May 13, 2021
In today’s episode, we celebrate Dr. John Sweetenham, outgoing Editor-in-Chief of ASCO Daily News after nearly a decade of service. He is also the associate director for Clinical Affairs at the Harold C. Simmons Comprehensive Cancer Center at UT Southwestern. This episode brings together Dr. Sweetenham and his longtime friend, and today’s guest host, Dr. Derek Raghavan, President of the Levine Cancer Institute. They discuss the luminaries who shaped Dr. Sweetenham’s career path, practicing oncology on both sides of the Atlantic, and editorial roles in oncology publications.
Transcript
ASCO Daily News: Welcome to the ASCO Daily News podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. We have a very special episode for you today to celebrate Dr. John Sweetenham, the outgoing editor-in-chief of ASCO Daily News after nearly 10 years of service. Dr. Sweetenham is also the associate director for Clinical Affairs at the Harold C. Simmons Comprehensive Cancer Center at UT Southwestern, and specializes in hematologic malignancies. We are honored to have his longtime friend and mentor, Dr. Derek Raghavan, in the host's chair today for this engaging conversation. Dr. Sweetenham and Dr. Raghavan report no conflicts of interest relating to today's discussion, and full disclosures relating to all episodes of the ASCO Daily News podcast are available at asco.org/podcasts.
Dr. Derek Raghavan: I'm Derek Raghavan. I'm the president of the Levine Cancer Institute, and really delighted to be able to help to note and to mark the retirement from a specific role with the ASCO Daily News of John Sweetenham, who has guided that ASCO publication for the past decade, and has guided it so well. I guess there must have been people at ASCO who weren't thrilled with John because they made me his interviewer for this session. And I think it is fair to say that John and I have been really good pals for many, many years. I had the delight of working with him at the Cleveland Clinic. And it gives me an opportunity to kind of review the many things he's done thus far in his career. And obviously, he's got so many more contributions to make.
One of the things that's been interesting, John, is the two of us are from other nations. We speak grammatically correct English, and that's allowed us to become quite good friends without correcting each other. But you started out in the United Kingdom. And perhaps you could just quickly review how you got started in oncology, and where you worked and the people that you thought influenced your career.
Dr. John Sweetenham: Yeah. So first of all, thanks for doing this. It's really great to have an opportunity to talk with you, and for it to go on the record for once, as well, which will be fun. You know, I started out in the UK Medical School in London at St. Bartholomew's Hospital. And quite what motivated me to go into medicine in the first place I still reflect on quite often.
And if I'm really, really honest with myself, I think it is that, when I was really quite young, there was a black-and-white American TV program that used to show in the UK--Dr. Kildare. Derek, you're probably not old enough to remember it. That was a sort of--I thought at the time, when I was, I don't know, 5 or 6 years old, that wow, that seems like that's a pretty cool job. And I didn't ever really think about doing anything else seriously. And so I sort of went through high school and so on, medical school in London. And while I was there, became interested in cancer really more at the level of just finding it sort of scientifically very intriguing, and the whole idea of this sort of loss of control.
And then once I was lucky enough to get exposed to clinical experience with oncology at Barth's Hospital, which, at the time, was actually the very first academic medical oncology outside of the Royal Marsden, I believe. And so there was a very strong tradition of medical oncology at my medical school. And I think the influence of people, some of whom you know, Jim Malpas, Andrew Lister, my subsequent boss Michael Whitehouse are all people who I found quite inspirational. And so that's when I decided to go down that path. And it's probably why I ended up with an interest in lymphoma because hematologic malignancies were a very big part of what they did there.
In terms of mentorship, there are a couple of people, maybe three, who I really value as being my UK mentors. Mike Whitehouse, who was my boss for a number of years. Ben Mead, who was a lymphoma and GU oncologist with a particular interest in testis cancer, who was--indeed, still is incredibly kind of intellectually honest person who taught me a lot about how to think and how to think critically, which is something that I think I hadn't really learned up to that point.
Another individual, Brian Vaughan Hudson, who was a statistician, actually, who was very involved with one of the British lymphoma groups at the time. And he was very influential as well. So I would say those were my three sort of primary mentors during my medical school years and as I went through postgraduate training and developed my lymphoma interest.
