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Interview with Dr. Fei-Fei Liu

Journalist: Haleema Ahmed

Haleema: Hello everyone and welcome back to SciSection. I'm Haleema, your journalist for this week, and today we are delighted to have Dr. Fei-Fei Liu. She is the chief of the radiation medicine program and the head of the radiation oncology department at the Princess Margaret Cancer Center and the University of Toronto. Thank you for joining us, Dr. Liu.

Fei-Fei: Well, thank you so much for inviting me Haleema. I'm delighted to be here.

Haleema: Just to break the ice and get started, what is one scientific fact that fascinates you?

Fei-Fei: Thank you for asking that question. There are lots of things about the world that fascinates a lot of us. One of these things is related to the interaction between physiology and psychology. What happens to our body physically and how that changes the way that we think or how we feel. This is a very complex topic and we had conducted a study several years ago about it. We were trying to understand why it is that some women, when they undergo radiation therapy for breast cancer, will oftentimes say they'd become tired. We were studying about 150 women. I'm trying to understand why it is that some patients will experience fatigue in the middle of the radiation treatment and yet some do not have any of these types of symptoms. From these 150 women with breast cancer, we had drawn blood before they started radiation and then serially over several days and weeks and even up to a month after they finished their radiation. We were analyzing these cytokines or hormones or proteins that were circulating in their bloodstream. At the same time, we'd also ask them to fill out questionnaires to describe how they're feeling, their level of fatigue, their energy level, their anxiety, whether they are sleeping, et cetera. We don't have a very simple answer to this, but there were a few of these circulating proteins or cytokines that do seem to track with the patients reporting fatigue. What I think happens is that there's a very complex interplay between our physical body and the types of proteins and cider callings that circulate as a function of how we are responding to the environment, what treatments were undergoing, the effects on our hunger, our brain, our mentation, and how we think, et cetera. There's also the reverse interplay where some of this data is emerging recently. For example, patients with mental illnesses have a higher incidence of problems with cardiovascular diseases. I suspect that there's this sort of this yin and yang between how our body is responding and how our brain is responding; they are deeply interconnected. I think to understand that, it would be very illuminating on how different people respond to their diseases differently and their treatments differently. This is something that I think is really fascinating and very wonderful, and odd for us to try to understand.

Haleema: That is incredibly fascinating. And this whole idea of the ying-yang of the outer body and our interaction with the environment and what's going on inside. Is this something that we're studying more recently, or has history always been this prominent?

Fei-Fei: When I started practicing years ago, if a patient complained of being tired, you just pull up your socks and grind your teeth and just work your way through it. I think now we, as a society, have a much better appreciation of the complexity of the relationship. For example, things like meditation, right? A recommendation that I think a lot of people would like is meditating because it is an inexpensive way to manage, for example, high blood pressure. So rather than taking a whole bunch of expensive medications, many of which may have a lot of side effects, why don't we just try to meditate regularly to relieve distress and it may lower your blood pressure too.

Haleema: Now talking a little bit more about medicine, could you tell us a little bit about your early days immigrating to Canada and now leading to that process of becoming a radiation oncologist?

