Success through mentorship, opportunity and teamwork
Susan M. Chang, M.D.
Director, Division of Neuro-Oncology
Department of Neurological Surgery
University of California, San Francisco
In 2017 I had the honor of being selected by the Society for Neuro-Oncology as the recipient of the distinguished Victor Levin award. I saw this as a great opportunity to acknowledge and thank my mentors, collaborators and colleagues who have encouraged and supported me along my career. I am often asked by junior faculty and trainees about what I see as the keys to success in our field, and I thought that this would be an appropriate venue to address that topic and share my experience around the evolution of my career. Ultimately, I believe that achieving success hinges on three things: effective mentorship; the ability to recognize and seize opportunities; and the capacity to work as part of a team. You may have a brilliant mind and a strong work ethic, but without those three ingredients, I think it’s difficult to get to a place where you can really make a significant impact.
Beginning with mentorship, it is especially meaningful to be receiving the Victor Levin award, as Dr. Levin was really instrumental for not only building the neuro-oncology program at UCSF but the whole field. I remember first meeting him in 1996 at the inaugural SNO meeting and being impressed with his passion and energy to find new treatments for patients, something that he continues to pursue. I think that one of the things that also distinguishes him is that he has done so much to educate and mentor others in the field. In 1995 I submitted a review on chemotherapy for glioma to Current Opinions in Oncology, for which Dr. Levin was the editor. He sent me a letter thanking me for my contribution. It was really a proud moment in my early career and receiving the award named in his honor from him is a true privilege.
The importance of mentorship is exemplified by Dr. Ian Tannock who guided me during my fellowship in medical oncology at the Princess Margaret Cancer Center in Toronto. Beyond his innate ability as a wonderful educator, he had a great love of continued learning and would never accept that things could not be improved upon. Dr. Tannock remains one of the most influential figures in my work not only because he was the person who introduced me to the challenges of clinical trial design, but he also instilled in me the concept of translational research. As a clinician he authored a textbook on the basic science in oncology and he really impressed upon me the importance of not divorcing the clinical entity from the underlying science. As a result of that, when I became a neuro-oncologist at UCSF, I would attend the Costello lab meetings and participate in their journal club so that I would know what was happening on the research side. This also allowed me to share the clinical aspect of the disease with the scientists. And I think that has served me incredibly well, not just for leading an oncology program that is deeply entrenched in translational work, but also for building relationships beyond my immediate clinical colleagues that ultimately help us get over hurdles in bringing improvements to patients.
I joined UCSF in 1992 as a neuro-oncology fellow and had the very good fortune to be mentored by an incredible team, which included Mike Prados and Dr. Charlie Wilson. I was impressed by how inclusive Mike was about engaging members to work on projects and the incredible focus of Dr Wilson and his drive to get results. Around this time I participated in a teaching scholars course where I had to complete a questionnaire asking what my career goals might be. And looking back, I had quite a low bar- “design and conduct clinical trials in Neuro-Oncology, publish an article in JCO and give a presentation at ASCO”.
It was such a low bar that by 1998, together with Mike Prados and a great group of collaborators at the North American Brain Tumor Consortium, I was already the PI of several clinical trials, published a paper in JCO and was able to present the results of the work at ASCO. Having accomplished those early goals, I realized there was still much to do, especially because 10 years later, despite the promise of targeted therapies, we were faced with so many negative results. I continue to be involved in the development of new treatments with my colleagues at UCSF and through consortium based studies.
As I gained experience in the field, I became interested in how we were assessing response to therapy in our patients and some of the challenges we were facing. In 1996 I wrote an application to attend the inaugural joint ASCO-AACR workshop on Methods of Clinical Cancer Research, or what I considered a boot camp, in which I outlined the fact that what we were seeing on the MRIs after therapies was not always an accurate reflection of the biology – it was often transient treatment effect – and it was a major obstacle to directing appropriate therapy and evaluating response to treatments and determining valid clinical endpoints. This was a problem that remains a major challenge for the field. At a meeting in Barcelona in 2008, Martin Van den Bent and Patrick Wen and I began having some informal discussions around what we were seeing in MRIs following treatment with bevacizumab. We recognized that there was a both a need and an opportunity to initiate a major shift in the field. So with David MacDonald and Mike Vogelbaum, we formed the Response Assessment in Neuro-Oncology executive committee and began working on guidelines for clinicians to use to interpret these often misleading imaging findings.
