David B. Agus M.D.

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0:32One of the most respected and best known oncologists in the world is Dr. David Agus. He leads the Ellison Medical Institute at the University of Southern California, where he's also a professor of medicine. I had a chance recently to sit down with him to talk about the high incidence of cancer now and how one treats cancer in modern life. Cancer's been around for thousands of years. How does one get cancer? Is it genetic? Is it behavioral or environmental? Yes. Yes. Yes, and yes. So there certainly are what we call genetic predispositions. There's, you know, several dozen genes that if you inherit a faulty copy of it, your risk of cancer is dramatically higher than the average population.

1:12But cancer is a change in the genome. Sometimes behavior, sometimes things you smoke, things you do can cause or induce changes in DNA. So you don't get it from your parents. You can cause them through what you do, but there has to be a change in DNA to get cancer. JOHN YANG, President Nixon said that we're going to have a war on cancer when he was president, and that was more than 50 years ago. Have we really made progress in combating cancer in the last 50 years? JOHN YANG, President of the United States, The answer is we've made tremendous progress, but it's not enough. So we now have immunotherapy, right?

1:46Your own immune system can attack the cancer. We now have molecularly targeted therapy with every single patient in the country. it's covered by Medicare, can have their cancer DNA sequenced, and we could potentially use a pill to target a molecular alteration or an on switch in this cancer and turn it off. All of those by time, but we haven't cured the disease. Now, some people say they get full body scans, and other people say that's not good for you because it's not cost effective, and also you might get too much radiation. What do you think about full body scans as a way to detect whether you have cancer or not?

2:21So there are MRIs now which don't have radiation to do full body scans. So certainly looking on a scan can be helpful many times. You know, a one centimeter cancer is still many hundred million cells. So it has yet to be proven that using a technology like that, with the exception of lung cancer, where it clearly works in smokers. So smokers every year should get a scan. You catch it early, you can cure the lung cancer. But in other cancers, it really hasn't been shown to make a dramatic difference. Breast cancer it does, lung cancer it does, but many of the others it hasn't yet. We need better imaging technology, we need better blood tests, but most of our resources are spent on treating and figuring out new ways to understand the biology of cancer, very little on the diagnosis and the identifying early of cancer.

3:11Now there are different types of cancer in terms of its potential fatality and you measure cancer by how long one survives after five years is that more or less it? Yeah I mean from diagnosis. Cancer is categorized by having stage one, stage two, stage three, stage four. Right. What does that really mean? They're all a little bit different depending on the type of the cancer. Stage four means it's all over the body. It's metastasized to different parts of the body. Stage one means it's confined. Stage two normally means it's spread but in a local area and stage three means it's spread a little bit more than local but it's still in half of the body and again the stage four is all over so as you go up in stages survival goes down and outcome goes down.

3:54Now I've been told that the cancer that is the most survivable is breast cancer if detected in stage one I think at 98 % survival rate or something like that and and we detect this by having mammograms right so what should men get should men get a PSA every year which helps with prostate cancer detection? Why not? I mean, so there's an argument that, you know, well, if you find a PSA test and PSA is high, we're doing over number, too many biopsies, too many prostate surgeries and too many radiation. And that's true. So finding a cancer doesn't necessarily mean you need to treat it, which I know is a weird statement.

4:31But there are many cancers, some indolent prostate cancer, indolent thyroid cancer, some, you know, indolent breast cancer, so don't necessarily need aggressive treatments, but can be followed. So we call that active surveillance. So we need to develop better guidelines, better ways of framing or talking about them. I say cancer, you panic, I want treatment. But in many of them, there's no benefit to doing treatment and lots of side effects. Now, some people say that the incidence of cancer, which is to say people getting it, is higher than it was 20 or 30 or 40 years ago. Is that because detection is better than it used to be?

5:06All right, so the dirty secret is we have no idea. We don't collect data well in the United States. What we do know is that there's not a dramatic rise in cancer in the United States, but what we are seeing is a troubling trend is younger people are getting more cancers. That's real. We have no idea why, but we are seeing younger people, more colon cancer, more breast cancer and other cancers in younger individuals, 20-, 30-, 40-year-olds, that we never used to see. And what do you think could possibly be the cause? I assume pollution or the environment in some ways? We assume it's either something in the environment, we assume it's diet, it's ultra-processed foods, it's microplastics, it's changes in the microbiome.

5:48We really don't know. Until we start to collect data, we can't, and we don't really have a data collection system, unfortunately, in the United States. So when younger people get cancer, what is their prognosis these days, and what can they really do to deal with cancer? So it's interesting. All of the regimens we have, surgery, chemotherapy, were designed around people who are older with cancer. I do think the biology of younger cancer is very different. So first of all, we need to develop regimens meant for younger people. That being said, we also have to start screening younger people for cancer.

