Darrin Godin: Hello and welcome to Talking Hope. I'm your host, Darrin Godin. Today I'm pleased to be speaking with renowned radiation oncologist, Dr. Percy Lee. As medical director and vice chair for clinical research in the Department of Radiation Oncology, Dr. Lee is increasing City of Hope's reach in Orange County and growing its radiation oncology research network. He graduated from Harvard Medical School and trained at Howard Hughes Medical Institute, Massachusetts General Hospital and Stanford University. Dr. Lee practices at City of Hope Orange County Lennar Foundation Cancer Center, where he is part of a team leading next-level cancer treatment and research.
Welcome to Talking Hope, Dr. Lee. We're so glad to have you on the show today.
Dr. Percy Lee: I'm very happy to see you, Darrin. I'm looking forward to this discussion.
Darrin Godin: I am looking forward to this conversation as well. Your area of expertise is so fascinating and I know there's a lot to discuss today. So how about we start there? Let's talk about Radiation Oncology 101. What exactly is it? How does it benefit patients?
Dr. Percy Lee: Yeah, thank you for that question. I think radiation therapy could sound scary to patient, but I would say in the last 30, 40 years there've been so many advances. We've always known that it's effective against cancer. What we've done in the last 30 years is make it more precise and accurate and save normal tissue from getting excessive radiation. So basically what the improvements are, better cancer control and then less side effects for patient with precision guided radiation therapy.
Darrin Godin: So talk about some of the technology that's used in it, and I know we have some very unique technology here at City of Hope and its configurations are also highly advanced. Talk about some of those offerings that we have.
Dr. Percy Lee: Yeah, we have, I would say, one of the more advanced suite of technology for radiation therapy. So one is called MRI guided radiation therapy. That's fairly unique. It's been around only in the last, I would say, seven or eight years. But the field quickly adopted to it for difficult to treat cancers and what it is that there's an MRI built into the actual machine that delivers the radiation, so allows for better visibility of the soft tissue around the tumor and the soft tissue of the healthy tissues.
It allows us to change our radiation the daily basis because the tissue moves around, so instead of injuring normal tissue with radiation, we can now adapt the radiation to that day's patient's anatomy and then we can also track what we treat. And that's something that is only unique for something like this where the MRI is always on. And so we can see the tumor, track it, only turn on the beam where it's in the exact position we want to radiate it, instead of treating normal tissue. I compare it to being like you're a flight pilot, you don't necessarily want a pilot or surgeon to be kind of blindfolded when you treat. You kind want them to see what's going on. So this sort of opens the door and eyes, if you want to put it that way, to be able to target the treatment during the radiation therapy instead of guessing at it.
We also have another platform called CT guided or adaptive radiation therapy. It's called the Ethos Machine. The other one was called Meridian. Ethos can do a lot of the same thing with high quality CT image, we can also change the radiation on a day-to-day basis, which most radiation machine can't and doesn't do that, based on that day's anatomy. So again, we image the patient, we see what the anatomy looks like, if there's some changes in it we can, on the fly, make the radiation go where it's supposed to go and then hit the cancer with the treatment and not the healthy tissue.
So those advances allows us to personalize the radiation. Then we have the TrueBeam, which I think a lot of patients will be treated on it. It has its own capability, including sort of having cameras and visualizations and imaging so that we're exact, but it's also more versatile. So I guess the idea is that all three, they all serve a purpose. We try to pick the right machine for the right patient and that's because we have experts in all three technologies, but also deep expertise in the cancer types that they're treating so they can match the right treatment with the right patient.
Darrin Godin: So that's very interesting. And when you're saying match the right treatment with the right type of cancer for that patient, talk to us more about what types of cancers are treatable by these therapies?
Dr. Percy Lee: Yeah, so I like to say radiation, probably about two thirds of all cancer patients will need or benefit from radiation therapy at some point in their journey through cancer. Some of it is curative, meaning that for head and neck cancer or lung cancer, sometimes it's radiation only or chemotherapy and radiation in combination without surgery is a curative approach. And there's sometimes we are sort of adjuvant or we use radiation after surgery or after chemo to consolidate or to, hate to use the word mop up, but to kind of clean up any kind of cancer cells that might be in the area. So that's what we call adjuvant or after the surgery.
