Topic of cancer

Oncologist Suzanne Conzen encourages would-be molecular biologists to think about the human aspects of their lab work.

Suzanne Conzen, associate professor of hematology and oncology, belongs to an extremely small subset of Chicago professors—those who arrive to class early. Ten minutes before nine, she’s at the front of the room, conferring with her teaching assistant, setting up the overhead system, making sure her beeper is silenced.

The classroom, BSLC 240, with its black tables, lectern, and board, is stark and sterile: a laboratory crossed with a corporate board room. The tables form two concentric rings; the inner ring quickly fills, forcing three relative latecomers to the outer edge. Two women in the inner ring work their way through thick medical texts. Another sits down and flips open her laptop. Just then a young man walks in and engages all three in a light-hearted, laughing conversation—on cancer biology labs.

Today is the third meeting of Cancer Biology I: Human Cancer Presentation and Modeling. The first of four courses in the core curriculum for doctoral students in the Cancer Biology program, it’s also open to biology undergraduates. Both groups know more than most people about molecular research, but this course is designed to help them think about how their lab work may affect human lives.

Conzen, wearing a white lab coat and plastic name badge over a pale green, scallop-edged sweater, flicks on the title slide, “Human cancer: An overview. Incidence, presentation, and systemic treatment of the patient.”

“The beginning of the class is a bit torturous for both teacher and student,” she admits, with lots of terminology and concepts. “But you need to have a big-picture view of cancer in order to understand the parts that I think you’re going to find really interesting—the individual cancers.”

The slides themselves are simple: yellow text against a blue background, few illustrations other than graphs or maps. The students follow along on printouts, occasionally taking notes. “Please interrupt,” Conzen suggests to the silent class. “It works better when students ask questions.”

Her first slide, on U.S. mortality for 2004, shows that cancer is the second most common cause of death for Americans. Only heart disease kills more—accounting for 29 percent of deaths, compared to 22.9 percent for all cancers together. The next slide charts changes in U.S. death rates by cause; while heart-disease deaths have been cut in half since 1950, cancer deaths have remained almost the same.

A hand goes up in the outer ring. It belongs to Paul Butera, director of communications at the U of C’s Cancer Research Center, who’s auditing the class. According to a news report he read, cancer has surpassed heart disease as the top killer in the United States. “We fight about this all the time,” Conzen says, “because it means funding.” A knowing laugh spreads through the class. “My husband is a cardiac surgeon,” she jokes, “and he’s always very happy whenever heart disease is ahead.”

Whatever the ranking, the implication is serious. The next slide shows U.S. men’s lifetime risk of developing cancer: 1 in 2. The four male students don’t seem to react to those odds. Perhaps they’ve heard the statistic before. Cancer is a delayed-onset disease (as Conzen will explain later), and for these twenty-something students, perhaps it’s so far away as to be meaningless. Or perhaps cancer is something that happens to someone else: to patients, not to doctors, not to molecular biologists.

For women, the lifetime cancer risk is 1 in 3. No reaction from the seven female students either. If this small group were representative of the nation as a whole, it would yield two male cancer patients, two female. It’s not clear why women’s risk is lower, Conzen notes: possibly estrogen has a protective effect.

Another slide. “I am primarily a molecular biologist,” Conzen says, “but I’m also interested in differences in race and ethnicity.” She is a member of the University’s Center for Interdisciplinary Health Disparities Research, which in 2003 received a $9.7 million federal grant to study why African American and African women are more likely than their Caucasian counterparts to develop breast cancer.

The room suddenly dims; Huiping Liu, the TA, has flipped off the lights to make the small print easier to read. It shows that African Americans, both men and women, have a significantly higher rate of cancer deaths than any other ethnic group. “This is a huge area of interest for the NIH,” Conzen says. “Does the difference have to do with access to care, environmental factors, genetic factors, or what?” She doesn’t know the answer. No one does.

On to risk factors: cigarettes, carcinogens that cause DNA damage, asbestos, a diet favoring animal fats, stress, obesity. A slide on tobacco use suggests why young people who smoke seem blasé about cancer. Men’s smoking began to increase around 1920, Conzen explains, but cancer deaths did not increase until 1950. More women started smoking around 1950, and cancer deaths rose around 1980.

