Dr. Lynda Roman, Dir. of Gynecologic Oncology at USC, Shares Her Insights on Ovarian Cancer Research & More
Out of all our interview subjects thus far, Dr. Roman is by far the most busy. It is so special to be able to take even 30 minutes out of her day doing the amazing things that she does. Dr. Roman did her fellowship in gynecologic oncology at MD Anderson Cancer Center in Houston. And right now she serves as the Director of the Division of Gynecologic Oncology at USC. She's also the Director of Research and the Fellowship Program Director there. Dr. Roman is the Co-Director of the Lynne Cohen and Georgia Cord Preventive Care Clinic at USC Norris Cancer Center. Here, she shares her brilliance with us in this very special interview delving into the state of the world and women's cancers
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Amy: I am so excited and beyond honored to always talk to Dr. Lynda Roman, but today, even more because there's so much going on in the world. When someone coined the term “bedside manner” they must have had you in mind, Lynda.
Dr. Lynda Roman: That's so nice of you to say.
Amy: You're never afraid to speak your mind, you're never afraid to speak up, and I have a feeling you've always been that way. I can't imagine you as a little girl being shy in the back of the room.
I've never been able to ask you this. What were you like as a young girl and then a young woman?
Dr. Lynda Roman: So when I was young, I was born to parents who were refugees from Hungary, refugees after World War II, who had been very effected by the Holocaust.
My dad lost his whole family and my mother was in a ghetto and they all survived in Budapest. And I think she was like 13, 14 when the whole thing happened, and I think she felt extremely betrayed by her country. So when the Russians came in and it was clear what life was going to be like under communism, she and her parents left. My dad picked up and left to start a different life and both ended up through complex mechanisms in New York City and that's who I was born to, my grandparents also joined my mother.
So when I grew up I actually learned Hungarian before English. And. to be honest with you, when I was young, I was very shy and I think very childish. I was born December 30, so I was always the youngest in the class. And it was actually to the point where my parents refused to teach my brother Hungarian because they were so convinced the fact that I learned Hungarian first and supposedly didn't know English was what kept me so quiet. I think in truth, I was just very shy and scared. So we switched over to English when I was five. When my father got his PhD in history, we moved to Connecticut, and I grew up in Newtown, Connecticut.
But what I think you're seeing and what ended up happening — it's quite a heritage growing up with parents who've gone through this and my father was difficult with everything. So I think I learned early on that there was only so much they could handle; I had to handle stuff myself. I had to stand up for myself. I think that's what you see.
Amy: Clearly.
Dr. Lynda Roman: So to make a long story short, I lucked out because I loved biology and I quickly found the right career. The caretaker side was my mother who was the world's best caretaker and had a wonderful sense of positivity about her. Both my parents were very, very, very smart and very academic so I grew up in that kind of household.
So anyway, you put it all together and at some point I just remember deciding that I could either live with fear, which is what I felt like when I realized what had happened to my family and how ugly the world could get. Or else I could just do what I can to control my own behavior and move forward. I think that is what led me to becoming much more courageous and willing to speak my mind. People are people, no matter what. They're all actually very similar in their needs. I think of all the difficulty growing up — good came of it.
Amy: It makes you who you are.
Dr. Lynda Roman: So anyway, a long winded answer but there you go.
Amy: It's amazing. Of all these years I've known you, I feel like I know you so much better and it's unbelievable. And I think it makes sense. How did you pick oncology and how did you pick gynecologic oncology and decide to work with women as patients?
Dr. Lynda Roman: When I entered medical school, it was my goal to be a pediatrician. I always loved kids and I spent a lot of time when I was younger, kids and animals. I worked as a camp counselor and the kids always loved me. That was the idea. And I remember my father saying to me, "You really should go into oncology. That's the future." And I said, "Are you kidding? That's way too depressing. I couldn't never do that. No way."
So in medical school, I did pediatrics. And guess what? The kids did not love me when they were scared to death of me. Psychologically, I could not handle that. And so I realized I was way too emotional to do this. You can't let your emotions be that raw when you're a physician; you're not helping anybody. I then got drawn into obstetric gynecology because it's a unique balance of medicine and surgery. And I really liked surgery, but I liked the idea of the ongoing relationship. To be honest, at the time for a woman, this was a way of entering surgery without getting decimated. It was at that time, very hard for a woman to just pursue general surgery.