Fei-Fei: That's a very long journey because I've been around the block a lot. I'm a first-generation immigrant. My parents brought us from Taiwan and immigrated to Toronto, Canada when I was eight years old and that was back in 1966. So you can calculate how old I am. I have a brother, Peter, who was 12 years old at the time. My dad was a professional engineer but he wasn't able to find a job in Toronto or Ontario because his English was not very good. So he had to find a job as an engineer in Halifax, Nova Scotia where he was working there. My mom was really like a single mom bringing up two young kids. They did pretty well though in that my parents bought a house in downtown Toronto back in 1966 for $34,000. This was like a house in downtown Toronto but we weren't well off. The three of us lived on the first floor and then we rented out the basement and we rented out the second and the third story. I learned how to identify good tenants when I was a very young teenager. So that was sort of our childhood. It was very focused on education because part of the reason my parents brought us to Canada and left Taiwan was really for the opportunities for the kids. It was a classic immigrant child story and we all were pretty happy. My brother, who's four and a half years older than me, sort of bore the brunt of all the high expectations. So he was the one who went to medical school before I did. We've always had this sort of healthy little rivalry going on and I always thought, well, Peter can get into medical school, so could I. I just followed his footsteps, got into medical school, and in those days, it was a lot easier than it is now. My parents didn't even know that I was applying. I showed up one day and I said, "Oh, I'm going to medical school." I don't know Haleema if you know what Encyclopedia Britannica is but my parents had an entire set. Back in those days, there was no internet. There were just books. We had the entire set of Encyclopedia Britannica. I remember reading the cancer section, which was only a couple of pages back then. I've always had this fascination for inexplicable reasons with the idea that there were these cells that could just grow completely out of control. I've always had a fascination with cancer and so throughout medical school, I had always wanted to be a cancer doctor. Then as I got closer to that possibility, I realized that there were two different specialties. There was medical oncology, which is where you gave chemotherapy and there was radiation oncology, where you gave the radiation, which I never even heard of before that. Back in those days, which would have been like in the early 1980s, medical oncology and cancer were pretty depressing because most patients died. I found out about radiation oncology, where it was a bit of a happier specialty because you got to treat patients with skin cancer and very few of those patients died. As a predisposed individual, I thought I'm going to do radiation oncology because I don't want to be depressed all the time. That was how I ended up in radiation oncology and then trained. In those days we could train in both general medicine, which I did for three years, and then subsequently, I trained in radiation oncology all here in Toronto.

Haleema: So the term radiation, what does it exactly mean when you're treating people with radiation or electromagnetic radiation? What exactly is that?

Fei-Fei: They are high energy particles or photons. It's like having a chest x-ray except for its several hundred folds with higher energy. When the ionizing radiation enters your body, which you can't see, you can't smell, you can't touch it, it interacts with the tissue, and because of its high energy, it produces what's called oxidative damage. It interacts with oxygen and it produces these reactive oxygen species, DNA damage, and all sorts of other effects in cells which is the benefit in terms of treating cancer. It comes from the fact that the normal cells and the normal tissues have a normal repair mechanism to repair themselves from the damage from the ionizing radiation; however, cancer cells do not have that same repair capacity and so the cancer cells die and the normal tissues recover and repair from the effects of treatment.

Haleema: You mentioned that many people assume cancer is super depressing because you're dealing with patients who are so critically ill and it's such a debilitating kind of disease from that outside perspective. So as a physician who supports patients like these, what do you think is the largest misconception about cancer treatment cancer patients today?

Fei-Fei: Back in the early 1980s, cancer was pretty depressing because patients died. But the truth of the matter is that we have advanced tremendously in terms of improving the outcome for patients with cancer. I specialize in breast cancer and the advances that have been made over the three decades I've been in practice have been just phenomenal. We are now treating a lot of early-stage breast cancer because patients undergo screening. About a third of our patients have cancer that's never detected except through a mammogram, for example. They're very early stage and highly curable and so there is a relatively happy group of patients to treat. There is of course still the spectrum of patients who have advanced disease and do not do as well. But I think it is a privilege for us as physicians and as cancer specialists to be able to share in each patient's individual story and their journey. What I find most gratifying is the fact that I'm able to help my patients and help patients differently in different ways particularly in breast cancer because of the improvement in outcome. I grew up with many of my patients. We have these long-term relationships over decades and I became a mother and they became a mother and we share stories. Many of my patients have now become grandmothers and they teach me how to be an effective mother and how to be an effective professional. I've learned tremendously from my patients. I think it's a privilege and it's very gratifying to see how well they do. Just as an example, I got a card from a patient who I've been following for 29 years. She's doing well. And I said, you know Ms. Smith, we probably should be parting ways cause you moved outside of the cities and you're doing so well. She sent me a card and said, thank you for looking after me for 29 years. That is like more than a quarter of a century. It just brings us all so much joy when we see patients who do so well for so long and have an excellent quality of life.