Then there's of course a large population of patients where they have metastasis or spread of their cancer to bone, soft tissue to areas that may be painful, affecting their quality life. So a lot of what we do also is using radiation to shrink the tumor to help the patient have less pain and suffering from the cancer. So it goes from curative to adjunctive after other treatments to palliative. But I would say overall, I mean cancer patients are doing significantly better now than say five years ago, 10 years ago. I started my career about 17, 18 years ago and we're seeing people living longer and therefore they're getting multiple courses of different treatments. So we pass the baton back and forth between oncologists, our surgeons, the radiation and back. And I think with sort of that multidisciplinary approach, we've been able to keep a patient healthy.
So I guess my point is that sometimes we're in the lead or sometimes we've in the backseat, but we all communicate, we all communicate with our colleagues and that's what's the benefit of being at a cancer center, City of Hope, where we're in constant communication about the patient in front of us, on email, on chat, on the phone, and we talk about the plan. And I think that's unique because unfortunately, cancer care is still a little bit fragmented in general. But in our situation, we're able to offer all these services under one roof, and that coordination and that communication really benefits the patient. It's more timely in terms of delivering treatment. It's more coordination of offering clinical trials. It's about sequencing of therapy in the most optimal way, either standard or kind of innovative manner on trials. So I think just really proud that we have a team, not just in radiation oncology but across our cancer center that we serve our patients in that matter rather than kind of a little bit more fragmented approach.
Darrin Godin: I'm glad you mentioned research. So talk about some of the research you've done or the research that you're currently involved with that is benefiting patients today.
Dr. Percy Lee: So I think I could speak to some of the work I've done. It's sort of combining radiation with novel therapies like immunotherapy. So sometimes we've learned over the last six, seven years that if done correctly, that combination helps the patient do better in lung cancer, for example. A lot of my work was also developing this MRI guided radiation therapy over the last, I would say seven, eight years when it was a new technology and then showing its clinical value through clinical research, clinical trials and publications as a new treatment approach. And we learned that, for example, in pancreas cancer, we read a couple of multi-center Phase II studies that showed the outcomes were better in locally advanced or unresected pancreas cancer using higher dose of radiation that's enabled by this MRI technology, enabled by precision and also, despite that, cause less side effects than traditional radiation.
So those are the [inaudible 00:08:40] we're continuing that work here at City of Hope, we're building a center of excellence for adaptive radiation. That's what I was talking about being able to change the radiation while the patient's on the table, fitting to what that patient's anatomy looks like that day. And we want to continue that work for prostate cancer, for lung cancer and other cancers where we haven't done as much work to show the benefit in those situations. And eventually, it's sort of using biological information like as the tumor changes, we're able to use those kind of information to customize the radiation. So there's a couple trials that we're doing here in that vein. So RTIRE is a prostate cancer trial, provides treatments on the Ethos platform where we're trying to use this adaptive reshaping of the radiation to see if we can reduce side effects, patients' urinary side effects, patients' GI side effects from treatment. So that's one example of what we're doing here at City of Hope, kind of pushing the envelope on some of these technologies.
Darrin Godin: That's very exciting. You mentioned how long you've been in your career and you're such a servant leader I know and very humble, but you really are one of the national, if not international leaders in some of these therapies and using this technology. So can you talk to us a little bit about what you've done to help move the field of radiation oncology forward with these technologies?
Dr. Percy Lee: Thanks, Darrin. Yeah, it's hard for me to brag about what I've done, but I'll try to do my best to talk about what I've done. So I think a lot of the work was on establishing SBRT, the shorter course of treatments, stereotactic body radiation therapy for early stage lung cancer. So that's something I was very passionate about. We'd also done studies, like I mentioned before, using combination of that SBRT and immunotherapy for early stage lung cancer instead of surgery. And some of the patients are too old or too frail for surgery, as example. And then it's really a lot of work on using MRI guided therapy for liver tumors, liver metastasis, pancreatic cancer, showing the value, not just the ability to do it, I would say, but the clinical benefit to the patient, showing the less toxicity, as example.
We used to quote about 15% short-term, moderate to severe toxicity side effects from pancreas radiation therapy using traditional approaches, lesser dose of SBRT still but in five treatments, now we're doing 50 grade in five treatments, much higher dose with 0 to 5% side effects. So that was borne out of this work. And I would say it's not just me, but it's a team of national, international experts that were pushing the field forward with MRI guided radiation therapy. So I'm very proud of that work, yeah.