I did a rotation in the Mass General Hospital in Boston in gynecology for the summer — just exploring this interest — and, without my knowledge, they put me on the G1 oncology service.And to my shock, I absolutely loved it. I did another rotation at Sloan Kettering in G1 oncology. And then when I went into residency, what I came to realize is that number one, it's extremely challenging: you have to really balance off medical knowledge with surgical knowledge. But also, what I realized about obstetrics is that everyone thinks everything's going to be perfect, and then when it isn't, it's beyond devastating. You go from high expectations to devastation.
“I'm sure that we will make very significant headway if we can just get some great minds to focus on this disease.”
Oncology people come in thinking everything's going to be terrible, and sometimes it is, but often it isn't. So you start with low expectations. In a way that was easier on me than when you could either trounce people's expectations or you disappoint them, right? I also had a really hard time with obstetrics when things didn't go well. So I found that heartbreaking for the baby. And once I made up my mind, I never looked back.
Amy: Obviously you and I focus so much on ovarian cancer and this cancer that is just so difficult to understand. It’s difficult to make headway in in terms of prevention. What's your take on describing it to the layperson? Could you bring us up to speed on where we are in terms of the advancements we've made?
Dr. Lynda Roman: From the preventive side, probably the biggest piece of knowledge, as far as changing the thinking, came when realized that the vast majority of ovarian cancer actually doesn't start from the ovary; it starts from the end of the fallopian tube.
Amy: Right.
Dr. Lynda Roman: And so now we're looking at it very differently. Now, this also tells us that ultrasounds where you're really looking for ovarian masses are not going to catch a little lesion in the fallopian tube. It can spread very quickly once it forms because the fallopian tube is hollow. So we've come to realize there are two key aspects of prevention. One is surgical — if women no longer want children, rather than a tubal ligation, removing the fallopian tubes is very likely to lead to a very big risk reduction in ovarian cancer.
Similarly, when a woman is having a hysterectomy for other reasons and wants the ovaries left in, it's now become routine to remove the fallopian tubes. The studies to prove that this is going to have an impact are beginning to just trickle, but it's going to take multiple years to prove what the impact is. I think everyone is pretty certain this is going to make a difference down the road. So there's the basic surgical side.
And then there’s the question of: Are there other screening tasks that could be done that might predict who's getting into trouble? And most people feel that any kind of screening test for ovarian cancer is going to have to be a blood test where you pick up the alterations, particularly the genetic alterations that start to occur when a cancer is forming in the fallopian tubes. So there are a lot of companies out there working on liquid biopsies, working on identifying signatures in the blood that might indicate the development of a malignant lesion.
Taking out the ovaries and fallopian tubes in any woman who's done with childbearing is not the end of the world. So it doesn't have to be a perfect test as long as it's pretty predictive that there is going to be 80% likelihood of a serious issue down the road. I would guess a lot of women would say "Do it."
Amy: Yeah.
Dr. Lynda Roman: So the bar doesn't have to be as high when you're looking at a screening test for ovarian cancer as it might be for like stomach cancer or pancreatic cancer. And I've told the company, at least two that have worked on this, that there's a unique opportunity with ovarian cancer for this very reason. So those are really the two areas that are under active practice and investigation.
Amy: Is there any way to see the fallopian tube with an ultrasound?
Dr. Lynda Roman: So ultrasound is pretty useless.
Amy: Right.
Dr. Lynda Roman: There's been talk about the idea that stuff from the fallopian tube may shed into uterus and you may be able to capture some cells that way, but an actual scope that could pass into the fallopian tube through the cervix, the uterus to the fallopian tube, isn't something that's really available.
Amy: Right. Yeah. You were up in there.
Dr. Lynda Roman: Yeah. It'd be a pretty, I mean, it would definitely be an invasive thing to do, but I think one of the big problems is you have to catch this very early on in the development. It's amazing how quickly it can spread to the abdomen from the time it actually starts. And it can be very small.
Amy: Right. So once it's out of the fallopian tubes, is that what we're saying? Once it's out of the fallopian tube and it's actually called ovarian cancer?
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Dr. Lynda Roman: It rapidly seeds, yeah. And I've had many cases where I look as a surgeon, I feel the fallopian tube, I look at it, it looks totally normal, but there's cancer all through the abdomen. But when the pathologist looks, they find something in the fallopian tube.
Amy: Right.
Dr. Lynda Roman: But I would never be able to tell.
Amy: Amazing.
Dr. Lynda Roman: Yeah.
Amy: And that's why it's just so difficult.
Dr. Lynda Roman: Exactly, that's why you have to find something that picks up the changes. Cancers do shed cells into the blood and DNA into the blood and that's really the basis of the present, you hear about liquid biopsies all the time. Many companies are developing liquid biopsies and that's really the basis to try to find alterations in DNA that are very, very characteristic of cancer.