Haleema: That's amazing! You've been following this profession of cancer for quite a few decades now. So with that and the rapid, innovative nature of cancer treatment, how do you become an adaptive learner? As somebody who always has to keep up with the science because obviously with cancer and being a person who treats people with cancer, you have to keep up to date. What are some kinds of values or some of the skills that you've learned to kind of become better at that?

Fei-Fei: I think one of the fundamental characteristics is to always be curious about life, right? In my world, where I started as a clinician-scientist, I was treating patients and also running a lab doing a lot of investigations and research. It was always driven by this idea that there are things that I need to understand when I see my patients in the clinic. We obviously have not cured cancer. There are opportunities for improvement. Why do these things happen to my patients? We try to be able to then answer some of the dilemmas in the lab by developing different models and doing translational research to try to bridge the gap between the patients and the laboratory. At the same time, we have to master both sets of literature, right? We have to be masters in the clinical world to understand what the latest developments are and adapt our learnings to the patients that we have. We're seeing right in front of us very rapid advances. Therefore, you have to be able to adapt to what tools you have available to undertake scientific investigations and scientific inquiry and then be able to do your best in terms of trying to understand the science. Ultimately, we try to bridge the two sides together.

Haleema: You are a physician and with that, a physician-scientist. So you run a lab. What is the main difference between being a physician and also having a lab to take care of? What are some of the adventures that you guys are taking in your lab?

Fei-Fei: Running the lab is hard because they're not a lot of us. I always say that if you want to be a successful clinician-scientist, you have to be naturally neurotic, to begin with, because it is very hard. But it's also incredibly gratifying. One of the most gratifying things for me is to actually watch our graduate students graduate by finishing their work in our lab and they become a member of our family. I have a whole pile of all the thesis in the quarter of this room year which is a tangible testament to all the grad students' hard work. We keep in touch and all of them have been very well placed after graduating from our lab. The difference is as clinician-scientists, we spend about 80% of our time working in the laboratory writing grants and writing papers. We're also learning and also tutoring and teaching and mentoring our graduate students. Running a small lab successfully is almost like running a small business. You have to be entrepreneurial. You have to be able to capture the grant money coming from whichever sources there may be. You need to pin it a little bit. As an example, there's an incredible amount of money in COVID research. Some of my virology friends say,"God, you know, we had no idea there were so many virologists in Canada." But those are some of the things that you have to pivot very, very quickly for. When you see there's a funding opportunity, it's like running a small business and every time you write a grant, it's almost like a small marketing exercise. But it's based on scientific evidence also.

Haleema: Do you see this bridge of medicine and business entrepreneurial aspects? Do you see that kind of growth in the future, more medical students, doctors going that route? Is that something that you or your vision kind of see as somebody who pursues something like that?

Fei-Fei: Yeah, I think so. When I started in this world 30 years ago, there was a distinction; an almost semi-permeable wall between the pure academic and the business. I'm a pure academic so I'm never going to involve myself in any sort of business or entrepreneurial activities. I see the two worlds merging now which I think is wonderful because, in the end, everybody can learn from each other. The business world can learn to be more academic, more scientifically focused perhaps, but they are driven by different motivations. The academics are evidence-based, but we also require funding and commercial activities and we feel a need for that. One of our youngest recruits is a very successful clinician-scientist and he's just formed a company with another Ph.D. scientist in our research institute. It's a very stressful time because as physicians, we're not trained to be business people. But you've got to have a different mindset. When you're pitching your ideas, it's not the same as when we're writing a research grant application. It is a completely different skill set. When it's successful and you're true to the scientific motivations of the work that you do, but you also recognize the commercial value of your work and you make sure that the two are aligned and you still are functioning with guiding principles. I think sometimes we do get into trouble because when the two worlds merge we have to protect and maintain the avoidance of the conflict of interest, right? So when you've got financial motivations, people's brain changes, right. Their way of thinking and their priorities change. We have had many examples where the conflicts of interest have not been well managed, and then both the investigators and the institutions run into problems. It's really important to make sure that everybody understands how best to proceed and manage successfully to protect everybody, the patients, the investigators, and the institution.

