Investigating Breast Cancer: Dr. Lawrence Shulman

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Chris Riback: I’m Chris Riback. This is Investigating Breast Cancer, the podcast of the Breast Cancer Research Foundation and conversations with the world’s leading scientists studying breast cancer prevention, diagnosis, treatment, survivorship, and metastasis.

Did you ever think you’d end up working in Africa?

Neither did Dr. Lawrence Shulman. But then we never had Paul Farmer as our intern. Dr. Shulman – an oncologist who specializes in breast cancer – did.

Farmer, if you don’t know, is the American anthropologist and doctor who in 1987 co-founded Partners in Health, an international non-profit that, in its own words, brings “health care to the world’s poorest families.” That means in places like Haiti and Rwanda.

Which is why some eight years ago, Shulman found himself in Rwanda, as he wrote, walking “through hospital wards filled with patients with advanced cancers, who had never had a biopsy or diagnosis, and had no options for treatment.” He continued: “I knew that many of these patients would survive if they had access to the types of treatments available in the United States, and I was determined to help bring these treatment options to patients in Rwanda.”

And that’s what Shulman has done. He has helped establish cancer programs there and in Haiti, and now has branched out to Botswana – places where, historically, because of delayed and late-stage breast cancer diagnoses, the chance for a successful outcome was greatly diminished.

Shulman and colleagues have now trained nearly 200 rural health center nurses in clinical breast exams and evaluation, nearly 2000 community health workers in the basics of breast awareness and patient education, and multiple district hospital clinicians in breast ultrasound. As you’ll hear, the work is remarkable, and the results outstanding.

More on Shulman: He is Deputy Director for Clinical Services, and Director, Center for Global Cancer Medicine in the Abramson Cancer Center at Penn. He is the former Chair of American Society of Clinical Oncology’s Quality of Care Committee, and currently is a member of ASCO’s Global Oncology Leadership Task Force and International Affairs Committee.

Chris Riback: Dr. Shulman, thanks for joining me. I appreciate your time.

Dr. Lawrence Shulman: Thank you for having me, Chris.

Chris Riback: Let me start with congratulations. You recently were given the American Society of Clinical Oncology’s 2019 Humanitarian Award. That’s quite an honor and, my guess, given what you do for a living, the Humanitarian Award in particular must be meaningful to you.

Dr. Lawrence Shulman: Well, I’m very humbled by the award, frankly, and honored that ASCO has chosen to award it to me this year. I will say, right from the start, that there are many, many people who are my partners in the work that I do in Rwanda and Haiti and elsewhere. They should be probably be getting the award, not me. But I’m very grateful to be getting it on behalf of myself and my team.

Chris Riback: It’s not every day that one comes across a physician, researcher, or scientist who is active, as you just mentioned, in improving breast cancer outcomes in Rwanda or Haiti or elsewhere. But that’s not the beginning of your story, while I fully expect that the bulk of our conversation will focus on your work in those locations. Your career in research includes development of new cancer therapies and implementation of cancer treatment programs in low-resource settings. I really focused on that low-resource setting.

Chris Riback: What inspired you in the first place to focus on that area, and what did that mean historically? Were you historically U.S. focused in terms of low-resource settings?

Dr. Lawrence Shulman: Sure. I’ve been doing this for a long time. I’ve been caring for breast cancer patients now for over 40 years, and I still remember what it was like in the 1970s and how radically it’s changed over the last four decades. A lot of which really is credited to the vision and the support of BCRF and the types of research that they’ve funded and allowed us to make the progress that we have. For most of that time, or a lot of that time, my focus was on developing new therapies in the U.S. Things were pretty crude in the 70s. Over these decades, they’ve gotten better in several respects. One of which is that the cure rates are much higher now than they were then. But also, the therapies leave women with a much better quality of life now than they did then.

Dr. Lawrence Shulman: So, there have been a lot of advances. But in the early 1990s, one of my interns on the oncology service at the Brigham and Women’s Hospital in Boston was Paul Farmer, who has made his career doing global health, first in Haiti and then in Rwanda and other locations. Paul and I became friends. As he and his colleagues got better at treating things like HIV and tuberculosis and malaria, patients were living longer and living to get cancer, and cancer became a bigger and bigger problem in places like Haiti and Rwanda. In the late 2000s, he and Jim Kim, who has been his partner is a lot of this work, called me up and asked me to build cancer programs in Rwanda and Haiti, and I said, “Yes.”

