Dr Sacchini, nowadays is there much difference between the quality of the doctors in Italy, Switzerland and the United States?
The quality of doctors is very good everywhere. Globalization of medicine means that protocols are now online internationally, and new medications are available around the world. There is better access to information, because on the web it is possible to follow several cancer conferences around the world and to have real time information and to discuss their findings with different investigators. The standard of care is similar, at least for cancer, in the entire world.
You are an oncologist specializing in women’s breast cancer. You started in Milan, working closely with Dr Veronesi, and then were invited to America. Has there been a lot of progress since you started?
There is a lot of progress in general for the diagnosis and treatment of cancers. For breast cancer in women the screening and identification of high risk patients with the use of genetics is better and better, diagnosis is earlier and earlier, and the treatments are more targeted.
What is the percentage of women who survive breast cancer?
The probability of curability is constantly improving. It depends on the stage and type of cancer, but the probability for a woman with breast cancer to be alive in five years is now about 90 percent. That quite good percentage increases to 98 percent if the patient is diagnosed at stage one. Early diagnosis is still very important.
Should women have a regular check-up?
Mammography to detect early cancers should start when a woman is 40, and continue every year until she is 75. This can really increase early diagnosis and improve patient survival. Unfortunately, in these Covid moments, we are seeing an incredible drop in screening for all cancers. Mammography for breast cancer screening dropped by 85 percent, and the same percentage for colonoscopy for colon cancer.
In the United States, or also in Europe?
Europe and the United States are more or less the same. The drop in screening for breast, colorectal and lung cancer is quite impressive. This is of great concern because it means that in future we will diagnose later stage cancers. We are now diagnosing 40 percent less skin cancers.
“Mammography to detect early cancers should start when a woman is 40, and continue every year until she is 75″
Memorial Sloan Kettering Cancer Center mammography technologist Jamie Thaniotis guides a patient through a mammogram
Dr Sacchini, have patients who are afflicted by cancer or heart problems been neglected because of coronavirus?
Absolutely. The health system is concentrated on treating Covid patients. It is an important emergency, so there are fewer resources for other diseases. Plus, patients don’t want to go to hospitals because they are afraid of getting coronavirus.
The Sloan Kettering in New York is a hospital which specializes in oncology. What happened to your work there during coronavirus?
During the highest pandemic peak in April and May we were only able to operate on urgent patients because all the resources were for Covid patients. We had to delay the treatment of non-urgent cancers because we couldn’t operate, but cancer is always an urgent matter because sooner is better.
In America coronavirus was not treated with tremendous success in the first wave. We are in the middle of a second wave, is the health care system functioning better?
It is much more prepared in terms of the identification of coronavirus carriers, and better prepared in terms of quarantine and isolation of coronavirus patients. We learned how to treat coronavirus patients better and there is less mortality.
Why did some areas have more mortality than others?
Probably because of population concentration, which in some areas of New York – Queens, the Bronx, Brooklyn – is high. There are buildings in which thousands of people live. In the same manner, in Lombardy, in Milan, the density of the population is quite high. The virus is more contagious where you have a high density of people.
What is the better treatment that you have learned to give patients with Covid-19?
Some protocols are a little different, but in the United States the protocol is quite uniform. At the beginning they treat with cortisone, anticoagulants like heparin – because the virus can give blood clots – and antivirals. This early stage protocol is often applied to patients at home instead of admitting them to hospital. Treatment at home is a good solution for patients if they don’t require ventilators or heavy treatment, because they are better isolated. In Italy when there was this incredible flare up patients went to congested emergency rooms and hospitals. For the most part, patients can be treated or monitored at home without going into and overflowing their hospitals.
Is monitoring the oxygen concentration very important?
If the oxygen concentration drops to below 90, 89, 88 percent, it may be worrisome, and then the patient has to go to hospital. Monitoring is important, as is having the resources for calling these patients to be sure that they are self-monitoring.
The Trump administration did not give great importance to coronavirus. Will health care be better in America under President Biden?
We didn’t see a big difference in treating patients between the Trump administration and the Obama administration. We were able to take care of poor patients with Medicaid, and we were able to take care of Medicare patients. We didn’t see any restriction in the quality of the treatments and available drugs. With the Obama administration there was probably an increase in the number of insured people with respect to the uninsured, but I don’t think the difference is very important.
Wasn’t it dangerous to minimize the importance of Covid and wearing a mask?
Precautionary action such as isolation is very important, and masks can really decrease the spread of the virus. Nothing is a hundred percent, and the impression is that the virus may continue to infect the population until we have a vaccine. If the concentration of contamination is in a narrow time interval the health system may collapse, because an incredible number of people require treatment. If contamination is spread over months and weeks we have less stress on the health system, because you’re not going to have a lot of sick people at the same time.