Dr. Derek Raghavan: So they were true luminaries. I knew Mike and Ben. I just never really understood why Ben, as a GU guy, wanted to dilute his time with lymphoma, but I'm sure you understand that much better than I do.
John, one of the things that I remember from when we first met was--we were chatting because I did, as you know, my PhD in London--and we chatted about the fact that you were involved in something rather unusual and rather awful. And that was, as a young fellow, you actually were injured in a horrible railway incident at Clapham or Clapham Commons in London. And I've always thought that must have given you kind of a unique perspective of being a patient and dealing with pain and stuff. And I just wondered, how do you recall that, and do you think it had an influence on your subsequent evolution?
Dr. John Sweetenham: Yeah, I think it did. So very briefly, I was involved in a rail crash that happened, as Derek said, just outside London. This was in 1988 just before Christmas of that year. And it was essentially a signaling failure, and that the train on which I was traveling, and was in the front car of that train, was traveling at about 70 miles an hour and collided with the stationary train that was on the track ahead of it. And I think the final number was 37 people were killed in that accident, including the person that I was sitting next to that I didn't know, and another person who I was kind of back to back with.
In terms of how it affected me, I think there's this assumption that you emerge from that with kind of a new perspective on life and so on. If I'm really honest, I don't really think that that's what I got from it. I did learn a number of things about being a patient. And the thing that sticks in my mind most of all from that experience, I would say, would have been I remember very clearly the nursing staff who came across to me as extremely kind and competent, and those who came across to me as extremely kind, but maybe just not quite so confident and competent.
And so what it really made me understand a little bit better is, particularly if you're in the hospital and you're an inpatient, you really put your trust in the nursing staff because they're the ones who are there the whole time. Physicians come and go. They make rounds and they come and go. But the nurses are there much more. And I really developed the very, very deep respect for the nursing profession from having been on the wrong end of an accident and spending some time in the hospital. So I would say that that was sort of my abiding impression.
The other thing that often occurs to me-- and this is a little bit more philosophical, I suppose-- but I do remember getting on the train that morning. And I had the option of going to the front half of the car or the rear half of the car. And it was a totally random decision to go to the rear half of the car, and nobody in the front half survived.
So it was just this sort of unusual reflection on sort of how sometimes what's seemingly the most trivial decision that you could possibly make can have very, very profound consequences, which is something I've kept with me as I've tried to make career decisions over the years, that what seems like not a very big decision can actually turn out to be an extremely big one in terms of the consequences.
Dr. Derek Raghavan: Clearly the recognition of the extraordinary value of nursing and nurses stuck with you because I can attest, as one of your clinical partners at the Cleveland Clinic Taussig Cancer Institute, that you're one of the nursing favorites. And the reason, apart from being competent, was the fact that you treated them well and with respect, and that obviously has stuck with you. And when I visited you to the Huntsman Utah and met some of your nursing staff there, they said the same thing. So that clearly had an impact, John. Did you feel ever that you had some survivor's guilt from that episode? Did that ever impact you at all?
Dr. John Sweetenham: You know, it really didn't. And in fact, if anything, I sometimes felt a little guilty that I hadn't had that, if you see what I mean, because it was interesting that we all were fortunate enough to be offered counseling after the event, and I had some. But the theme of it was, I think, trying to relieve us of any guilt that we may have felt, which I understand.
But in fact, quite the opposite. I actually just felt extremely fortunate, especially in terms of the people around me and what had happened to them. I just felt very fortunate that I was alive and able to fully recover. And it's actually quite interesting because I gave evidence at the public inquiry. And coming out of the inquiry, there were a load of press around. And the reporter from The Independent, which was quite a reputable newspaper at the time in the UK, actually said to me, Dr. Sweetenham, do you do you still feel haunted by guilt and by memories of that day? And I said, actually, really, I don't, no. I just feel very fortunate.
And in the newspaper the following morning it said, Dr. John Sweetenham, and then in parentheses, 32, because they always put your age, Dr. John Sweetenham said, I'm still haunted by memories of that day. So I think there's a little bit of an expectation of that sort of guilt thing. But I think I was very fortunate that my feelings were quite the opposite. I just felt, frankly, lucky to be alive and very grateful for it.
