Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on old episodes!

We welcome Kevin L. Schewe, a radiation oncologist, as we explore the evolution of cancer treatment from the perspective of someone who has witnessed groundbreaking advancements firsthand. From the significance of targeted therapies in improving patient outcomes to the transformative impact of cutting-edge technology like the radiation linear accelerator, Kevin sheds light on the intricacies of modern cancer care. We’ll also discuss the role of multidisciplinary teams, the importance of minimizing side effects, and the ethical considerations surrounding access to advanced treatments.

Kevin L. Schewe is a radiation oncologist.

He discusses the KevinMD article, “Evolution of targeted cancer therapies: a radiation oncologist’s perspective.”

Our presenting sponsor is Nuance, a Microsoft company.

Together, Microsoft and Nuance are leveraging their rich digital technology and advanced AI capabilities to tackle some of health care’s biggest challenges. AI-driven technology promises to revolutionize patient and provider experiences with clinical documentation that writes itself.

The Nuance Dragon Ambient eXperience, or DAX for short, is a voice-enabled solution that automatically captures patient encounters securely and accurately at the point of care. DAX Copilot combines proven conversational and ambient AI with the most advanced generative AI in a mobile application that integrates directly with your existing workflows.

Physicians who use DAX have reported a 50 percent decrease in documentation time and a 70 percent reduction in feelings of burnout, and 85 percent of patients say their physician is more personable and conversational.

Discover AI-powered clinical documentation that writes itself. Visit https://nuance.com/daxinaction to see a 12-minute DAX Copilot demo.

VISIT SPONSOR → https://nuance.com/daxinaction

SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://earnc.me/1T7xmH

Powered by CMEfy.

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Kevin Schewe. He’s a radiation oncologist. Today’s KevinMD article is “Evolution of targeted cancer therapies: a radiation oncologist’s perspective.” Kevin, welcome to the show.

Kevin Schewe: Hey, it’s great to be here with you, Kevin. We have two Kevins today.

Kevin Pho: All right. So let’s start by briefly sharing your story and journey.

Kevin Schewe: Yeah. So I’m originally from St. Louis, and I went to Marquette, what used to be Marquette medical school, training for radiation oncology, and entered private practice July 1st of 1987. So I am literally in my 37th year of practicing radiation oncology full-time.

And if you think about the evolution of all of cancer care over the past 30 years, it’s really all about targeting. Because the goal of cancer treatment in 2024 and beyond is to take care of the cancer and cure the patient, but to do that without causing undue harm to the patient.

So I frequently tell my patients, the ones that I know that we’re treating for cure, that our goal here is to cure you of this cancer so that you have an opportunity to live to die of some other cause.

And so it’s the targeting of cancer treatment that has changed my world as a cancer specialist. And of course, we have so many new drug treatments now that are targeted to cancer, but my job is to target radiation treatment. And that has gone through an evolution of, you know, the Apollo space program compared to going to another galaxy. I mean, it’s like the Star Trek of cancer treatment now in oncology.

Kevin Pho: I have to admit, a lot of physicians aren’t really familiar with the day-to-day of what a radiation oncologist does. I have some medical students who just simply ask me, what is radiation oncology, what do they do? So just walk us through a typical day. What would be some common cases that you would see?

Kevin Schewe: Well, I treat all adults with cancer. And so in radiation oncology it’s really a lot of solid tumors that we treat. So we treat breast cancer, lung cancer, head and neck cancer, colorectal cancer, brain tumors, any tumor that has spread to another organ, like bone metastases or brain metastases. But really my day is taking care of adults with cancer.

And one thing, if you were my student, Kevin, I would tell you that our job as a radiation oncologist is really very much like the surgeon’s job. So a surgeon goes in to cure a patient surgically, the surgeon has to go in and remove the tumor and a rim of normal tissue around it and take that out cleanly to cure the patient. Well, radiation also has to treat that tumor with a rim of normal tissue around it to ablate it.

So what radiation does is, it damages DNA, which is the reproductive molecule of all cells. And that’s why targeting is important, because radiation damages good DNA as well. But good DNA, normal tissues, are able to repair the damage in between radiation treatments, whereas tumor tissues, that damage accumulates over time. So the cell tries to divide in the future and it dies, so we call it post mitotic death.

But at any rate, the only reason that radiation ever fails is either you missed the target, or you didn’t give the target enough radiation. I mean, there are very few examples of tumors that are totally resistant to radiation.

So what we do in radiation is very much like a surgeon, we have to know anatomy and we have to hit the target. One of my favorite quotes that I use, and this is one I taught my daughters and my grandchildren, is that he who aims at nothing hits it. And it’s a life principle, but it’s also a great principle if you’re a radiation doctor, because to cure the cancer you have to make sure you hit the target.

Kevin Pho: Let’s talk about your KevinMD article, “Evolution of targeted cancer therapies: a radiation oncologist’s perspective.” For those who didn’t get a chance to read your article, tell us what it’s about.