“We need to tell the population that there are important diseases, not only the coronavirus, to prevent and to treat”
Dr Sacchini, they have found, or at least announced, three types of vaccines, two from America and one from the UK. These are not exactly the same kinds of vaccine, but they all say that they have 90 to 95 percent success rates. What is your opinion about this?
The two types of vaccines work very well. The mRNA one is able to stimulate the body to produce antibodies against the protein that would allow the virus to enter the cells. The other one is classical vaccination with a similar, but not so dangerous virus as the real virus. Vaccines are the only way to protect people and stop the spread of this disease, and in my opinion they are quite safe. There was an incredible effort to maintain the classical phase 1, phase 2, and phase 3 studies, so as to be able to declare a vaccine really safe and effective before approval. With all vaccines there are sometimes side effects, but we need to accept this, because if you calculate the risk and benefit, the benefit is much more than the risk. The only difference in approving these vaccines was the time. They developed everything much faster than in the conventional vaccine, first because there was an emergency and second they had a lot of support. I don’t think these vaccines would have any more side effects than the conventional vaccination that we give for the flu. You cannot exclude the possible increased risk of side effects, but, by looking at the studies, the side effects seem to be very acceptable.
Is there optimism?
Here in the States, with the Pfizer and the Moderna vaccine, they are speaking about vaccination in a couple of weeks, and especially for health workers, for whom the vaccine wouldn’t be mandatory, but if you don’t get the vaccine you may have some restrictions. Probably vaccination will give you confidence and liberty in doing things.
When do you think that we will be confident to see each other again, to go to the cinema, to lead a normal life without suspicion and fear?
For me a normal life would be normal screening, normal operations, normal treating of my breast cancer patients. This is my priority. If you look at history, sooner or later people return to normal. The problem is that we don’t know enough about this virus. We know that it can change and we know that at a certain time it will disappear or only remain in a little bit of the population. It’s very difficult to predict, but I hope that in a couple of years we will be completely back to normal.
This was an incredible lesson for a humanity which forgot the pandemics and forgot plagues like the Spanish flu. Health systems and the population will be much more prepared for these possible diseases. We cannot exclude that we may have another virus in the future.
As a cancer doctor and a professor of medicine, how did you personally face this Covid period that has now lasted more or less a year?
First we were concerned for ourselves, because we are very exposed. Not exposed like intensive care doctors, but we see and treat Covid patients with cancer so we are exposed, and are concerned to get the coronavirus and die. I have a colleague who almost died from coronavirus. We need to be very well protected, but in the meantime we need to treat, because we estimate that delaying diagnoses brings an increased mortality for cancers in general by 10 percent in the next 5 years. Every year, almost 10 million people in the world die from cancer. This means that we may expect 11 million to die in the next years due to this pandemic. We need to treat, we need to treat. We need to tell the population that there are important diseases, not only the coronavirus, to prevent and to treat. Specialists in cancer, in the heart, in neurological disease, need to tell people and patients that we are ready and they don’t need to be afraid to search for prevention and treatment.
What did you learn for yourself in this situation?
I learnt that life can be very unpredictable. Several times I was scared that I got the coronavirus, not sleeping at night, with palpitations, difficulty in breathing, telling myself I probably got the coronavirus from that patient, now I may die from the coronavirus. It is an incredible stress, not only for the population, but also for the health workers. My colleagues, my nurses are the same. Every two weeks we need these mandatory swab tests to try to maintain a Covid free environment in our hospital, and it is always a relief when this is negative. We have learnt to fear an invisible enemy that can really kill people.
It is not surprising that there is fear. We are all human after all.
We are human, of course, but we need to take care of patients and the problem is that we operate less. We have fewer patients because they don’t do the screening. In these months of pandemic, we have 35 percent less cancer patients. 35 less. Why? Because they are not doing the mammography, so they are not diagnosed. Six months from now we would have 35 percent more, because the patient would be diagnosed, but unfortunately with a later stage.
Even with Covid-19 is the heart the number one cause of death?
First is the heart, and, unfortunately, corona can increase the risk of heart problems, blood clots and stroke. The second is cancer. As I said, 10 million people die every year from cancer in general. This doesn’t mean that we don’t need to take care of the coronavirus now. Absolutely we do. But we must not forget about the other patients, the other diseases that are very important.
Early Diagnosis by screening mammography of a Stage 0 Breast Cancer (Ductal Carcinoma in Situ)
Stage 2 Breast Cancer with palpable mass and palbable axillary lymph-nodes
At Memorial Sloan Kettering Cancer Center all diagnosed cancers are checked for mutated DNA in the blood stream to see if the cancer DNA can be detected.