Dr. Derek Raghavan: Moving away from that, you worked in the UK for a long time, and then you had the opportunity of coming to the USA. How did you find the contrast of practicing medicine in Britain and the move here? What were the most strident or amusing differences in style and the way things work?
Dr. John Sweetenham: Yeah, so I'd say right up front--and I don't know whether the experience was the same for you coming from Australia--but overall, despite my expectations, I was more struck by the similarities than differences. I think people are the same the world over. I think the patients and the problems that they encounter and the challenges they have are pretty much the same the world over.
I would say the big difference is probably three things. Number one, documentation and billing. I think in the UK, because it is a government-funded health system for the most part, your communication with a patient's primary physician could be a two-line letter that essentially said, I saw your patient today and he's doing fine. We'll see him in 3 months or something like that. And that was about all the documentation that was necessary. So I think it took me a long time--not a long time, but it took me a while to adapt to a high level of documentation, which I think is actually a good thing, and trying to unravel and navigate the billing process, which was foreign to me for quite some time.
The other things that I would say that really struck me were number one, the fact that health care--clearly there are major disparities in health care in the U.S.--but when it's at its best, I think the health care and oncology care in the U.S. is well-resourced. And that opens up the possibility for patients, and to me as a physician, to do things that I simply couldn't do in the UK.
And then the third thing, actually, is simply that the expectation of patients, what they're expecting of their physician in terms of engagement, communication, and so on is much higher in the USA than it is in the UK. Now I have not worked in the UK for 20 years now. That may have changed. I think it's a positive thing. But I think my experience would be that patients in the USA expect much more of us, and as they should.
Dr. Derek Raghavan: One of the interesting things that you and I both shared is we've worked for nationalized medical system, and we've worked for the hybrid of for profit, not for profit with some nationalized elements and so on. And I always wonder, people tend to say that--because you mentioned the disparities of care--that nationalized medicine is sort of the panacea for disparities of care. Do you think that's true, or do you think that in a nationalized health system, disparities still exist, and so physicians there actually need to focus just as clearly on those issues?
Dr. John Sweetenham: I think disparities exist. I mean, I think, to me, the contrast between the two systems, having experienced both, is that I think for somebody with a very serious life-threatening illness like a cancer in a nationalized health system such as the one that exists in the UK, somehow it has to be less scary because you know that if you, for example, need a bone marrow transplant, you're probably going to get your bone marrow transplant, and it isn't going to be expensive for you at the level of having to shell out money, although obviously it's expensive in many other ways, and the loss of income and so on are big factors.
But I think it's also we have to be realistic that a lot of the factors that play into health care disparities are social determinants of health and factors which exist within a country that has a government-funded health system in just the same way as it does in one where it's an entirely private system. And then play into that the implicit and explicit biases that exist within our societies anyway. So I absolutely think that there are very significant disparities, or at least there were during my time in health care and oncology care within the system that I came from, for sure.
Dr. Derek Raghavan: Yeah, and I agree.
Dr. John Sweetenham: I'm sure you'd say the same.
Dr. Derek Raghavan: Same deal in Australia. The one other thing I wondered about, you might know or not know that John and I were co-editors in chief of HemOnc Today for several years, 7, I think it was. And you might remember, John, I wrote on the topic of death is an un-American activity. And I wonder, do you think that also is a difference?
From my experience moving from Australia to the USA, the Australian will certainly fight cancer very actively, but when there isn't a lot of hope left, is much more comfortable with reaching out supportive oncology and palliative medicine than is often the case in the USA. And that applies, also, to the physician's approach. Did you find a change in that side of things when you moved from the United Kingdom to the USA?
Dr. John Sweetenham: You make a really good point. And I often quote you, actually, because I remember that when I was at Huntsman, you came and gave a talk in Salt Lake City. And one of the things that you mentioned in your talk--I won't get it absolutely right, but I know you said that the USA is a country where many people believe that death is optional. And that really stuck with me because I think that that is a marked difference, bearing in mind that I came from the UK, which was really where the hospice movement, in particular, really sort of started to develop.