Darrin Godin: Well I know we're proud to have you as part of our team. But I've heard it said by some of our other physician leaders that it's one thing to have the high-end sports car, it's a whole nother thing to really know how to use it and how to use it to its maximum benefit. And I know that you're often described as the person who really understands these technologies and can move that forward for patients' benefit. And that's exciting that we have you here in Orange County.
Dr. Percy Lee: Well, thank you. And I would like to sort of amplify that in the sense of the team. So I think one of the things that maybe patients don't often understand is that there's a whole team behind the radiation oncologist. We have great radiation oncologists where sub-specialists, but there's a team, they see the nurses, they see the front desk greeters and they see our technologists, they're all very, very valuable in their care path. In fact, I always say they get the most compliment of anybody in our team are those patient-facing people and experts that are compassionate but also technically very good. And that's why we try to build that team in Orange County. But it's also the people they don't see, physicists, dosimetrists, that help the physician, the radiation oncologist to plan these complicated treatment. And I think that aspect of it, they don't get enough credit for the work they do.
And I think that's where maybe the analogy I thought of is sort of like the race car driver is great analogy, but you see that race car driver, he or she may get the most of the credit, but you see the pit crew comes in and they do their thing and they get the driver back on the road. Well, without that pit crew, that driver is not going to be able to execute, despite the technology. So I think we have that whole complement of a team that allows us to excel in taking care of the cancer patient like a race car driver.
Darrin Godin: Yeah, we should mention that-
Dr. Percy Lee: Does that make sense? I don't know.
Darrin Godin: No, it absolutely does and I'm glad that you brought that up because... And again, I'm not just trying to give you high accolades or whatever, but that shows the type of leader you are to bring forth that team. And it really is important. And I know you and I know firsthand, I have a family member who's been a patient of yours and he's talked about interacting with the different folks in the team, everyone from the front desk all the way to the time he leaves and how seamless and coordinated it is from a compassionate standpoint as well. But also that level of expertise and making sure that the patient feels like they are absolutely getting the very best and most advanced care that they can. So I'm grateful for that team as well. It expands even beyond just radiation oncology but across our entire campus.
Dr. Percy Lee: Yeah, I appreciate it, Darrin. I think the team is very happy to sort of hear patients have great outcome, they're grateful, I think they celebrate, they ring the bell. All those things I think helps us to continue to strive to be the leader in radiation oncology in Orange County and beyond. So yeah, very proud of it.
Darrin Godin: Well Dr. Lee, let's go back in time a little bit and tell me what kind of drove you to become a physician in the first place and to choose this profession of radiation oncology?
Dr. Percy Lee: Yeah, Darrin, that's a long time ago, but I'll try to reflect on that a little bit. I think I kind of since late high school and early college, maybe some words from my parents who suggested that that may be a good profession, but really I think it was in college as I learned more about being a physician and what it means, volunteering in the ER. I went to school on the east coast. I think that solidified me to say that being a physician allows me to take care of people, be able to truly help people of need.
And then in medical school, I would say what's been most monumental in my decision to go to oncology was I spent a year in the laboratory of a cancer laboratory and that cancer laboratory was studying how cancer grew and how cancer leverage blood supply from the body to grow. And we were trying to figure out ways, drugs or mechanisms to inhibit that. And I would say during that time I met another fellow who was a radiation oncology resident at the Harvard program where I was doing my medical school and he asked me a question about what I wanted to do. I said either cardiology or cancer. And he said, "Well, you really should think about radiation oncology." He sat down with me for a good number of hours and I decided to do a rotation that summer after I did that year of research. And that individual's actually still the head of radiation oncology at the NCI.
Really I look at that moment serendipity wise, he came to our lab, neighboring lab to ask about an essay that I was doing, I was just a medical student, and then he kind of told me about radiation oncology and then I did rotation. And it kind of makes sense, kind of full circle. I wanted to help cancer patients. Radiation is very specific, we get to spend a lot of time with a patient, but we have a job to solve, which is using radiation to help cancer patients. And as an engineering background, it was also very interesting to me that I can leverage that a bit, that nerdy side or the technical side while still have that patient-facing side.
So it a really combination of being interested in taking care of cancer patient, the cancer work that I was doing, this mentor that I had in medical school plus other mentors. And then I learned that radiation really leverages physics and engineering, that I don't need to necessarily know because we have a physics team directly, but it's interesting for me to understand it, and so to work with our physicists to understand that a little better. So it's a combination of things. I don't know if that helps.