With any large-scale changes to everyday clinical practice, one of the biggest hurdles is reaching a consensus. And RANO was no exception. These were difficult problems and it was critical that everyone agreed with how to address them. I cannot understate the importance of inclusivity in this setting and giving everyone a chance to be heard. So while consensus did not necessarily come easily, the collaborative spirit of this group, the willingness to volunteer time, effort and expertise and our ability to work together carried the day. The resulting guidelines for high grade glioma were published in 2009 to supplement the MacDonald criteria, followed by subsequent multiple guidelines that deal with so many aspects of neuro-oncology. I’m especially proud of being a part of this community of colleagues and the RANO effort is a career highlight for me.
There are so many other instances about how critical teamwork is to success. On a local level, our Department holds a Program Project Grant that has been funded since the 1970s and a CNS Specialized Program of Research Excellence (SPORE) award from the NCI that has been funded since 2002. The continuous success of these programs has all to do with Dr. Berger’s leadership and this incredible team and our culture of collaboration. We genuinely have fun working as a team which makes the work seem less onerous and taxing. A major focus of these intra-programmatic awards has been to advance novel neuroimaging technologies, and I am fortunate to serve as co-PI with Dr. Sarah Nelson on several noninvasive imaging studies, and she has been a brilliant collaborator and friend. Our group is especially interested in imaging metabolic and physiologic changes within a tumor that may be able to give us an earlier indication about progression or response to treatment than can currently be achieved with standard MRI. Instituting standard operating procedures to identify patients, acquire the multiparametric images and procure image guided samples was critical in serving as the basis for numerous studies. We were able to show the value of these tools in detecting changes, culminating with the first-in-patient hyperpolarized carbon 13 imaging of a brain tumor last year. Partnering with the lab of Joe Costello, we have since added genomic data to the rich patient cohort. These are methods that we continue to be really excited about and I believe are going to have a profound impact on our ability to diagnose patients and guide treatment.
A clear example of mentorship, opportunity and team work that has had a major impact on my career is through my involvement in SNO. In 1998, Dr. Berger was the president of SNO and the meeting was hosted in San Francisco. He asked me to lead the meeting. It was an opportunity that I was initially apprehensive about since I had not organized any meeting before but Dr. Berger reassured me that I would be fine. Jan Esenwein was instrumental in guiding me through that meeting. Accepting that first step to take on something that may seem like an isolated event or project can often spark a chain of other doors to open, and that was the case with my leading the meeting in 1998.
Since then through my involvement with SNO, I have been able to serve on the Board of Directors in several roles including being President of the society. Through his amazing example, Ab Guha instilled in me the serious need for us to be more integrated globally in order to share advances and information. During my own SNO presidency, one of my biggest priorities was to build a larger and more integrated international coalition of physicians and researchers. Working with Chas Haynes and EANO and ASNO leadership, the World Federation of Neuro-Oncology Societies (WFNOS) was created and we began sending a SNO representative to the ASNO and EANO meetings every year and vice versa, which increased international attendance at all these meetings overall, instead of just getting together every four years at the WFNOS meeting.
I am grateful to so many of my international colleagues from EANO and ASNO whose friendship has enriched my life. These collaborations foster international fellowships and educational opportunities, exposing trainees across the globe to different modes of practice. But one of the biggest advantages about global team-work is that we are seeing more multi-site international clinical trials and more data sharing, which exponentially increases our knowledge base.