Haleema: And we often hear the concept of, just like you mentioned, medical people need to kind of get into that business mindset. But I feel like, throughout history, you've often seen business people get into the medical aspects of the medical leadership aspect without necessarily having that experience. I think it's quite interesting to hear you talk about that as well. As a physician, compassion is one of the most essential qualities and so I wanted to ask, how do we approach, as many people often do, their loved one experiencing cancer, and maybe even in their last stages, how do we approach a loved one with compassion when faced with a disease like cancer?

Fei-Fei: Compassion and empathy are the two key elements of any successful clinician. When patients come to us in a hospital, they're vulnerable and they're sick and their primary motivation is to get better. It is about placing ourselves and understanding what our patients are experiencing. I think that the key is to be able to understand it and appreciate it. It's not feeling sorry for someone because that's not compassion or empathy at all. It's really to be able to appreciate the struggles that they are experiencing themselves. Then trying to advise and make recommendations that would be appropriate for that particular individual. As an example, we're cancer specialists so when seeing patients, we understand the extent of their disease. We have a set of recommendations, right? That's our job to make recommendations. It isn't to tell people that you are going to be doing A, B, and C. We as the oncologist specializing in this area, would recommend that you think about A, B, and C, and this is how we would recommend that the treatment plays out. Not every single patient will accept our recommendations. That is where compassion is really important to understand why patients are responding the way that they are and then to try to help them to work their way through that. As an example, I had a patient who was a ballet dancer. The physique of what she looks like and how she presents herself was the most important aspect of value to her. She didn't want to go through the treatments that we were recommending because she thought they would have a damaging effect on her physical and emotional appearance. We had several conversations and sometimes, it requires that the patients and we as providers understand each other and where we're coming from. And so I did successfully manage to convince her to go through the treatment, but it took several conversations and a lot of reassurances to her that she doesn't have to be fearful about the effects of her treatment on her physical and mental wellbeing. I think that's the empathy and the compassion of taking the time to understand and then to be able to speak the same language in terms of communication.

Haleema: And lastly, I think that the stigma around cancer, for sure now, even with all the advancements that we made, it's still so eminent, you know, you think that as soon as you're diagnosed with cancer, death is the next thing to it. Or, you know, you're going to lose your hair, just a lot of that typical stuff. So within your practice, how do you try to revise the disease?

Fei-Fei: Yeah, reassurance is a key role here. Haleema, when patients are confronted with a diagnosis that you have cancer, one immediately thinks, “I'm going to die.” In the lay public, that's the clear association. What we try to do is try to uncouple that, right? We're saying that, yes, you do have cancer but your cancer is highly curable and this is how we're going to help you get there. You are going to become a grandmother or a grandfather and you are going to see your kids graduate. A really important role that we have to play is to provide the facts to the patients and to reassure them that you're not going to die and we are going to cure you and in fact, we are curing a very large number of patients. The areas of research in our laboratory where we've pivoted to is looking at the late tissue toxicities of cancer therapy because of the increasing incidents of cancer. We're doing so well that we have the fortune of having a very large number of cancer survivors being about 2 million in Canada. So that's the good news. The fact that reassures people is that you will survive your disease and you will have an excellent quality of life. So it's reassurance and the facts that we hope to be destigmatized.

Haleema: And on that note, thank you so much, Dr. Liu, for joining us today and talking to us all about the work that you do, cancer and discussing a lot of the important things that people need to understand about this disease. It was such a pleasure speaking with you.


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