6:23The age of colon cancer screening dropped from 50 to 45 recently, and it probably should drop even further. So if you have any family history of cancer, we probably should start screening earlier. So the best way somebody can prevent cancer is eat well, exercise, get an annual checkup, and what else can you do? I think there's a cadre of blood tests you should get at a regular cadence. I think that you need to talk to your doctor about potential medicines that can lower risk. things like aspirin, statins, and other things can lower cancer risk in the right individuals if you have a family history or others.

7:06And it's know your family history. Figure out what Aunt Marge died from and really understand because many of those family histories carry down from person to person. Important to know. In today's world, I can sequence your genome literally overnight and know if you inherited the gene that gave you higher risk for those diseases and then we can of a targeted prevention based on that gene that you have. Well, should everybody get their genome tested or mapped because is it expensive to do that? You can look at all the cancer risk genes for about$100 in today's world. And I think it's important, knowledge is power.

7:39OK. Remember, the generation before us, if they had cancer, it was considered a sign of weakness and many never talked about it. So getting a real accurate family history sometimes is really hard. JEFFREY BROWN, MD, I have been told that if a man lives long enough, he will get prostate cancer. Now, if you're 80 or older, you're going to die of something else probably. But is that true, that every man probably, if he lives long enough, will get prostate cancer? So, there's no question that indole and prostate cancers are very common. If I walk through the streets of New York City and biopsied everybody over 60, I would find 35 or so prostate cancers.

8:14But again, most of them won't cause a problem. What we know is we can grade the aggressivity of the cancer and know which are the ones that are going to cause a problem. We have a blood test called PSA that is very good based on the slope of the curve, the change in the number. It's starting to identify which are the more aggressive ones. Doing a biopsy is not a horrible procedure. And under the microscope, we can say, hey, this is going to be bad or don't worry about this one. So we're getting a lot better about dealing with them. Now, at Johns Hopkins, where you trained, a famous procedure was developed for prostate cancer that kind of minimized some of the adverse effects of a prostate surgery.

8:55Is that a good thing to do? Or if you're going to have prostate surgery, have this kind of procedure, it's done by a computer, and it's a robot, I guess I should say, that does the actual surgery? Patrick Walsh was a rock star. Patrick Walsh was a young urologist at Hopkins who, at the time, people took out the whole prostate. And the problem is the nerve looked like the prostate tissue. So they were taking out the nerve, and they had continence problems and potency problems in all the men. So Patrick looked in kids who had basically died during childbirth, young kids, and was able in those kids to know where the nerve was and developed what's called the nerve-sparing prostatectomy and started to pioneer that approach.

9:38Now, with a robot, we can go in and throw a small incision, blow up the abdomen so there's a high pressure, so there's almost no bleeding. And instead of looking down a cave where the prostate is deep in the abdomen, you blow it up at a big Sony screen. Great visualization. You could take out that prostate and have better outcomes in terms of side effects. And the patient literally can go home. Every business starts with an idea. How can you go from daydreamer to industry leader? Amazon Business accelerates your journey. With smart business buying, get everything you need to grow in one familiar place, from office supplies to IT essentials and maintenance tools.

10:15Amazon Business takes the buying experience you know and love from Amazon, plus tools that help you save costs and make insights-based decisions. Ready to bring your visions to life? Learn how at AmazonBusiness.com. So I know you do things other than oncology, but tell us, what does the Ellison Institute do? We are a technology application institute. So we developed drugs. We now have a large AI group that can design molecules targeting areas of cancer. So we're designing a molecule that hits part of the prostate cancer signaling cascade to block it that will go into the clinic next year. We have a breast cancer molecule that we made with AI.

10:56So with AI, we can actually use AI to what is the structure of the target and then what is the structure of the molecule. And what would have taken many years, we literally can do it in months, is design a molecule to go into the clinic. So that's been a tremendous advance for us and enable us to have a whole pipeline of drugs to treat cancer. Now, I am now 75 years old. And when you get to be 75, you worry about your body collapsing and not working. You also worry about your mind not working so much. So on Alzheimer's, what's the best way for me to prevent myself from getting Alzheimer's or some kind of dementia?

11:33So one of the largest studies ever done in Europe, what they showed is every year you delay retirement, you reduce the incidence of Alzheimer's by 3%. So it's the old adage, you don't use it, you lose it. So keeping your brain engaged, making yourself uncomfortable, what you are good at doing with your myriad of activities is fantastic, and I love that. Now you've had a lot of very famous patients, like Steve Jobs. Are famous patients more difficult to deal with than the average person because they have big egos, or are they easier to deal with because they just say, take care of this problem and I'll trust you?