Kevin Schewe: So back in 1987, when I first started as a radiation oncologist in private practice, we were treating with linear accelerators, but, for example, if we were treating a pelvic tumor, we’d be coming in from both sides and from front and back. So kind of imagine four fields coming in to treat a tumor. Well, the normal tissues in that are all getting somewhere between 25 and 50 percent of the dose that you’re giving the tumor.

And so, flash forward to 2024, now our equipment, I use a Varian TrueBeam, which I have no association with Varian, I think it’s the finest equipment on earth. It has 120 tungsten leaves, 60 on each side of the field, and every one of those leaves is controlled by an individual computer controlled stepper motor. And so they’re sliding through the field to shape the radiation field to the shape of the target inside the body.

If you look at my face as I’m looking at you, I’m shaped this way. If I turn like that, I’m shaped that way. So inside your body, it changes shape from the perspective that you’re approaching it. So the machine does a 360 degree arc, it can shoot radiation every two degrees as it’s coming around.

And so the normal tissues are all getting, let’s say that we shoot from a hundred different angles, they’re all getting 1 percent of the dose. It’s where all those little beams of radiation are intersecting in space that get 100 percent. And so that is what I mean by targeting.

And then also we’re able to literally image the tumor while we’re treating, so if there’s motion with breathing, we can actually account for that. And the physics of being able to do that is nothing short of miraculous.

Kevin Pho: Now, how does that translate to improved patient outcomes and fewer patient side effects?

Kevin Schewe: You know, I love this question. So I want to use the example of lung cancer. So nowadays we do what we call stereotactic body radiotherapy for lung cancer, and it consists of five treatments given every other day. The old way of treating lung cancer would be Monday through Friday for seven weeks along with chemotherapy. The new way is to give five treatments basically over one to two weeks.

And so the old way, of giving it over seven weeks, we were curing 30 to 40 percent of our lung cancer patients. Now we’re able to put six or seven weeks of radiation treatment into a lung tumor over five treatments, and it literally ablates that tumor. And so the control rate for that is now 90 percent, give or take. And so it’s more than double the cure rate, and it does it in such a shorter period of time.

And really the only effect, and I don’t want to sound Pollyannaish about the side effect, but all the patients are going to have some degree of fatigue that goes away in two to four weeks. But we’re turning that tumor to scar tissue, and we call that a side effect, but really, if a surgeon operates on you, you’re going to have scar tissue.

Kevin Pho: Now, the technology that you’re talking about, is this pretty much the standard of care today? Do all patients in the United States have access to this targeting technology that you’re talking about?

Kevin Schewe: The answer is yes, it is the standard of care, but it’s not available to everyone everywhere, because you have to be living in or near a hospital or a medical facility that actually has invested in the equipment that can provide this treatment. And of course you have to have the professionals that know how to use it.

Kevin Pho: So tell us, what are some of the next steps in the foreseeable future when it comes to the continuing evolution of oncology?

Kevin Schewe: Well, I think that I can imagine a day where the stereotactic treatment that I’ve just described to you is used for not just localized tumors but tumors that have spread to multiple areas of the body. Because there are new linear accelerator devices that look more like a CT scanner, and so the patient can be moved through and the radiation can be directed to multiple targets. And so I see a future where you’re combining targeted drug treatment with this very finely targeted radiation treatment, to take patients with what we call stage four disease and render them disease free.

Kevin Pho: Now, I want to talk about medical students who may be listening to this. Tell us what kind of students would lend themselves to a career in radiation oncology. What kind of characteristics, what kind of traits and interests should these students have if they’re considering a career in radiation oncology?

Kevin Schewe: So my major in college was biology with a minor in physics, and in school I was always great in math and physics, it just came naturally for me. And everything that we do in the world of radiation oncology obeys the laws of physics, and then it depends on how the physics of radiation interacts with the biology of living tissues.

And so I think that if you have that kind of mind, or you like physics, that would be a natural fit. But that said, it’s not a prerequisite to be a PhD person in physics or something like that.

I think that if you like the challenge of being a cancer specialist, which means that everything that you do changes up every three to five years, sometimes faster. And so I always tell students that rotate through our service that change in medicine is the only constant, and it’s true. I mean, even if you’re in primary care that’s true.

But in oncology you develop a relationship with your patients and their families, and so it is a relational field. And a lot of people will say, well, Dr. Schewe, isn’t that depressing, taking care of cancer patients every day? And I just say, I think it’s anything but that. Because cancer patients, they feel like death has visited their doorstep, and in today’s world that’s really not true. We are curing roughly 75 percent of the patients that we treat.

And so I think that anything that you’re able to do to help a cancer patient, they are so eternally grateful for that help. And so to me it’s extremely rewarding.