And so I do think that there is, to your point, a similarity with the Australian psyche in that regard, that there is probably more of an acceptance of the reality of death both among patients and among the profession. And so the likelihood of getting into many of these kind of end-of-life treatment issues which confronts us almost every day here, certainly I did not experience so much in the UK.
Dr. Derek Raghavan: Between the two of us, we've been in an awful lot of different cancer centers. I think people would say that we share in common the inability to hold a job. But you've been in some fantastic places. You were at the University of Colorado. And you might even want to tell the story of how you found your way to the Cleveland Clinic. And so you were there for a while. Then you were at the Nevada Cancer Center, then at Huntsman, and now at UT Southwestern, all amazingly good places.
What characterized the differences between the places? What did you feel you can compare and contrast in terms of the way things were done? Were they all pretty much the same, just in different places? How did how did you view the different places you worked?
Dr. John Sweetenham: Yeah. It's a really interesting question. And I would say that for the most part, that the challenges and the opportunities at all of the places I've worked with have been similar. And I think that you can take conversations about whatever it might be. It might be how you organize your clinical trials. It might be how you set up advanced practice providers and have them partnering with physicians. I mean, there are so many of these issues that I know that you confront on a regular basis as well.
I would say that in general, the challenges and opportunities of everywhere I've worked--with one possible exception, but it wouldn't be fair to single out anything out--would have been fundamentally the same. I think the difference has very much been in how that's approached. And this may seem a bit soft and a bit lame in some respects, but I would say that for me, what really has distinguished the cancer centers and made them different has been two things.
One of them is something which I can only define as institutional culture, which I didn't used to believe in, really. But I think that having not been able to hold down a job, I've sort of experienced various different institutional cultures and realized that that can actually make a very significant difference to how things move along.
And then even more so, I think the cancer center leadership, and in particular, the cancer center director, just by their engagement and their attitude, really does, in my opinion, set the tone. And so I think that as I look across all of the places that I've worked--and I've had the good fortune to work for really an extraordinary group of people--but I would say that that's where the real difference is. The issues are the same. How those issues are addressed is very much driven by the individual leadership of each of the cancer centers. And it can be quite a contrast from one to the other.
Dr. Derek Raghavan: Do you think that scientists with a PhD approach cancer center leadership differently from clinical, medical, radiation, surgical oncologists with an MD plus or minus a PhD? So in other words, is their training creating differences, or is it more personality, past experience, and focus? How do you see that?
Dr. John Sweetenham: I would say it's the latter. Now I've only worked for one cancer center director who was not an MD. But I would say that that individual had a very good understanding of clinical issues. So I can't really pull that out as a reason why there's a difference. I think, honestly, it's much more personality-based, and that's where I see the contrast. And I would say the person that was not an MD who led one of the cancer centers that I worked at was able to really engage in the clinical issues and was extremely well-informed and very effective, actually.
Dr. Derek Raghavan: So I'm not going to go to the obvious fact that you were the happiest when you were at the Cleveland Clinic working with me until you got to your current employment status.
Dr. John Sweetenham: It goes without saying.
Dr. Derek Raghavan: But what I do want to touch on is, you've had two significant and pretty influential editorial roles. You're a prolific, great author yourself. You write very clearly and very well. But you've been the editor guiding the ASCO Daily News for a decade, and then you and I jointly worked on HemOnc Today together. What did you learn from that? What opportunities came to you? Did you change your perspective on any aspect of oncology or oncology reporting from either or both of those roles?
Dr. John Sweetenham: First of all, I think both of them have been extraordinarily helpful and actually very useful to me over the last 10 years or so. ASCO Daily News, the story there is--and you'll remember this well--but when I first went to Colorado, Paul Bunn had just become president of ASCO. And he was very helpful to me in getting me involved in what at the time was called People Living with Cancer, which you'll remember well because we worked on that together for some years. It was the forerunner of what's now Cancer.Net.
Once we got involved in people living with cancer, I had the good fortune then of having a number of other things that opened up for me at ASCO, one of which was I was asked to join ASCO Daily News as associate editor to actually provide some insight into hematologic malignancy. And then over time, I took on the editor-in-chief role there.