12:07They're all different. I mean, you know, there are people I take care of who are amazing. You know, Jack Kemp was a remarkable individual. And when I first started to take care of him, he goes, you need you to do me a favor, and I want you to come to my house. And I go, okay, thinking we're going to discuss this case and what's going on. And what he did was he had his whole family sitting at a long table and he had his church come and serve them dinner He wanted me to see who he was and he said listen you make all the decisions I trust you, but I want you to understand my value system And it really was a beautiful way of approaching things and it's a privilege to take care of anybody that they put their health their future into my hands Let's talk about your own background.

12:49So where were you born? Baltimore, Maryland. Balmer, as they call it. Balmer, okay. And was your father at Hopkins? My father went to Hopkins undergraduate and University of Maryland Medical School. Where did you go to school? In Baltimore or somewhere else? I went to school in Philadelphia. My father had moved as a professor. He was initially drafted from Baltimore to the Air Force. We went to San Antonio, Texas. And I went to St. Mary's Hall. I was the first one of the first two boys that went into a school that went from nursery all the way through college. And, you know, I still remember first grade.

13:23I was one of two boys in the school. Then we went to Philadelphia. Okay. And then I went undergraduate to Princeton, med school at University of Pennsylvania, and then internship and residency at Johns Hopkins, fellowship at Sloan Kettering, and then to the NIH for a few years. And so did you know from the beginning you wanted to be an oncologist or a medical researcher? When did you realize what you wanted to do? Well, I was a geek as a kid. You know, it was about 10 years after Sputnik, and I did this little competition where you had to do this test, and we were one of four kids chosen, and we went lab to lab across the country where we kind of, you know, got to tinker in the labs, and I loved being in the lab.

14:01And so as I got older, I kind of realized that I wanted to apply the lab to patients. I couldn't just be in the lab. Oncology cancer was an amazing place because something in the lab could be translated right away to patients. Patients were willing to take the risk. I was willing to take the risk. So that got me into cancer. So today, how many people work at the Institute now? About 250. And so you're teaching at the medical school and also running the Institute. And you also do clinical work for patients. Yeah. So how do you take care of your own health? You know, you have to set priorities and you have to learn to say no.

14:38So I've been at home every day of the week for dinner. I don't go out. I say no to a lot of things. my business it's easy to say no I have a patient emergency I can't go to this I can't go to that it makes it very easy to say no I really try to make my schedule regular you know it turns out if you snack in between a meal the next day your body expects that snack and insulin cortisol the stress hormones go up you lose productivity your metabolism goes down you gain weight it's really tough on the body so I'm very regular with when I get up when I eat when I go to bed. And that makes an enormous impact on your overall health.

15:17JOHN YANG, MD, You have two children. Were you able to convince them to go to medical school? DR. DAVID BROOKS, One of them went to medical school, the youngest. I didn't convince him. You know, he wasn't going to go. He was, you know, went to MIT, was a total techie, totally into programming, AI and data. And then COVID happened. And he was privileged to work for a group analyzing data on COVID and trying to help with some of the COVID software for some of the clinical trials and he kind of learned you know I want to do things to help people I want to do things that matter so what about some free medical advice what about a statin should everybody take a statin after a certain age they are remarkable drugs lowering LDL which is a surrogate you know for many camps for inflammation in the body lowering that LDL has a benefit in heart disease and there is a risk reduction in cancer and so I certainly am I'm a believer if you have a family history of heart disease or cancer that you want an LDL in the more acceptable range or the lower risk range and it makes sense.

16:17What about red meat? I don't eat red meat, but I don't know whether that's going to make me live longer or not. Is red meat healthy for you? In a large study in Europe, they showed that three servings a week had no health detriment. There is a health benefit in several studies with grass-fed beef. So the key is moderation. Don't eat processed meat. People who had processed meat, you know, every day for 20 years had about a 20 % increase in colon cancer. So, yeah, if you have a hot dog a day for 20 years, it can increase colon cancer. So I probably wouldn't do that. But in moderation, it's fine.