Dr. Lawrence Shulman: It occurred to me at that time that the great advances that we had made in the US and the benefit that women derive from those advances were just not available to many other people in the world. When we got to Rwanda in 2011, there was not a single oncologist, not a single cancer doctor in the entire country. There was really no cancer care in the country, so that if you developed breast cancer, you were certain to die of it. I’ve heard that story over and over again from patients over the years. So we really started from scratch. There was no healthcare infrastructure that was trained to detect women’s breast cancers at early stage, and there was no treatment for surgery, chemotherapy, hormone therapy, and so on. Over these subsequent years, we’ve put all those in place.

Dr. Lawrence Shulman: Again, a lot of the progress that we’ve able to make in Rwanda has been due to funding from BCRF. They’ve helped us to build care teams and research teams that have figured out the best interventions that we could use in these types of locations to bring patients in at earlier stages of disease where our chances for a cure would be much greater. We’ve already seen those benefits, even over this short period of time.

Chris Riback: Yes, and I want to ask you about those benefits and, in particular, some of the decisions and implementations that you’ve made. As I was reading some of your writings and about the various work that you and Paul Farmer and Partners in Health and others have done in low-resource areas, the thing that’s particular disturbing to me … And I assume to you, as well, and to many others. These women don’t necessarily get the disease at higher rates. However, the lack of screening and follow-up increases the chances that they will be diagnosed with advanced breast cancer and may not get quality treatment. Isn’t that right?

Dr. Lawrence Shulman: That’s absolutely correct. We actually studied this, again with support from BCRF, early on when we got there. We didn’t make any assumptions, and we wanted to better understand why women were coming in with such advanced cancer, which is just must less amenable to curative therapies. It turned out that it was more complicated than we thought. I mean, certainly women were not coming in as early as they might when they discovered that they had a breast lesion. In fact, we shouldn’t have expected them to, because they grew up in a scenario where there was no breast cancer care, so why would they bother going to the doctor if they discovered something?

Dr. Lawrence Shulman: But the other thing that we discovered, which should not have been a surprise for similar reasons, is that once they got to one of their community health centers, that the clinicians there, the community health workers and the nurses, did not recognize breast cancer. They didn’t understand what was going on. They had never been trained in it. And again, they probably shouldn’t have been trained in it, because there was no breast cancer care, so there was no reason to. But they were not trained in it, so they basically didn’t recognize it. They sent the patients home. The patients eventually would return, and eventually would get to our cancer center, but very late on in their disease.

Dr. Lawrence Shulman: With BCRF support, we’ve developed a program of education, ultrasound usage, and other technologies within the health centers in Rwanda. We started with half a dozen of them, and we’ve now been expanding across the country. The providers, community health workers, and nurses were actually thrilled to learn about breast cancer. They really didn’t know what was going on, and they obviously want to help their patients. What we’ve seen has been dramatic. That between an increasing public understanding that there is treatment for breast cancer and women coming in to the health centers earlier, and the clinicians in those health centers understanding what was going on, being able to detect breast cancer, the patients are coming in with much earlier disease that’s much more curable. Again, over really a relatively short period of time, we’ve been able to change the paradigm. And again, that’s really with incredible support of BCRF.

Chris Riback: And in your history, let’s say the first 20 years, the 70’s until all of a sudden a kid named … a young man named Paul Farmer ended up as your intern, a course that really impacted both of your lives. And the work that he’s done, obviously, in so many areas is really just quite amazing and widely recognized. What did low-resource areas mean for you? Was that perhaps the neighborhoods in Boston or other areas in the U.S.? Is that what a low-resource area meant to you at that point? Or was international always part of your repertoire?

Dr. Lawrence Shulman: International work was not always part of my repertoire, quite frankly. I think that when I got into medicine in the 70s, it was a very exciting time for cancer. Richard Nixon had declared his war on cancer when he was President, and so on. But our entire focus was on the U.S., was developing new treatments here. It was not in my consciousness to think about places in other countries. And I was in Boston at the time. We did think about the underserved areas of Boston, and I subsequently thought about a lot of the underserved areas in the U.S., a lot of places like Eastern Kentucky and Appalachia, and Navajo Nation and others. Other areas in the U.S. actually don’t have very good access to high-quality cancer care, and that is a problem.

Dr. Lawrence Shulman: We have lots of people trying to address that. And in fact, Partners in Health has a program in Navajo Nation trying to do that in the Southwest. But there are plenty of places in the U.S. where we’re not doing as well as me might like. One of my other roles is as Chair of the Commission on Cancer, which is the national organization that accredits hospital cancer programs and has the largest cancer database in the world actually, with 37 million patients in it. We can show out of that database that there are major discrepancies in care and outcomes for our cancer patients across the U.S.