In 2012, Al Yung, then editor-in-chief of Neuro-Oncology, asked me to serve as the editor of a special international supplement dealing with practical issues in neuro-oncology and topics related to quality of life and survivorship. Again this was a small opportunity, but one that I really wanted to take on because there was a need for more of this type of information for the global community. SNO had already acknowledged the importance of these issues and had a QOL component to the education day. But we did not realize just how much it was needed. It quickly became one of the most downloaded and cited issues of the journal, and in 2014, SNO and Oxford University Press invited me to be the Editor-In-Chief of Neuro-Oncology Practice, a new journal which would be dedicated to publishing articles on quality of life, survivorship, caregiver issues, and applying the results of clinical trials to everyday practice. One of the most important aspects of this journal is that my co-editors from SNO, EANO and ASNO help to solicit articles from their respective regions and it has really become an incredible resource and learning tool for the international community.
The opportunity to serve on other teams has been another rewarding aspect of my career. Several of these include service to the National Cancer Institute and scientific advisory boards of many philanthropic foundations such as the Sontag Foundation, the American Brain Tumor Association, Cancer.net (the patient portal for ASCO), the National Brain Tumor Society and the Brain Tumor Charity. Working with such dedicated groups whose mission is to improve the care of our patients through patient and caregiver education and resources, to support the research efforts in neuro-oncology or to invest in the future careers of young investigators of the field, have extended my community of friends and colleagues.
While working on clinical trials, publishing in JCO and presenting at ASCO- fulfilled my initial ideas of success, I remained focused on issues related to quality of life of my patients. Kris Hardin was one of my patients who found joy and comfort in painting beautiful and colorful pieces and her art-work adorns our clinic space, reminding us that while we strive to improve survival for our patients, optimizing their quality of survival is paramount in the care we provide.
Over the past several years I was presented with some very big opportunities on that front and have also come to realize that teamwork really extended beyond working with my colleagues. Our patients and their caregivers are very much a part of the team, and without their help and support we would never be able to make progress. Of course this is exemplified at every scientific meeting through their courage and altruism in their willingness to participate in clinical trials, and also through partnerships to advance research and education. But they also keep us focused on “to quote Jashiri Blakely”- the “heart and soul of neuro-oncology”- the needs of the patient and caregiver. With the generous support of Sheri Sobrato Brisson and working with my colleagues Drs. Hervey Jumper and Oberheim Bush, we have initiated a new survivorship program that combines neuro-oncology, neurosurgery, neuropsychology, physical and integrative medicine, and psycho-oncology. This is what I hope the future will be for all patients undergoing treatment anywhere in the country.
I was also given the opportunity to launch a program specifically for caregivers at UCSF. The UCSF Neuro-Oncology Gordon Murray Caregiver Program is named for one of our patients, Gordon Murray, whose family and close friends came to us and spearheaded the idea. This not only involves providing caregivers with practical resources and support groups, but also reaching out to them at known points of stress throughout the trajectory of the illness to help with difficult transitions. We have also supported the Milton Marks family camp for the last 4 years focused on patients who have young children in the home, offering a fully supported weekend of fun, relaxation, counsel and community. It has been an unbelievably rewarding experience to be able to launch this program and the effect that it has had on our patients and their families has been wonderful. This was entirely funded through philanthropy and with the help of my colleague Margaretta Page, we now have a program that provides an additional layer of support to caregivers. We hope this model can become the standard for all practices, nationally and internationally.
I am so fortunate to work with my current team at UCSF, with colleagues who have an incredible passion and commitment to the care of patients and clinical research. I now find myself in the position of mentoring others and I hope to be able to pay forward all the wonderful mentorship I myself received over the years, to pass on opportunities for others to seize, and to continue to promote the collaboration and teamwork without which we would achieve so little. And finally I’d like to express my enormous gratitude to my family- my mom, aunt and children and especially my husband Doug, whose unwavering love and support throughout my career and genuine enthusiasm for my work has provided the base for all of my success.