16:49I don't drink alcohol either. Is that going to make me live longer? Not necessarily. Again, the warnings on alcohol show there's an association small with alcohol and cancer, particularly women and breast cancer. There's also an association of things like toast and coffee with cancer. When you burn the coffee bean or toast, that brownness is acrylamide, which has carcinogenic properties just like alcohol does. But it's a very, very minor contributor, despite all the hullabaloo that was made over the last couple of months. So today, if I wanted to live another 10 or 15 or 20 years in a healthy way, your recommendations to me if I can summarize it is maybe take a baby aspirin maybe take a statin exercise a little bit every day don't eat too much red meat don't drink too much alcohol and and pray a little bit and consider heart imaging okay figure out where we are where we're starting from look at all you know be up to date with all your vaccines which is critical make sure that regular blood values are in good order and then consider genetic testing if you have a family history of anything one thing i've often wondered about and maybe you based on your experience you can tell me what age do people really begin to think about dying in other words what age do they really go to their lawyer and say all right i really want to worry about my will or i really go to the doctor and say i want to live longer is that at age 60 65 70 where do you see it based on your pages that they're really beginning to think about death for the first time so it's interesting a study came out earlier last year or later at the end of last year that was looked at biologic age and said the biggest change in health happens at age 43 and age 60.

18:32So that's when you know medical issues change the most 43 and 60 and both of those time points when things happen is when you start to kind of realize that you're not immortal and so I see that very commonly in patients. You know most of my patients you know the first thing I have is listen you have a cancer I'm gonna be able to control it. I don't think you'll die from it. But I would recommend getting your affairs in order. There's nothing wrong with being prepared. You know, hope for the best, but plan for the worst is a very reasonable thing. I've seen too many, and I'm sure you have too, people who weren't prepared and horrible fights within family because they weren't prepared.

19:10And that's not a good thing. So I guess the most dangerous words in the English language are maybe get your affairs in order? No, I think it's a reasonable thing. I think it's an important thing. There's nothing wrong with it and i'm not saying it is an alarmist thing i just believe in it people live to 100 but they really have a lot of physical and mental problems you think we can ever get to people living to 100 and actually have the physical and mental abilities of somebody who's 80 or 70 100 we can and i think we will i can't see a reason why all of us can't live in a healthy quality way till that point you know the early 1960s was the last time in the united states you can die with the cause of death being old age on a death certificate.

19:50Now you need a death, Alzheimer's, heart disease, cancer. I want to go back to people dying of old age. Can you go to a cocktail party without people saying, I got this pain here, I got this pain here, what should I do about it? Do you ever get that? I get that constantly. And what do you tell people? I consider it a privilege to talk to them. It doesn't bother me. It bothers my wife, believe me. But it doesn't bother me, and I'm happy to try to help them. I mean, the ability to help someone, you know, I look at it as that it takes two seconds of my brain time to help them, and the benefit to them can be very significant.

20:24So there's an asymmetric part of the relationship here. For new kinds of treatments, like stem cell treatments and things like this, are these the kind of things that medicine's working on? And 10 years from today, what do you think we will be able to do that we can't do today? So, first of all, when you go to any mall now, you know, and you go to a mini mall in California or a mall here, you see a stem cell center, you know, a nutritional center selling NAD and vitamins and supplements, all of them promising you the fountain of youth. Every single one of them is a fraud. And I think it's important to say that.

21:00There is no data behind them. And so it's difficult because they have great marketing. it makes intuitive sense. Well, stem cell, I read in the New York Times stem cells were good. This says stem cells, therefore I want them. And that's the reductionist approach many people take when they see these buzzwords. So these are the future, but they're not here today is the important message. There's no question we will at some point get to them. There now are ways of turning the stem cells back on. And so there are clinical trials now doing things to turn them on back in the hip in elderly people who broke their hip after repair, in the heart, in the eye, in the hair, other places.

21:41And it's going to be very exciting. It's still early days, and we have to perfect that science. But this is something in the future to turn on the regenerative capacity of our body is something that will enable us to have, you alluded to before, is quality years in our 80s, 90s, and 100s. With stem cell technologies, we're going to be able to reverse that. What do you most enjoy about the profession you have? Is it helping other people, solving these problems that are going to help people you may not know, but people around the world? When people come to see me, I mean, most of the time they have advanced cancers, so they fail conventional treatment.

22:15So I get to think out of the box, look at all of the data, and come up, you know, before AI with something that I think can work for them and try it. I get to watch evolution happen. When I give a drug to a patient, that cancer evolves. I'm watching evolution happen in weeks to months in my patient and learning the biology of cancer from perturbing it Believe it or not. I'm a weird species in that I work in the lab and I see patients There aren't many of us left in the world and to be able to do the both I do autopsies on my patients who pass away So I see what I missed where I was right where I was wrong and I learned to get better Have you ever thought if you were in college today?

22:58whether you would go in today's environment, go to medical school, or would you go to Silicon Valley? Well, first of all, I would never get into medical school today. I look at what they do in the tests and the whatever. It is hard. Back when I did it, it seemed easier. I probably would still go into medicine. I love it. I pinch myself every day. I get to do what I do. Thanks for listening. To hear more of my interviews, you can subscribe and download my podcast on Spotify, Apple, or wherever you listen. Thank you.