Amy: Right. Wow. And what about on the treatment side? Have we had any major developments and changes in terms of treatment let's say from 20 years ago till now?
Dr. Lynda Roman: Well, definitely without question on the treatment side: the data show very clearly that women with ovarian cancer are definitely living longer and longer. Definitely the number of years after diagnosis of metastatic ovarian cancer, without question, is far greater than it was 20 years ago. What we have not made any impact on is the cure rate. And part of it is that it's very hard to cure when it's spread widely, which is usually the case, even though we're much better at controlling it. We have lots and lots of new drugs that have surfaced in the last 20 years. Taxol pretty much got its approval a little bit more than 20 years ago now, but since that time, a lot of other drugs, many of which are very tolerable, have come on the market. Initially chemotherapy drugs, but there have also been what we call “targeted therapy” or “anti-angiogenesis therapy” that's very useful in ovarian cancer. The PARP inhibitors will work very well in ovarian cancer that has certain alterations in it. It's not for everyone, but depending on the study, about a third, sometimes even up to 40% of cases will have alterations in the tumor that make the tumor unable to repair certain DNA damage. So the use of these drugs that kind of exploits that deficiency in the tumor and these drugs can be very effective in that group of patients whose tumors have it. There's a test that we can do that will tell us who's going to benefit from those drugs and who is much less likely to benefit from those drugs. So that's one of our first biomarkers, right? It's always nice when we can test the tumor to kind of help guide us. And that's really the only test that so far has merit.
There's a lot of work ongoing now regarding the role of immune therapy: does it work? And the answer is yes, sometimes, but not as commonly as in other cancers. Should it be mixed with some other agent to help it work better? And then the newest iteration of immune therapy is what we call T cell therapy. Cancers, many cancers can camouflage themselves. So the immune system doesn't see that. And what this does is it interferes, all of a sudden it exposes the cancer. But not all cancers use this mechanism.
The T cell therapies tend to work, it's a much more aggressive maneuver where you actually prepare, you manipulate the potent fighters of the immune system, the T cells, to actually recognize and attack the tumor. You give the T cells back and you give drugs with them that stimulate part of the immune system but then also suppresses the part of the immune system that sometimes gets in the way of a proper immune response. I mean, the immune system is extraordinarily complicated. And so you have to literally manipulate it sometimes to do what you want.
And cancer's evolved with us in the immune system. While I'm not saying it has no role against cancer, it definitely does, but it's not particularly effective. And what we're trying to do is kind of program it to learn to fight cancer better. But this is an evolving concept and the T cell therapies have worked very well in the blood malignancies, particularly lymphoma. And now we're trying to see about, can we get them to work against the solid tumors, including ovarian cancer?
Amy: I think of it as like massaging it, like massaging the immune system to work against ovarian cancer.
Dr. Lynda Roman: Yeah. We're trying to wake it up, kind of trying to educate it and manipulate it. Cancer's a very wily enemy, again, it evolves with us, right?
Amy: Right, right.
Dr. Lynda Roman: It's like it knows all our tricks. I mean, I assume this was incorporated and this was a population control measure, right? I mean, why else? Why can a body do this, right?
Amy: Right.
Dr. Lynda Roman: All kinds of things have a part of our life that hurt us. Look at this pandemic, right?
Amy: Yeah.
Dr. Lynda Roman: But cancer is a very, very tough enemy because it knows our secrets.
Amy: Yeah. Speaking of the pandemic, how is it right now with immunocompromised cancer patients? What is the feeling right now in women you're working with?
Dr. Lynda Roman: Well, it's certainly invoked a lot of fear. To answer your question, I think that the preliminary studies have shown overall that patients with cancer are more likely, which is not shocking, are more likely to die from COVID than others. But we've continued all the cancer care here because we're fighting a bigger enemy than COVID. We've made some adjustments when the data allows for options to try to avoid doing things that might mean a long ICU stay because we're trying to protect patients and we never know how available the ICU's are going to be with everything that's going on. But for the most part, we've continued chemo, we've continued cancer care, and at least the patients I've seen have done very well.
I know that of a few patients within the cancer centers that have tested positive in the area, all of whom have done fine, but obviously if you actually get COVID and you get ill and you can't get your chemotherapy because you're too sick, that could be a big problem even if you survive the COVID.
Amy: Right. Right.
Dr. Lynda Roman: So definitely cancer patients are a more vulnerable population and we're doing everything we can to keep them safe.
