David B. Agus M.D.

One of the most respected and best known oncologists in the world is doctor David Aegis. He leads the Ellison Medical Institute at the University of Southern California, where he's also a Professor of Medicine. I had a chance racing to sit down with him to talk about the high incidence of cancer now and how one treats cancer in modern life. Cancer has been around for thousands of years. How does one get cancer? Is it genetic? Is it a behavioral or environmental?

Yes?

Yes, and yes so there certainly are what we call genetic predispositions. There's a several dozen genes that if you inherit a faulty copy of it, your risk of cancer is dramatically higher than the average population.

But 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.

Has it.

Nixon said that we're going to have a war on cancer when he was president, and that was more than fifty years ago. Have we really made progress in combating cancer in the last fifty years.

The answer is we've made tremendous progress, but it's not enough. So we now have immunetherapy right your 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 can potentially use a pill to target a molecular alteration or an on switch in his 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 take whether you have cancer or not.

So 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 one centimeter cancer is still many one hundred million cells. So it has yet to be proven that using anology like that with the exceptional 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 cancer 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.

Now, 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. 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.

Now I've been told that the cancer that is the most survivable is breast cancer if detected in stage one I think a ninety eight percent survival rate or something like that, 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 biopses, too many prostate surgeries, and too many reiation.

And that's true.

So finding a cancer doesn't necessarily mean you need to treat it, which I know which is a weird statement. But there are many cancers, some indolent prostate cancer, indolent thyroid cancer, some indolent breast cancer, so that don't necessarily need aggressive treatments but can be followed. So we call that active surveillance. So we need to develop better guidelines,

Now, some people say that the incidence of cancer, which is to say people getting it is higher than it was twenty or thirty or forty years ago. Is that because detection is better than it used to be.

All 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 twenty thirty forty year olds that we never used to see.

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 its diet, it's ultra process foods, it's microplastics, it changes in the microbiome. We really don't know until we start to collect data we can, 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 were 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. The age of colon cancer screening dropped from fifty to forty five 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 check up, and what else can you do well?

I think there's a cadre of blood tests. You should get an irregular cadence.

I think that you need to talk to your doctor about potential medicines that can lower risk. Things like aspirins, statins and other things can lower cancer risk in the right individuals. If you have a family history or others, and 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

Well, should everybody get their geneme tested or because is it expensive to do that?

You can look at all the cancer risk genes for about one hundred dollars in today's world, and I think it's important.

Knowledge is power.

Okay, Remember the generation before us, if they had cancer was considered a sign of weakness, and many never talked about it. So getting a real accurate family history sometimes is really hard.

I've been told that if a man lives long enough, he will get prostaate cancer. Now, if you're eighty 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 prostaate cancer.

So there's no question that the indulin prostate cancers are very common. If I walk through the streets of New York City and bib seed everybody over sixty, I'd find, you know, thirty five or so prostate cancers.

But 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. They kind of minimize some of the adverse effects of a prostate surgery. Is that a good thing to do? If you're going to prostate surgery? Have this kind of procedure. It's done by a computer and it's a robot. I guess i'd should say that does the actual surgery.

Patrick Walsh was a rock star.

Patrick Walls was a young urologist at Hopkins who at the time people took out the whole prostant and the problem is the nerve looked like the prostate tissue. So they were taking out the nerve and they had continence problems.

Impotency problem and 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 develop what's called the nerve sparing prostatectomy and started to pioneer that approach. Now with a robot, we can go on through 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 on 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 the same day.

So I know you do things other than on college sheep and tell us what does the Ellison Institute do.

We are at Technology Application Institute, so we develop 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'll go into the clinic next year. We have a breast cancer molecule that we're made with AI.

Now I am now seventy five years old, and when you get to be seventy five, 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.

So one of the largest studies ever done in Europe, what they showed is every year you delay retirement, you reduce the incidents of Alzheimer's by three percent.

So it's the old adage you don't use it, you lose it.

So keeping your brain engaged making yourself uncomfortable, which 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. Our famous patients are more difficult to deal with than the average person because they have big egos, or they're easier to deal with because they just say, take care of this problem and I'll trust you.

They'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 care of him, he goes, you need to do me a favor and I want you to come to my house.

And I go, okay, thinking we're going to discuss his case and what's going on. And what he did was he had his whole family sitting in 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. So where were you born?

Baltimore, Maryland?

Balmer as they call were 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 Saint 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. I was one of two boys in the school. Then we went to Philadelphia, and then I went undergraduate to Princeton and med school at University of Pennsylvania, and then internship in 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 ten 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, and 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 two hundred and fifty.

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. So I'd be 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, Oh, 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 corts. All the stress hormones go up, You lose productivity, your metabolism goes down, you gain weight. It's

Well, you have two children. Were you able to convince them to go to medical school?

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? Shouldn't everybody take a statin? There for a certain age, they.

Are remarkable drugs lowering LDL, which is a surrogate 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 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.

What about red meat. I don't eat red meat, but I don't know why that's going to make me live longer or not. Is red meat healthy for you?

Well, in a large study in Europe, they show that three servings a week.

Had no health detriment.

There is a health benefit in several studies with grass fed beef.

So it's the key is moderation. Don't eat process meat. People who had processed meat every.

Day for twenty years had about a twenty percent increase in colon cancer. So yeah, if you have a hot dog a day for twenty years, it can increase colon cancer. So I probably wouldn't do that, but a moderation it's fine.

I don't drink alcohol either. Is that going to make me live longer?

Not necessarily.

Again, the warnings on alcohol, So 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 a krylamide 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 ten or fifteen or twenty 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 pray a little.

Bit, and consider heart imaging. Okay, figure out where we are, where we're starting from.

Look at all you be up to date with all your vaccines, which is critical. Make sure that regular blood values are on 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 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 sixty, sixty five, seventy, Where do you see it? Based on your pages that are 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 happened.

At age forty three in age sixty, so.

That's when you know medical issues change the most forty three and sixty 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, and that's not a good thing.

So I guess the most dangerous words in 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 one hundred, but they're really have a lot of physical and mental problems. But you think we can ever get to people living to one hundred and actually have the physical and mental abilities of somebody who's eighty or seventy.

One hundred percent. 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 nineteen sixties was the last time in the United States you can die with the cause of death being old age on a death certificate. Now 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 with out people are saying I got this pain here, I got this pain here. What should I do about you? Ever get that?

I get that constantly and again?

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 is that it takes two seconds of my brain time to help them, and the benefit to.

Them can be very signifant.

So 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 in ten 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 of selling nad and vitamins and supplements, all of them promising you the fountain of youth. Every single one of them is of fraud. And I think the important to say that there 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

Well, what do you most enjoy about the profession you have. It's helping other people solving these problems that are 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 failed conventional treatment. So I get to think out of the box, look at all of the data, and come up 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

There aren't many of us left in.

The world, and to be able to do 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, whether 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 whatever it is hard. Back when I did it it seemed easier. I probably would still going to medicine.

I love it. I pinched 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