But it was really interesting to start to go back and sort of re-engage in issues outside of hematologic malignancy that I hadn't really been involved with for a number of years. And I can remember starting to read emerging data around colon cancer and some of the new agents, and thinking to myself, wow, this is really cool. I should start to get back into this more.
So I think starting with ASCO Daily News, and then within HemOnc Today, number one, I think it gave me an opportunity to sort of just broaden my perspective over what was going on in general. And the timing of that was great for me because it was just around the time that I was moving sort of out of a hardcore hematologic malignancies academic role and doing something which was a little bit more administrative in nature.
And then likewise with HemOnc Today, it gave me the opportunity to start thinking about issues that really had not been uppermost in my mind when I was only a lymphoma guy, so perspectives on anything from cancer care disparities to financial toxicity to drug costs to statistical analysis of clinical trials to some more kind of historical things. So I think that both roles really have enabled me to broaden my perspective on things a little bit, probably to de-skill, I would say definitely to de-skill in some areas as this has gone on. But as I've taken on this somewhat more kind of administrative role, it's been really helpful, added to which, of course, there's been the added pleasure of being able to interact with you on an almost weekly basis with HemOnc Today for a number of years now.
And I and I have to tell you that it's been a few months since we stopped HemOnc Today, and I'm bereft. I'm actually having major withdrawal, which is, I think, one of the reasons why talking to you today is such a big deal.
Dr. Derek Raghavan: Well, the good news is we're both tied into ASCO publications, the ASCO Post. And so I'm sure there'll still be opportunities. Hopefully next year ASCO will actually meet in person, and we'll have that opportunity.
Dr. John Sweetenham: Yeah, what I'd really like to do, actually, one of the things I still aspire to, is that I know when you do things in ASCO Post, they do one of those little drawn pictures of you instead of a photograph. I've seen yours appear on there several times, and I still aspire to that. It's one of my remaining ambitions. I want one of those pictures.
Dr. Derek Raghavan: It's really unseemly to beg to ASCO on your own podcast, but I'm sure that Cara Glynn will hear this. My advice would be don't waste your time. But she's a kind little soul, and she'll probably get you the picture that you're looking for. I would actually say to Cara Glynn, if you do get that, get the artist who can make a picture that ages annually because that'll put him in his place.
So John, just again, thinking in terms of working with ASCO Post and the other various journals that are out there, COVID has been a cataclysm in medicine. And you and I have jointly been able to be quite editorial and philosophical. I, at least, had a couple of political targets that I used to joust at, which I wasn't able to do through the ASCO Post because it's a not for profit organization. But what do you think was the impact of 2020 on medicine and nursing and the people who prosecute medicine and nursing? It was a cataclysm. How did you experience it? What do you think comes out of it at the other end?
Dr. John Sweetenham: I guess part of the answer to that is, in terms of what it's actually done for us, I don't know yet. I mean, I think that there are some very kind of practical and obvious consequences of this which we're all becoming familiar with now. The telemedicine thing that we've all become familiar with, remote working, with remote patient care, up to a point. And I think that there are elements of that which are probably going to stay with us.
I have to confess personally that I'm still a little on the fence about that. I think that there are clearly areas where telemedicine is going to help us overcome disparities in terms of rural populations and so on. And it's going to be incredibly important from that perspective.
You know, I still wonder about the nature of telemedicine interactions. And it may be a generational thing, I don't know. But there are aspects of it that still trouble me. And from a cancer center perspective, there's a part of me that thinks that because what we do is so high touch, I'm not sure that I want to be necessarily in a situation where we are renowned for being the virtual cancer center, if you know what I mean. I just have worries about that.
And the way I often think about it is the quality of the interactions over telemedicine is a little bit like a contrast between listening to music on vinyl and listening to digital music in that when you have digital music, something isn't quite the same, and there's something missing, but you can't quite put your finger on what it is in that communication and the way it comes over. And I do still think that to some extent, telemedicine kind of has that aspect. Those are important challenges, having said that, breaking down some of these barriers to practice across state lines and so on.
