Ramaswamy Govindan, MD, has shared the story countless times – “My kids will laugh, and my wife will roll her eyes” when they read it here, he admits – but its Horatio Alger elements give it wide appeal.
“I came to this country with $18 and two suitcases,” the India native said. “Actually, I had $20 when I boarded the plane in India, but I drank a Coke and ate some French fries at the Los Angeles airport while waiting to board the flight to Chicago.”
He arrived July 4, 1991. Govindan, then 27, had completed medical school and a residency in internal medicine in India. He found himself in Chicago, where he had another medical residency lined up, but little else.
“I took a $1,000 loan from the hospital to find a place to live,” Govindan said.
Twenty-three years later, he is a leading lung cancer physician, researcher and professor of medicine at Washington University School of Medicine and Siteman Cancer Center. Govindan is a co-chair of the lung cancer group for The Cancer Genome Atlas project, a national effort to describe the genomic alterations of common cancers. He also leads a national clinical trial called ALCHEMIST (Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trial) that screens tumors from several thousand lung cancer patients. Patients in the study can participate in clinical trials of drugs that target cancer-causing dysfunctional genes.
Govindan is married to rheumatologist Prabha Ranganathan, MD, a Washington University associate professor of medicine. They have two sons: Ashwin Govindan, 15, and Akshay Govindan, 12.
Below, Govindan discusses the future of cancer care, his inspiration for becoming a doctor and some of what he’s learned while bridging his native and adopted countries.
Tell us more about your early days in this country.
The residency program at Michael Reese Hospital affiliated with the University of Illinois was very supportive of foreign medical graduates. It took a few months to get used to a new country, a new system of medical practice and develop a network of friends.
What motivated you to study medicine?
Growing up, I got the usual childhood illnesses and a big one – smallpox. The physicians who took care of me inspired me to go into medicine. Despite my consistently good performance in school, my father was initially skeptical that I could get into a medical school in India. (The system was rife with problems then.) My mother unfailingly believed that I would. Eventually, my father became more optimistic and played a really huge role during my medical school years and beyond. As a clerk in a postal accounting office, he earned only a modest salary and had to take loans consistently to pay for my books and other expenses during my medical school years. A few public libraries in Madras (present-day Chennai), where I grew up, stocked medical textbooks at that time. He would borrow and carry heavy medical books from public libraries to help me out, using an overcrowded public transport system.
Give us a layman’s overview of the state of cancer research. What do we know? What are we looking for?
Cancer is a disease of the cellular genome, where the genes inside the cells get deranged, leading to cancer over time. While some cancers are inherited, most are not. Until a few years ago we did not have a good understanding of what these gene alterations were and how they led to cancer. Over the past five to seven years we have developed tools and technologies – next-generation sequencing – to study how the genes are altered in cancer. Now we can look at these alterations in great detail. In the past we were studying a few genes at a time, but now we can study the whole expanse of the cancer genome. It is almost like we were looking at the Grand Canyon through a pinhole then versus looking at a 360-degree view of it now. It is hard to devise highly effective therapies without fully understanding the biology and genetics of cancer.
What are the biggest misperceptions people might have about cancer and personalized medicine?
There won’t be one magic bullet. Cancer is not one disease. There are many different types of cancer. Even lung cancer is not one disease. Many different genes can be altered to produce an identically appearing cancer, and their treatments ought to be different. I think, more realistically, we may be able to control the disease a lot better, a lot longer, with better quality of life in the foreseeable future. Cancer increasingly is becoming a chronic disease. We now are seeing a small number of patients with advanced metastatic lung cancer surviving many years. I truly believe that this sort of improvement will affect a larger proportion of patients in the coming years. But we need to extend the survival significantly without affecting the quality of life. Cancer is a complex disease. We should not be making pronouncements that a cure for cancer is around the corner. We need to be much more realistic.
What do you find most challenging about your job?
The paperwork surrounding clinical research has become too tedious and onerous. We are forced to collect extraordinary amounts of data that don’t protect our patients or advance science. I do find this a bit frustrating. Our clinical trials process, while certainly the best in the world, can be tweaked a bit to ease this. I am certainly looking for partners who would work with me to make the clinical trial process more efficient without compromising patient safety or scientific rigor.
What is most rewarding?
The progress we’ve made over the past 10 years is absolutely fantastic. We have a long way to go, but we’re on the right path in terms of scientific research. The emerging technology that allows us to see the cancer genome in such great detail, the arrival of immune therapies directed against cancer cells, the possibility of fashioning immune therapies customized to individual patients based on their tumor genomic profiles are all exciting. The combination of patient care and cutting-edge research is very rewarding.
Tell us about your research.
We now know that at least some lung cancers have mutations in the epidermal growth factor receptor (EGFR) gene or alterations involving the anaplastic lymphoma kinase (ALK) gene. For those patients, targeting those altered genes is a better approach than giving chemotherapy that blindly kills some rapidly growing cells.
There are two major issues though. Even though it’s wonderful we have new therapies for patients with EGFR mutant or ALK positive lung cancer, unfortunately, the cancer begins to gain an upper hand over time. We need to understand the mechanisms underlying acquired resistance and develop innovative therapies that are effective.
The second issue is that a significant number of lung cancer patients don’t have these mutations. Though we have found “actionable” mutations in nearly 75 percent of patients with lung adenocarcinoma as a part of the TCGA study, we still need to do a lot more work in identifying key alterations in a number of patients with adenocarcinoma and other histological types of lung cancer. We are conducting a number of studies to figure this out and are planning a few more in the coming years.
What do you do outside of work?
I love to read – nonfiction, contemporary politics, philosophy and religion. I browse through four newspapers a day: The Guardian, Financial Times, The New York Times and The Wall Street Journal. I spend lot of time reading newspapers on Saturdays and Sundays. And I love to travel. We take our kids on an international trip almost every year. We recently came back from Australia and New Zealand. Travel expands your mind. You always learn so much about the culture, the food and the history of a country.
How has having grown up in India and having moved to the U.S. influenced you?
In India, while I was in medical school, we catered to very poor people who could barely afford the basics. They lived on a dollar a day. Seeing such physical and economic suffering has given me a different perspective. I grew up in a fairly modest household, so I’ve seen what it’s like not to have. I don’t take anything for granted. I have learned a lot from our patients and their families – their courage, generosity and fighting spirit. I am grateful for all the opportunities I have had here in the U.S., in particular at Washington University, where I have been my entire academic career. I am looking forward to many more years of a productive career here in St Louis.