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Following the Trail of a Cancer Sleuth

Born and raised in Rome, 50-year-old Michele Carbone, M.D., Ph.D., is a researcher and the director of the Cancer Research Center of Hawai‘i (CRCH). He also serves as a professor and director of the pathology department at the John A. Burns School of Medicine (JABSOM) at the University of Hawai‘i at Manoa.

Carbone, who has spent a major part of his scientific career researching thoracic cancers, is considered a premier authority on the deadly mesothelioma cancer. He is chair of the pathology department at UH Manoa and leads an international team of asbestos researchers. He joined the CRCH in 2006 after serving as professor of pathology and director of thoracic oncology at Loyola University Medical Center in Chicago. He was named interim director in December 2008 and was officially appointed to a three-year term as director in August 2009.

Why did you choose medicine as a career?

I had no option. My father would have killed me otherwise. The first son is supposed to be a doctor, so I am the seventh generation medical doctor in my family. The great thing about a medical career is that it allows you to do many different things. I didn’t want to be a surgeon like my father because he was on call 24 hours a day. So I chose to become a pathologist because I wanted to do research and understand why disease happens, with the hope that I could do something about it.

What was your first job in the medical field?

I started as a resident in pathology at the University of Rome. My [future] boss came to the lab to recruit researchers for a newly developing disease called AIDS. He said not much was known about it except that the virus could be dangerous to work with. Nobody wanted to do it, but since I was the new kid on the block, I volunteered. I handled the first 100 cases of HIV.

Did you continue to work as an AIDS researcher?

No. The National Institutes of Health was looking for researchers who knew about AIDS. But the funny thing is that when I went to work at the NIH in Bethesda, Maryland. I never worked on HIV. They hired me in a viral pathogenesis lab. I switched completely and began working with tumor viruses.

In 1986, I became a visiting fellow at the NIH, doing research on the RNA-tumor viruses. There was a lot of excitement in studying the oncogenes [cancer genes] of these viruses. That’s how we came to understand what we know today about how cancer develops.

At that time, we had no clue. For example, we didn’t know about the existence of tumor-suppressive genes and the mechanism by which cells live or die, which turned out to be very important in understanding cancer progression. If a cell dies, it cannot grow into cancer. In order for that to happen, the cell has to suppress the mechanism that would allow the cell to die.

We also didn’t know anything about the way certain genes cooperate with each other in the process of carcinogenesis. I would say that a lot has been learned in just the last few years.

I stayed at the NIH for eight years, and then I joined the University of Chicago and Loyola University Medical Center doing research on viruses. That led me to study a type of cancer that is linked to viruses. This tumor is in the membranes surrounding the lungs and the heart, and when it becomes malignant it is called mesothelioma. The prognosis is bleak. It is one the worst two or three cancers that exist, and current therapies have been ineffective.

What brought you to Hawai‘i?

I was at a friend’s house in San Francisco and his girlfriend said she was getting ready to leave for Hawai‘i to teach at the UH law school. I said, “You are so lucky, because I have always wanted to work in Hawai‘i.” She came back five minutes later and said there was a position open for a chief of pathology in Hawai‘i at CRCH.

I was very happy in Chicago and thought I would never leave the area. But I figured I could get a free week’s vacation in Hawai‘i and also form some professional collaborations. So I only came here to take a look. I had no plans to stay. But I loved it. Could I really live and work in Hawai‘i? I thought if I did not take the job I would always regret it. I’ve never had any regrets about my decision.

What is CRCH’s connection with the UH medical school?

CRCH is a unit under the UH-Manoa chancellor’s office. We report to the chancellor and president, M.R.C. Greenwood, whose support has been very critical to the CRCH. The medical school is an essential part of CRCH. The gynecologists and pathologist we recently hired also teach at JABSOM. So, it’s a win-win for everyone.

How important is it for CRCH to have an NCI designation?

We are one of 65 NCI-designated cancer centers in the U.S. They inspect cancer facilities and if they like what you are doing, they brand your facility as an “NCI-designated cancer center.” It also comes with a grant. The prestige from the “NCI” brand is huge. If you think of all the hospitals that don’t have the NCI designation, you realize how difficult it is to earn. We have to meet certain NCI standards, which then gives us access to many other resources.

Although the money we receive from the NCI remains the same every year, the monetary value the grant has significantly decreased. My first NCI grant in 1994 was $250,000. Today, we receive the same amount, but we can buy significantly less with that money. After receiving it, there is a mandatory cap of 25 percent, which means we only have $210,000 remaining.

