. "Severns is a big part of the success of the Joint Reconstruction Service. I could never take full credit."

Ball's day is filled with patients like Jackson, who have questions and concerns about their conditions and treatment options, and yet he has the knack of making everyone feel like he or she is the only one he will see that day.

Debra Kain is director of research communications, UC San Diego Health Sciences.

Jacqueline Carr is director of clinical communications, UC San Diego Health System.

Michelle Brubaker is senior public information representative, UC San Diego Health System.