Dr. Lawrence Shulman: I will say that there are common themes. Poverty influences people’s ability to partake in healthcare, particularly to seek healthcare when they’re not desperately ill because they have other competing needs and concerns. So, what we’ve learned in Rwanda actually, to some extent, helps us to think about how to do things better in the US, as well.

Chris Riback: Yes, that’s incredible. And yes, sadly, there is no lack of low-resource areas, whether that’s in the U.S. or outside of it. The moment that I’m really finding myself curious about is … So here you are, doing your thing, helping women as best you can, and working in these areas. And I guess, Paul Farmer had started some of his work, I’m assuming, in Haiti. Did all of a sudden one day he called you up and say, “Hey, it’s your former intern.” Which I’m sure you were keeping in touch, obviously, already. “Have I got an idea for you. Why don’t we go to Rwanda?”

Dr. Lawrence Shulman: Well, the Rwanda story is interesting. I will just back up a little bit. When Paul was in Haiti in the 90s, and he was primarily focused on infectious disease, but we did become good friends. I was in Boston. If he had a patient who came to his clinics in Haiti with cancer, he’d call me up. If it was a patient who we thought we could help, we made a plan, actually often got him chemotherapy to bring back to Haiti and to treat the patient. So we kept in touch, and we took care of a patient here and patient there over the years.

Dr. Lawrence Shulman: But as I mentioned, in the late 2000s, he asked me to consider developing cancer programs in Haiti and Rwanda, and that was the time that he got involved in Rwanda. And that was, to some extent, actually based on former President Bill Clinton’s relationship with Rwanda and with President [Paul] Kagame, the President of Rwanda. President Clinton and Paul are friends. With a developing conversation about this, eventually Paul made a commitment to start the work in Rwanda, as well. Shortly thereafter, I got involved.

Chris Riback: How aware were you of its history, politics, geography? I mean, Rwanda was just exiting … There was war with Burundi in the late 90s if memory serves. Were you aware of Rwanda and what was going on there?

Dr. Lawrence Shulman: Well, they had their terrible genocide in 1994, and I think that was the defining moment for the country. I think, since then, they’ve done remarkable things, and they’ve really pulled themselves out of the ashes, so to speak, and built a very, very strong society. It’s a wonderful society. I love my colleagues and my friends in Rwanda, and I’m amazed at what they’ve done. This is the 25th anniversary of the genocide. In a relatively short period of time they’ve become, I think, one of the most rapidly developing, in a very positive way, countries in Sub-Saharan Africa.

Dr. Lawrence Shulman: They are in the midst of crises all around them. They border with Burundi and with the East Congo and other areas which are challenges. Right now, as I’m sure you know, there’s an Ebola outbreak in the East Congo, which literally abuts western Rwanda. So, yes. There are forever challenges in these areas, but I think President Kagame has been an incredible leader. He’s partnered with people like Paul Farmer. The whole country has been a wonderful partnership in all of this work, and I feel very privileged to be there and be a guest of the people of Rwanda.

Chris Riback: I’m sure. In looking at the picture, the transformation is remarkable. Do you remember the first time you walked through Butaro Hospital? How do you even imagine the changes that have occurred in a location like that and in terms of the care over the time that you’ve had the privilege? I’m sure you see it as a privilege, the privilege of getting to work with your colleagues there.

Dr. Lawrence Shulman: Butaro Hospital is relatively new. It opened actually in 2011. We put our cancer program there for a variety of reasons, one of which was it was a relatively new physical plant, and it was outside of the capital city and was a little bit more protected from the pressures of healthcare in Kigali, which is their capital city.

Dr. Lawrence Shulman: The ministry hospitals in Kigali are very, very busy to say the least. The first time I went there in 2011, I walked through the wards of their main ministry hospital in Kigali. It was a site that I could never have imagined. The staff was working incredibly hard, but the beds were all lined up and pushed against each other. There was little room for the patients or the families. They didn’t have much in the way of facilities to actually diagnose or treat patients. And, as I mentioned, there was no cancer care. So they were doing their best with the infectious diseases and maternal and child illnesses, but it was a very discouraging sight in spite of how hard and how skilled the staff was.

Dr. Lawrence Shulman: In the last eight years, it’s changed radically. The hospital has been built up and strengthened and has more modern facilities in it, laboratories and so on. And the care there now is much, much different than it was in 2011. But it was a tough situation. They are doing the best they can, but you don’t go from zero to 60 in a minute. I think their progress has been incredibly quick when you look at the long view of it, but it’s an ongoing phenomenon.

Chris Riback: What are the cultural challenges? Not having been there myself, is breast cancer something people will discuss? Are there cultural taboos around it? Or it was simply a lack of knowledge once upon a time, and you’ve been helping there? What are the cultural challenges?