Amy: Yeah.
Dr. Lynda Roman: And we'd really prefer they not be the ones to catch the disease.
Amy: Yeah. I can think back to even when my mom was really sick and she was so stringent about just keeping sickness away in general, obviously there was no pandemic at the time. So I would think that most people fighting cancer, that's already part of their sort of routine, but I would assume they would kick it into high gear. But of course this has been unprecedented and nobody knew. So before we even knew about it it was already present.
Dr. Lynda Roman: Yeah, yeah. We got a lot of information all over the place at the beginning.
Amy: Right.
Dr. Lynda Roman: We were getting hints, but for a multitude of reasons we weren't really getting the information we needed; it was a very complex situation and there are many, many reasons for that, but the bottom line is we didn't have the information. It's always problematic when you make decisions with hints and speculation and in medicine they teach you get the data first, be sure the data is right, and then make your decisions.
You just got to use your critical mind to assess it and react to it, not based on your emotions and not based on wishful thinking, or anger or whatever the million emotions are, but you have to just look at the data and make solid conclusions, and that's how you're going to make the best decisions.
Amy: Yeah.
Dr. Lynda Roman: The other concern with cancer patients is immune therapy. There have been concerns since a lot of the healthier people have died of COVID seemingly because of their immune system's over responding and creating enormous damage. And there's been concern that immune therapy might make this more likely to happen. Because that's kind of how it works, it's stimulating the immune system and I could understand what the concerns are about, but I don't think we have in any way have been able to prove that that's really the case. So we have not stopped immune therapy.
Amy: Immune therapy. Okay. That's interesting. One of the things I've been talking to different people about and friends of mine is how many people have not gone to the doctor in the last three months and missed checkups and in particular relevant to this conversation, women who haven't seen their gynecologist or haven't had their mammograms. What are your thoughts on that?
“There's a reason we have a national government and so many agencies that are activated when it comes to pandemic — it's a national security issue.”
Dr. Lynda Roman: Yeah, well, it made perfect sense when this whole thing blew up not to go in because we were very much in the midst of an unknown. I cannot emphasize enough how we were not as a medical community prepared and how much distress there was from the lack of information. There's a reason we have a national government and so many agencies that are activated when it comes to pandemic — it's a national security issue.
But it was extremely problematic what was happening as far as communication. And it became almost like the whole thing became politicized rather than data-driven. But so we were a mess. We did not have adequate equipment.
So to go to see a doctor under those conditions would have been a bad idea, but a lot has changed. We now do have much more access to testing, most hospitals test everyone who gets admitted or who's going to surgery. We have much more protective gear. We have definitely more knowledge about this virus and what happens and who's vulnerable. So most hospitals have opened up operations, including us here. And I wouldn't hesitate at this point to go.
I'm pretty optimistic we're going to get a vaccine. I hope it's sooner rather than later, but I truly don't know. There's a very real possibility this is going to be our world for a while longer. And how long do you want to put these things off?
Amy: Right.
Dr. Lynda Roman: So I never stopped coming to work. And I must say at the beginning, it was a little bit of a surreal experience, but maybe because I've been doing it every day and I see all the safety measures and we have been very, very effective here at preventing issues. We've done some telemedicine, but we have resumed the in person visits as well. How do you do a pelvic exam with telemedicine, right?
Amy: Yeah.
Dr. Lynda Roman: We've resumed the visits and honestly, I'm much more at peace about that than I am doing some other things that are permissible today because I kind of feel this situation here is tried and true.
I think at this point physician's offices. for the most part, those that are open, have now prepared themselves to keep people safe.
Amy: Are you optimistic about future of gynecologic oncology, even during times like this?
Dr. Lynda Roman: You know, I have to say, gynecologic oncology has always been a big challenge; there's so much competition for resources. And it's been hard to get both national attention and adequate advocacy for a multitude of reasons. With COVID, everyone's focusing on it and you know what's going to happen? We are going to come up with solutions. If you can really focus intently, good happens. And I am seeing you and others like you who are stepping up. And, with some good luck, we've gotten some really powerful people paying attention.
We're working on a platform trial and we have quite a bit of backing. A platform trial's just a much more nimble, fast-acting trial and it highlights resources. Because you know what, Amy? The answers are there, I'm sure of it. I'm sure that we will make very significant headway if we can just get some great minds to focus on this disease. And we're benefiting from knowledge in other cancers as well. It turns out the cancers have a fair amount in common with each other. So my answer is, I can't always say I have hope for the way people carry on, but I definitely have hope for the future of gynecologic oncology.