I think the most profound thing, though, to me from this whole experience has been the politicization of medicine and of science, and the erosion of the credibility of science in the eyes of the public, and the erosion of common sense medicine. And I think when you look at what will be the lasting effects, the really lasting effects, I don't think so much it's going to be the practical aspects of how we deliver cancer care. I don't think it's going to be the trust of the public in what we do and what we say.
Dr. Derek Raghavan: I agree with all that, I, like you, share some concerns about telemedicine, although it's clear that patients like telemedicine. I think the other thing that happened in 2020 is it refocused doctors and nurses on what their primary responsibility is. I will never forget the image of those five ICU nurses standing with their arms folded against a mob of screaming idiots. And that made, I think, all of us realize what an important profession we're in.
So John, we're running out of time. And I was going to ask you about lymphoma because you've been a real contributor there, but you've published most of your thoughts on that. So in the last two moments, looking to the future, what do you see coming down the road for John Sweetenham? What's going to be happening at UT Southwestern Oncology? Closing thoughts?
Dr. John Sweetenham: Yeah, thanks. So two things, I guess, at a professional and personal level. From the perspective of UT Southwestern, I'm loving my role here. Despite what my gray hair might suggest, I'm not even close to wanting to move away from this right now. We're in a phase of growth, and I think that it's really exciting. Really aspire to getting us to a situation very much like one that you've built at Levine, where we can really give access geographically as well as in every other sense to our patients wherever they are within our region, and help to eliminate disparities. And as I said, I kind of think that what you've done in Levine is a real model of how that can and should be done. So that's one big part for me.
I think also continuing to focus on patient-centered care, and how we can really organize care around what works best for our patients rather than what works best for us. And then, I think increasingly I feel drawn towards issues like disparities, and whether working through other organizations like NCCN is a way to sort of help us to address some of those issues as well. And I enjoy my role there, and that's something which I really hope I can continue for some time to come.
On a personal level, I think I'm going to be continuing to work and enjoy my family. You asked me right at the beginning about what had drawn me to medicine, and I said that it was really the only thing I ever considered. It's not entirely true because the other thing that I really did consider when I was much younger is that I was really very interested in a career in music in some form. The only thing that really helped me back in that regard was a complete absence of any talent.
But I still figure that there's a chance. So I very tentatively started to try to learn to play the piano, which Caroline, my wife, encourages me to do, although I notice that she usually puts her ear buds in when I start to play it. But that's one other thing that I would really like to do. No intention of slowing down at the moment, having said that. So my piano practice is sporadic, as anyone who listens to me play will understand. So, I think for now, it's going to be more of the same. And I'm really enjoying it and hope to continue to do so for a long time.
Dr. Derek Raghavan: Well, John, we've been friends for decades. It's been a pleasure to interview you. I guess my takeaway for it is the fact that you draw a distinction between the lack of talent that you could bring to music compared to what you brought to medicine. And I'm happy you see that distinction. I think people out in reader land have benefited from wisdom and good choices that you've shared with your editorial team, and you've really prosecuted a wonderfully useful broadsheet.
And it's been a pleasure to partner with you on a number of activities and I look forward to reading how you evolve UT Southwestern Cancer Center with Carlos and the other leadership team there, and look forward to collaborating on other things. And thank the audience for listening to us both.
Dr. John Sweetenham: Yeah. Thanks, it's been great. I really have enjoyed speaking with you as well. And looking forward to the next chapter. This chapter with ASCO Daily News finishes for me officially on June 8 of 2021. And it would be remiss of me not to acknowledge the extraordinary work that the editorial staff do, who really do all the heavy lifting. And my job there has been really very easy because of all they do.
And in particular, I express my thanks to Faith Hayden for everything that she's done to help and support me during the time that I've been doing this. And thanks again to ASCO for giving me the opportunity to take on this role. I have thoroughly enjoyed it.
That was Dr. John Sweetenham of UT Southwestern speaking with Dr. Derek Raghavan, President of the Levine Cancer Institute. Dr. Sweetenham, we thank you and we'll miss you at ASCO Daily News. We wish you all the best.
Disclosures:
Dr. Derek Raghavan:
Consulting or Advisory Role: Gerson Lehrman Group, Caris Life Sciences
Dr. John Sweetenham: None disclosed
Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.