Dr. Lawrence Shulman: Every country is different, and the cultural challenges are different. I know this even from the few countries that I work in. One of the interesting things about Rwanda, and there are recent books that have been published about this, is that women in Rwanda are held in very high esteem at all levels. Paul Farmer’s wife, Didi Farmer, actually wrote an essay on this … She’s Haitian. She grew up in Haiti … about the differences in how women were looked at in Haiti and Rwanda. And in Rwanda, they are esteemed. Many of the high-ranking officials, including the current and previous ministers of health of women, and women are respected greatly within the home.

Dr. Lawrence Shulman: So there’s not the stigma that we see in many countries where women are denigrated because they have a mastectomy, they lose a breast to breast cancer, and they’re considered scarred and not worthy. That does happen in many locations around the world, but it does not happen in Rwanda. The people are wonderful, and so we can have very frank conversations with the patient, with her husband, with other relatives, the children. We can give them the treatment they need and not jeopardize their wellbeing. That’s not the case in many other countries.

Chris Riback: To close out … as you pre-warned before we started this conversation, I heard the Amtrak whistle in the background. I assumed that that was a subtle way to tell me, “Wrap this thing up, Riback. Doc’s got to go.”

Chris Riback: In terms of the results and translating the results into next-stage plans … You’ve talked a little bit in this conversation about the results. How, in the highest levels, would you characterize them? Without wanting to give the sense that folks aren’t grateful for everything that you’ve done so far, what’s next?

Dr. Lawrence Shulman: We have a lot to do, quite frankly. What we did with the support of BCRF is we went into the community health centers near our cancer center, which is in northern Rwanda. Rwanda has a very structured healthcare system. It’s got 500 community health centers throughout the country, and that’s the primary entry point for patients. That’s where patients go when they don’t feel well or they have a concern. We were able to show, going into the health centers around our cancer center, that we could change the way breast cancer patients were managed, much to their advantage, increasing their chances for cure. The government, the Ministry of Health, has now come back to us and said, “This is unbelievable. Thank you so much. Now, help us to figure out how to do this throughout the rest of the country.”

Dr. Lawrence Shulman: So one of the Rwandans who have been helping us to run this program based at our hospital at Butaro was hired away by the ministry, which we actually thought was a wonderful idea for them. He’s a tremendous colleague, but extraordinarily skilled and experienced. So now, we’re working with the ministry to try to scale this up across the country. That comes with a responsibility, which is that if in fact you find patients with breast cancer, you need to be able to treat them. Our program is still really the only functioning cancer program in the country, though we’re starting to develop a second site in Kigali together with the ministry. But we need to be able to scale up our ability to care for an increasing number of breast cancer patients. So we did a small experiment with BCRF’s help. We were able to show that, in fact, it was successful and that we could impact women, and many women are walking around alive now who would otherwise not be, and we need to scale up and expand.

Dr. Lawrence Shulman: One of the things that Margaret Flowers asked me the other day was, “What would happen if the BCRF funding wasn’t available?” These programs would not thrive. The end result of that is quite clear, which is women will die. It sounds very crude, but the reality is these are the only options these women have. In the U.S., if our hospital shut down, there’s another one down the block. That’s not the case here, so lives are on the line. It’s one of the reasons I keep going back to Rwanda. It’s because when you go there, you realize that in fact you have given women a chance to survive their breast cancer that they didn’t have before. The funding from BCRF has been critical in allowing us to do that and attain any success that we have up to this point, but there’s still lots of work to be done.

Chris Riback: Would you ever have imagined that this is where your career would have left you, or led you? I don’t if you grew up always imagining that you would be a researcher or physician, scientist, but I can’t imagine that … Did you ever imagine that you would be doing it in Africa?

Dr. Lawrence Shulman: I really did not. If you would have told me that 40 years ago, I would have looked at you mystified. As at Harvard, tremendous resources and trying to make a difference in cancer care. But the thought of going outside of the U.S., and particularly to a place that was so resource poor with really no cancer care when we got there, was unimaginable to me at the time. Very frankly, it was my relationship with Paul Farmer that got me to understand that part of our responsibility was to share what we learned and what we were able to do here with a multitude of people around the world who, up to this point, have had no such options.

Chris Riback: Dr. Shulman, thank you. Thank you for your time. And obviously, thank you for the work that you do.

Dr. Lawrence Shulman: No, thank you very much for your interest and giving me the opportunity to chat with you, Chris.

Chris Riback: That was my conversation with Dr. Shulman. My thanks to Dr. Shulman for joining and you for listening. To learn more about breast cancer research or to subscribe to our podcast, go to bcrf.org/podcasts.