Federal money looks good on a draft, but it has to be supplemented by private sector money. That’s why philanthropy is so critical for CRCH. Without it, we could not compete for grants. But thanks to the Friends of CRCH, the UH Foundation, and the private sector, funding has greatly increased. The center has raised $300,000 to $400,000 on average for the past five or six years.

Since I have become director, CRCH has focused much more on educating the community about the significance of our activities. As a result, this year we received $1.6 million in donations, our largest ever, and private donations have doubled. So we will continue to let the community know more about our activities and work with the UH Foundation for funding. We hope to reach the average annual funding level for other cancer centers across the nation, which is about $3 million or $4 million.

Is cancer no longer considered a death sentence?

Depending on which statistics you use, cancer outcomes can look good or bad. You won’t find any of my mesothelioma patients alive after five years.

Cancer is a big word for a number of diseases but depending on which organs are affected, some of the cancers are perfectly amenable to treatment and some are not. There’s a big difference between mesothelioma and skin cancer, for example. With skin cancer (except for melanoma), 99.99 percent of people have the cancer cut out, and then they don’t die from it.

Why do so many Hawai‘i residents believe their only option for good cancer treatment is to travel to the Mainland?

The first thing people do after receiving a cancer diagnosis is go on the internet and figure out where to go for treatment. Most of them prefer to be treated close to home. A depressed patient does not do as well as an optimistic patient, and it’s difficult to provide a supportive environment if you are many miles away from home. Hawai‘i doesn’t offer all the available treatment or clinical trial options, and not everyone can afford to travel off island.

We have excellent physicians here, but a patient might have no other choice than to go to the Mainland for treatment. One of the main goals of our CRCH consortium is to offer Hawai‘i residents every possible option.

Over the next few years, we will be building the new cancer center and expanding the consortium we have formed with the hospitals. This will increase the interaction between physicians and researchers. We can’t change overnight, but we will gradually work with the hospitals to expand the number of clinical trials and other options offered here.

And we will continue to hire prominent researchers whose specialties are needed in our state. For example, we currently have only two gynecology oncologists for a population of more than 1.2 million people. If one of them is sick, we only have one available. We recently hired two gynecology oncologists.

It would be difficult to find the money to hire them and provide sufficient patients if one hospital had to bear the entire financial burden. But the consortium shares the costs to recruit them. That would not have been possible before. Now we can deliver better care to our population.

What’s the most difficult part of your job?

Hearing someone ask, “Why haven’t you done it?” Or asking, “When will you do it?” Most research center directors have inactive research programs. My research program is more active than others. There is so much to be done – everything from forming the consortium, building a new cancer center, recruiting, etc. The demands on the director of CRCH are significantly higher here than those of a director at a cancer research center that is part of a hospital that has a dean who deals with everything.

Describe your average day.

I usually work about 14 hours a day and a half day on Saturday and a half day on Sunday. I run with my dogs in the morning before work. When I have time, I love to cook Italian food and entertain my prospective researchers, co-workers and friends. And I play ping pong regularly.

Last year, I traveled 156,000 miles. That’s about one month sitting on an airplane. But I get so much done. That stack of papers on my desk is ready for my trip to Turkey in a few days.

What are the big cancer discoveries you see on the horizon?

We will make strides with those cancers caused by viruses because we have learned how to make vaccines. As more viruses are discovered to have a link with cancer, we may be able to develop vaccines to prevent those cancers. Because we are learning more about how cancer develops, we may not be able to fix it, but we should be able to develop more ways to prevent it and decrease the incidence.

Is there anything related to cancer that is unique to Hawai‘i?

CRCH is studying why it is that certain cancers have different prognoses in some ethnic groups. For example, Hawaiian and Filipino women in Hawai‘i who develop breast cancer have much worse outcomes than Caucasian women. By educating and encouraging women to go to the doctor early, we can reduce the incidence of breast cancer.

How will you measure the center’s success a few years from now?

We will have completed the construction of the new facility, developed the consortium, and hired top researchers. In the end, we should be able to increase the cancer treatment options for Hawai‘i patients, an accomplishment that each of us would be unable to do alone.

We will be tested over the next three years. But if we all retreat into our own “hub,” there will be fewer resources available to get things done. So my hope is that we can all work together to give Hawai‘i a first-class research center that will work with our community hospitals to advance the care and treatment for cancer patients throughout our state.

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