Darrin Godin: Yeah, you actually used the word or the phrase, "problem solving." So as you were discussing and talking about what radiation oncology is earlier, it did seem like there's a lot that goes into it to adapt and solve what maybe can't always be seen easily. So you use the technology, the tools to do that. And that sounds like that's just a different approach and a different type of mind that is needed in this area to really get to the root of the problem. And like you said, in some cases deliver curative therapy.
Dr. Percy Lee: Yeah, like I said, I love my profession. I think I love radiation oncology because we could have both. We could have that patient interaction, but then what we're doing is actually trying to create a treatment plan that's customized to that patient's situation. And that requires some interactions with the team that I mentioned. But the radiation oncologist has to make the final decision, weighing risk and benefit of like, "Is this the adequate dose of radiation? Is this the right technology? Is this going to be giving the patient the best chance by delivering this treatment?" And there's a lot of nuance and experience and research going to that. And I think I would venture to say most radiation oncologists really like that aspect of problem solving and then creating a solution, a plan that they feel like is the best treatment for that patient. And then of course it's great when they come back and they have an image and their success and they're happy. We don't always achieve that, but a lot of times we do. And I think whatever we can do to help that patient, we feel grateful for it.
Darrin Godin: Well, thank you, Percy. So let's just think about from a patient perspective, maybe a newly diagnosed patient. What sort of question should they be asking their oncology team about if they're being recommended to go through some radiation therapy or surgery, what are the types of questions they should be asking if they're not at a place that has a good multidisciplinary team around them? What should they ask before they move forward with treatments and so forth?
Dr. Percy Lee: Yeah, and I think that's a very good question. I would start off kind of understanding the patient should feel comfortable and understand that there is a team that's taking care of it. Because I think cancer care is a team sport. So number one, they have to feel comfortable that their oncologists, if a medical oncologist, and if it's relevant, a surgeon and radiation oncologists are involved in their care and do they work together and how are they working together I think at a high level? And what's the overall treatment plan, not just is it, "Chemo now, and we'll see"? It's, "What is the big picture plan? If this is plan A, is this going to work? If it doesn't work, what is plan B?"
And I think asking those type of questions will really shed the light as far as maybe how much experience the team has treating this cancer. Do they co-collaborate with other oncologists? Are those collaborators within an institution, which is great, or within a network of physicians that they are close to, which is great too. But understanding the communication between the thing. And then I think delving into it's radiation oncology, what treatment are they getting? Is it know IMRT? Is it SPRT? There's all these acronyms. But is it short course treatment? How many sessions? What do they expect from those treatments? What are the side effects from the treatments? Expected short-term side effects, long-term side effects? And the kind of generally expected outcomes from this treatment course.
And I would say coming back to City of Hope, that those are the things that we try to have all our radiation oncologists be, to speak to not just the technology, but the bigger picture, like Dr. Wang, Dr. Schwer, Dr. Ladbury, myself, we constantly collaborate with our multidisciplinary team. More often than not, when we see a patient in front of us, we've already spoken to our colleagues, we already have kind of a comprehensive plan and then radiation is just one piece of that plan. And we can kind of fit that into the sequence of therapy. We know what's going to happen. Is it concurrent with the other drug? Is it before surgery? Is that after? I think sometimes those things get lost in the shuffle and patient.
I know I've tried to help family member friends who are at other places and that's what really they feel lost is that there's no cohesive maybe plan. And they feel very anxious because they're hearing different things from different doctors. Whereas here we try to have the same for message. Example, yesterday I got a call from Dr. Malhotra on a mutual patient and she had a scan and it showed something and the discussion was about was it going to be different kinds of systemic therapy or is it going to be radiation? So I appreciate those conversations because when I see that patient next time I already know I spoke with Dr. Malhotra, I can share that with that patient. And then the message is very clear that the treatment should be a second line therapy and then radiation will be as a fallback option versus some other patient they may be the other way around. So I think there's just a lot of behind the scenes work that helps a patient get the best care and we try to get that done as much as possible within our cancer center.
Darrin Godin: Yeah. Well, thank you for bringing that up. I mean, that is obviously the benefit of coming to a cancer center like City of Hope, where it is all on one campus or under one roof, where people are talking to each other and coordinating with each other for the best outcome for the patient. Here on our campus in Irvine for City of Hope Orange County, later this year, as you know, we're going to be opening our cancer specialty hospital and that will be Orange County's only hospital totally focused on cancer patients and delivering the care that cancer patients need. What do you think will be one of the benefits of completing that continuum of care for cancer patients here in Orange County?