Today’s slow-acting poison is food—lots of it. “There’s been a huge increase in overweight prevalence in your generation,” Conzen tells the students. An “amazing slide” breaks the trend out by state from 1992 to 2002: on this map “red states” are those where 55 percent of adults are overweight. By 2002, 48 states were red. “My geography is terrible,” she says, “but basically it’s every state but these two” (Colorado and Utah). “Everyone in here looks very thin, I might add. That’s great.”

Five slides on cancer screening flip by. “Screening is cost-effective for some cancers but not others,” Conzen says. For cervical cancer, a Pap smear is relatively cheap, while lung cancer requires a high-resolution CAT scan. Whatever the cost, “screening doesn’t usually find cancer.” Patients most often discover a lump themselves, or they tell the doctor about bleeding, pain, weakness, or weight loss—all indirect symptoms.

Once cancer is diagnosed by “someone like Amy,” Conzen says, meaning Amy Noffsinger, a pathologist and one of the course’s four directors, a team of doctors that comes together to treat patients. “One of the things that’s so fun about oncology, if you can imagine something fun about it,” she says, “is that you get to interact with a lot of different types of doctors”—pathologists, surgeons, radiologists. “There is more and more dialogue between basic scientists like me and clinicians.”

Up next is a “Treatment of Cancer” slide, with only three bullet-pointed options: Surgery. Radiation Therapy. Systemic Therapy. Systemic therapy, the next slide explains, is used to eradicate tumor cells that have traveled elsewhere in the body or—with surgery and radiotherapy—to eradicate the primary tumor. “Here’s some terminology you have to know,” Conzen notes: neoadjuvant therapy occurs before surgery, adjuvant usually after. “Why would you treat the tumor before surgery?”

The laptop user—a dark-haired woman in a black hoodie, one of two undergrads in the class—hazards a guess: surgery might spread the cancer, breaking through the tumor’s membrane. In fact, Conzen explains, some large tumors must be shrunk before surgery can be attempted. With breast cancer, for example, “sometimes the tumor is so big, a surgeon could not even close the chest wall.”

Skimming over surgery and radiation therapy, Conzen homes in on chemotherapy, of particular interest to a room of aspiring molecular biologists. Chemotherapy is usually given intravenously, she explains, although some drugs are given by mouth or implanted in a pellet during surgery.

“How does chemotherapy kill tumor cells preferentially?” asks the next slide. The answer requires four exclamation points: “WE DON’T REALLY KNOW!!!!” One theory is that chemotherapy kills rapidly dividing cells, but that argument doesn’t explain why it also works on slow-growing tumors.

A student with thick, wavy brown hair focuses on the rapid division: “Is that why you lose your hair?”

Conzen nods. “That’s also why your nails are affected, and why you’re prone to mouth sores.” They’re all regions of the body where cells divide rapidly. Not a woman in the room, including Conzen, has hair shorter than shoulder-length. Once again, the young scientists do not even blink.

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Syllabus

To say that Cancer Biology I is “team-taught” is unfair to Suzanne Conzen’s organizing acumen; “football-team-taught” would be closer. The syllabus lists four “course directors”: Conzen, Akira Imamoto, Amy Noffsinger, and teaching assistant Huiping Liu. There are also ten instructors: Maria Tretiakova, Phil Connell, Anthony Montag, Charles M. Rubin, Tong-Chuan He, John Anastasi, Michael J. Thirman, Todd G. Kroll, Xinmin Li, and Jeff Green of the National Institutes of Health.

The idea behind the course, says Conzen, is to teach students “what cancer is, how it looks, feels, and smells, how it affects patients and how it kills them, what we treat with now, side effects, etcetera—so they can put their molecular research into some sort of context.” Conzen describes Cancer Biology I as “an unusual class for cancer biology PhD students” but notes that it’s part of a trend. New York’s Memorial Sloan Kettering Cancer Center, for example, has announced a new graduate school to train basic scientists in the specifics of cancer—something Conzen and her colleagues have been attempting to do for the past five years.

Cancer Biology I requires only one textbook, The Basic Science of Oncology by Ian F. Tannock and Richard P. Hill, and two CD-ROMs: Pathologic Basis of Disease and Wheater’s Functional Histology—all on reserve at Crerar. Grades are determined by two problem sets (10 percent each), a midterm (30 percent), a final (40 percent), and class participation (10 percent).—C.G.