Memorial Sloan Kettering Cancer Center, New York
“Unless you move, unless you exercise, unless you experience collegiality, then you are at increased risk of cancer, heart problems, and mental problems“
Dr Sacchini, in the UK, the NHS has recently announced the trial of a new blood test to detect early stage cancers. What is your opinion about this?
It is not something new, but it is very exciting. The concept is that as soon as cancer cells develop they release some DNA into the blood stream. The DNA of cancer cells is different than normal cells, and can be detected by a process called methylation analysis. With this test we may not be able to understand what organ is developing a cancer, but we classify the cancer based on the specific mutation in the DNA cancer cells. The classification of cancers would be at this point based more on genomic (specific mutation) rather than organ classifications. For example, the diagnosed cancer could be classified as HER2 positive cancer rather than breast, gastric, colon cancer, and the treatment would be based on targeting the mutation with specific drugs (in the previous example, anti-HER2 medications) with less damage to the normal cells.
The problem with this diagnosis is the possible false positive and false negative results, as in all diagnostic tests. We may detect different DNA without any clinical meaning. We know that mutating cells are continuously formed in the body and self-destroyed, a process called apoptosis, by the immune system. At Memorial Sloan Kettering Cancer Center we are doing a similar study in which for all diagnosed cancers we check mutated DNA in the blood stream to see if the cancer DNA can be detected. This study is in progress.
In Sloan Kettering hospital are you very advanced in new technologies?
Yes, because we have developed the concept of precision medicine. This means we can better identify patients at high risk for cancers and screen these patients, women and men, in a different way. DNA study is important to identify mutations, and it is important probably in Covid too, because there are some men and women who are predisposed to Covid due to some genetic differences. Also the treatment can be different, because we saw that cancers are very different from the DNA point of view, and we can identify the DNA abnormalities, the genomic alteration in the DNA of cancer cells, and treat it in a different way with specific medications. DNA is really improving not only the diagnosis, but also the treatment of cancer, and especially precision treatments. Not blind treatments that may or may not work, but very precise treatments against a specific cancer cell.
Are these two years or so of exceptional life due to coronavirus going to impact the mental and physical health of the young generation?
Yes, and not only the young generation, but everyone. Unless you move, unless you exercise, unless you experience collegiality, then you are at increased risk of cancer, heart problems, and mental problems.
Are politicians in the Western world handling the situation decently?
They have an incredibly difficult position, trying to decide between the economy and the health of the people. It is a matter of life and death at a certain point. And also, this virus became political, with virologists from the left and virologists from the right, and science has to be based not on political parties but on scientific evidence. The problem is that we don’t have enough scientific evidence from this virus. The difference between the United States and Italy was that in the United States Anthony Fauci was the one voice of the National Cancer Institute, the National Institute of Health, and everyone followed his recommendation as he is a man of incredible experience. In Italy there were many opinions from different virologists, telling one thing one day, another thing another day, and sometimes the virologists were not very well qualified. For instance, veterinary virologists appeared every day on the major networks and of course in animals you have a different approach. It is not right to have several voices which are not coordinated by a single system like the National Health System and Institute in the United States.
You are a professor in New York and in Milan, and sometimes in Zurich. By looking at your students, do you think the doctors of tomorrow will be different from those of today?
They will be different because they will have more technology available. When I graduated, we didn’t have CT (computed tomography) for instance. Now you cannot practice without CT. With more technology available they need to be more and more familiar with those new technologies. They may work better, be more precise in diagnosing and treating. I see a lot of enthusiasm in the students, and I’m very happy about that.
Will the impact of artificial intelligence be important in the field of medicine?
Yes, especially in the evaluation of ‘big data’. There are amazing systems into which you can enter incredibly ‘big data’ and then the artificial intelligence can look at the data and make some final diagnoses. For instance, if you are working with X-rays and you put the X-rays into the system, the system is able to analyze down to a single pixel of an X-ray. Then you give the system the diagnosis on a specific X-ray, and at the end of the story, analyzing millions, billions, trillions of pixels, the system can make the new diagnosis by itself. This can really help. The other thing is the so-called Watson system, into which you put all the data of the patients that you treated for a specific disease in the last 10 years. Then you put in the results of the clinical trials, you put in everything you know, and in real time when you enter the data of your new patient the system looks at what happened in all the 2,000 or however many previous patients. That can give you both the diagnosis and the treatment. But at the end of the day you cannot substitute the physician. There is always a margin of error, like when they auto pilot a plane. You can sleep and the plane will do everything alone, but if something different and unpredictable happens, the pilot -who is the doctor – can provide the treatment and the diagnosis.