Dr. Percy Lee: Yeah, Darrin, I think it's really exciting. As you know, it's always been part of the vision to have this cancer hospital and it's coming to fruition, as City of Hope has promised. And I think for us as practitioners or leaders in our specialties, we want to be able to help complex patients, inpatient and also outpatient. Most care is done in the outpatient setting, but there are certain situations where the patient gets sick and they need to be hospitalized and they're still getting radiation therapy. With the hospital, it allows us to continue that radiation therapy without a treatment break, which is important in their big picture because sometimes a treatment break can compromise their outcome. So I think having the hospital allows us to just take care of more complex patients that may require occasional hospitalization.
And there are situations like surgeries and transplants that are going to happen in our cancer hospital where radiation may be a part of the treatment down the line. And as radiation oncologists, we're excited to be able to partake in that care by talking to that patient. Again, going back to explaining what the overall treatment paradigm will be, and then more seamlessly bring them back to the outpatient setting when it's time for their radiation therapy. And third, I would say there are patients that are admitted because they're having cancer related symptoms, cancer related pain due to their cancer. And that's where radiation can help a lot in the inpatient setting. A short course of five treatments, even one treatment of palliative radiation can really help a patient who has painful lesions in the bone or potentially a bleeding cancer that could help by radiation therapy. So there's also that service complexity that we can offer for our inpatient cancer patients when the hospital opens.
Darrin Godin: Well, that's fantastic. So I mean that really means if they were going to a community hospital for something else and they had that break in treatment, now they won't have to have that. They'll be in one place and they'll receive the level of care that, frankly, we're able to deliver because we understand the unique needs of cancer patients that perhaps a community hospital may not know or may not think about at the time, right?
Dr. Percy Lee: Yeah, agreed, Darrin. I think it's not something like our community hospitals would necessarily feel comfortable taking care of. I get messages from colleagues and they're really excited for us to have a cancer hospital here because they're just patients that really either unique kind of cancer type or very complex cancer situation, where a cancer hospital is probably the best place for that patient to get their care in a consistent, in a way that we can serve.
On the same flip side, because we're only focused on cancer, Dr. Kim says the same thing, we do need our partners in the different hospital because we are not going to be able to have experts that, say, in neurology, I'm just saying an example, maybe we will, maybe we won't. But that's where we need to partner with our experts in the community to still take care of non-cancer or non-oncological specialty needs where our partners in the community hospitals will really help us. So I think we all have a niche. Our niche is we really are experts in cancer care and really high level experts from the doctors, the staff to the whole team. Whereas we can leverage and work with other specialists who can take care holistically, the patients' other needs as well.
Darrin Godin: Well said, well said. Well, Dr. Lee, I'd like to close out our conversation with asking you a question about hope. What does hope or the concept of hope mean to you?
Dr. Percy Lee: Thank you, Darrin. I think that's a very important word. It's part of City of Hope. I guess, to me, hope means giving a patient a sense of optimism, but it has to be grounded in science, compassion, and reality. And it's not just wishful thinking, I would say. It's showing patients that we have expertise, the technology and the team to help them face cancer with confidence. And when it's someone who's frightened with a cancer diagnosis, then we can look them in the eye and say, "You're not alone and we have a plan to help get your life back to where it was before." And to me, that's what hope means.
Darrin Godin: Awesome. Thank you so much, Dr. Lee for your expertise. Thank you for your compassion. Thank you for your care for our patients, and thank you for your leadership across City of Hope Orange County, and across our entire system. We really appreciate everything you do for our patients.
Dr. Percy Lee: Well, Darrin, yeah, that's appropriate. But also I want to thank you for giving me the opportunity to share what radiation oncology is helping our patients. And all the things that you said, we're very proud to be here, happy to serve our patients, excited about the future for our Orange County patients, that we are kind of taking it a step further in offering comprehensive care to people that need it.
Darrin Godin: We hope you enjoyed that conversation with Dr. Percy Lee. City of Hope Orange County continues to lead the way in ensuring that our patients have access to an array of the most advanced radiation oncology technology available and the nation's leading experts in the field. We are top ranked cancer care in the nation available to patients right here in Orange County, where we are pursuing cancer cures at the speed of life. Visit us at cityofhope.org/oc for more information or to schedule an appointment and give us a call at (877) 541-4673. I'm Darrin Godin. Thank you for joining us on Talking Hope and we'll see you next time.