Kevin Pho: So I think, we were talking offline, is that you have a career outside of medicine as well. You’re also a published book author, a successful one at that. So tell us about this transition into a field outside of radiation oncology. What led you to become an author?

Kevin Schewe: Actually being a radiation doctor kind of provided the impetus. So I’m a World War II history buff, I mean it’s one of my hobbies. All of us doctors, I’m sure, Kevin, you probably have a few hobbies outside of medicine.

And so I read this story about the Phantom Fortress, which was a B-17 bomber in World War II that flew into Cortenbergh, Belgium, late one afternoon and landed all by itself, and there was nobody on board. Well, I’m not sure that’s a totally believable story, but it is in the annals of World War II history, it really happened.

And so I saw that and I thought to myself, man, time travelers could have been on that plane and got zapped back to the future before it landed, and they discovered that it was empty. Because those B-17s, they weren’t drones, I mean, they just didn’t fly themselves. And I thought, well, that would have been something that my neighborhood gang would have done.

And so then I thought, well, what could be the plot of that? And that’s where my physics background came in. And I thought, in World War II we had the Manhattan Project, and we had the movie Oppenheimer this last summer, and the Manhattan Project was for us to win the race to be the first country with the atomic bomb in World War II. I thought to myself, well, what if we wouldn’t have been the first country to get it? Did we have a backup plan? Because that’s what you do in oncology.

And so my theory, or my thesis, Kevin, was that Roosevelt had Einstein, well, Einstein was the one that sent the letter to Roosevelt to encourage him to be the first country.

So my thesis is, in October of ’42 Roosevelt invites Einstein to the White House, and he says to him that Hitler and the Germans might win the race to get the atomic bomb, which was true at the time, we were worried that we might get beat. And so, I’m commissioning you to build a usable time travel machine called the white hole project, that we will only use in the event that Hitler wins the race to get the bomb. We will go back in time and foil him. And I want you to build this adjacent to the K-25 plant in Oak Ridge, Tennessee, which is where we were processing plutonium for the first atomic bomb.

And so in 1945 we did get the bomb first, and so, no pun intended, but the white hole project gets lost in time. Until, in 1974, this group of rambunctious, ragtag teenagers calling themselves the bad love gang are out on a weekend adventure and stumble upon a tunnel that leads to the white hole project. And like any rambunctious group of 70s teenagers, they learn how to use it, and the adventure begins. And so they go back in time and they commandeer the Phantom Fortress on their first time travel mission.

And so that’s book one, that one’s called Bad Love Strikes. So it’s the bad love gang, Bad Love Strikes. And then there’s Bad Love Tigers, Bad Love Beyond, Bad Love Medicine, and right now I’m writing book five, which is Bad Love Rising. And I’ve written screenplays to Bad Love Strikes and Bad Love Tigers, and the Bad Love Tigers screenplay has won over 450 international awards, and it’s being considered in Hollywood right now by the studios. So we’ll see, you and I might have to meet again in the future to talk about these books being movies.

Kevin Pho: Absolutely. Always looking forward to publishing an excerpt on KevinMD. Now, as you reflect back on your almost four decade career in radiation oncology, is there anything that you would have done differently, knowing what you know now?

Kevin Schewe: It’s a beautiful question, because the reason that I, at my station and age in life, that I’m still practicing radiation oncology every day, is that I truly love it.

And I do want to transition, when I leave medicine, to the way that God created me. I’m not a guy that could buy a condo and live on a golf course and be happy ever after. I actually have to just be doing something where I’m building or constructing or whatever, it’s just the way that I’m made. And so I do want to transition into full-time writing when I leave medicine, but I’m not ready to leave yet, because I still enjoy taking care of cancer patients and it’s so incredibly rewarding. So I think there’s a future out there for those young doctors that might be listening to this broadcast.

Kevin Pho: We’re talking to Kevin Schewe. He’s a radiation oncologist. Today’s KevinMD article is “Evolution of targeted cancer therapies: a radiation oncologist’s perspective.” Kevin, as always, we’ll end with your take-home messages that you want to leave with the KevinMD audience.

Kevin Schewe: Well, I would just say that I write about time travel, and I’m in my 37th year as a radiation oncologist. Time goes fast, and the older you get the faster it goes.

And my theory about that is, when you’re five years old and you live another year, it’s like forever. You know, you’re in first grade, you’re waiting for your school picnic. But when you’re 50 years old and you live another year, it goes by in a flash. That’s because when you’re five years old, another year is 20 percent of your prior experience. And when you’re 10 years old and you live another year, it’s 10 percent of prior experience. You’re 50, it’s 2 percent of your prior experience.

So in relative terms, the older you get, time goes faster and faster. And I would just say, make the most of it, and find something to do that you really enjoy, because that’s really, I think, what makes you happy.

Kevin Pho: Kevin, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Kevin Schewe: You’re welcome. It was great to be here with you, Kevin. Thank you for having me.