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UMGCC NEWS

Q&A: Meet H. Richard Alexander, Jr., M.D., New UMGCC Surgeon and
Associate Chairman for Clinical Research in the Department of Surgery

H. Richard Alexander, Jr., M.D., an internationally known surgeon who specializes in treating gastrointestinal and endocrine cancers, has joined the University of Maryland Marlene and Stewart Greenebaum Cancer Center (UMGCC) as a surgical oncologist in Division of General Surgery’s Section of Surgical Oncology led by Nader Hanna, M.D. Dr. Alexander will also join the faculty of the University of Maryland School of Medicine, assuming the role of associate chairman for clinical research in the Department of Surgery.

Dr. Alexander comes to Baltimore from the National Cancer Institute, where he was deputy director of the NCI’s Center for Cancer Research. His research interests include perfusion techniques to treat patients with advanced cancers of the limb, liver and peritoneal cavity.

What made you decide to come to the University of Maryland?

I enjoyed my time at the NIH and felt very lucky to be able to do a lot of the work that I think is important in developing novel treatments for patients with very difficult cancer diagnoses. I had looked at a few other positions from time to time, but never seriously considered them for one reason or another. However, when I first became acquainted with this institution and it’s people, I immediately sensed that being a part of this organization represented an unprecedented opportunity for me.

I knew Dr. Cullen (Kevin Cullen, M.D. director, University of Maryland Marlene and Stewart Greenebaum Cancer Center) from his days at Lombardi Cancer Center at Georgetown University, and he invited me to come see what was happening at the University of Maryland. When I came to visit, I was very impressed. I felt that there was a lot that I could do here as a researcher and as a surgeon. The purpose and the goals of the medical center, so prominently displayed right in the front lobby, are the same values and goals that I have as a physician: to make advances in treatment, to improve the health of the people of Maryland, and to provide leadership to the community and to the field of medicine.

As I got to know some of the people here, I saw that they share tremendous vision and leadership. I have great respect for Dr. Cullen and Dr. Bartlett (Stephen Bartlett, M.D., chair, department of Surgery, University of Maryland School of Medicine). It captured my interest that I could be a member of a team that was committed to advancing the reputation of the University of Maryland as a premier public biomedical research and treatment institution.

How do you envision yourself fitting into the UM program?

I look forward to filling a number of roles here to help the medical center build on its ongoing successes. I look forward to helping the cancer center develop its portfolio of clinical and laboratory research activities. I would also like to help both the department of Surgery and the cancer center recruit additional talented, young leaders to be a part of our team and to further our mission.

Teaching is something that I have always enjoyed, and I’m particularly eager to become more involved in teaching the next generation of physician leaders in this country. That goes all the way from medical students, to residents, to junior faculty members in the department.

Integrated with all of this, I have my own personal research program that I would like to see established and developed at the University of Maryland.

Talk a little bit about your clinical practice.

My clinical practice has two major areas of focus. The major part of my practice is surgery for cancers of the gastrointestinal tract, especially advanced cancers of the liver and peritoneal cavity.

I also treat individuals with endocrine disorders — thyroid, parathyroid, adrenal and endocrine tumors that arise in the pancreas. We’ve had a very active program at the NIH for many years and individuals are referred there from around the country for these relatively unusual conditions. I would certainly like to continue that program at Maryland.

What are your primary research interests?

My research is principally related to developing new therapies for individuals with advanced solid organ cancers, especially of the intestinal tract. We have certain types of very innovative surgical procedures that allow us to deliver intensive doses of novel therapeutic agents to particular regions of the body that can improve the outcome of these individuals in many cases.

I’ve been very involved in developing a treatment called isolated hepatic perfusion (IHP). This is a technique that involves operatively preparing the liver and connecting it to a machine, just like the heart-lung machine used in open heart surgery. By completely controlling the flow of blood to the liver, we are able to circulate high doses of chemotherapy drugs to that one organ, in concentrations that you could never possibly give safely to the entire body. This technique allows us to eliminate a lot of unnecessary side effects while we intensify the treatment to the liver in a closed-loop system.

This treatment addresses an important clinical problem, because the number of individuals who develop liver metastases from any number of different types of cancer in the U.S. each year is very high. It’s been estimated that of the 150,000 new colorectal cancer diagnoses that are made each year in this country, up to 30,000 of those individuals will develop liver metastases. The liver is the site where the blood from the intestines is first filtered or directed. Because the liver is an essential organ to sustain life, treatments directed to keeping it healthy and preventing tumors from progressing in that one organ will translate into a meaningful clinical benefit for those thousands of individuals.

The challenge with IHP is that it is a complicated therapy to administer, and it requires a lot of resources. It is still an experimental procedure. But the medical center here is committed to developing innovative new treatments, so I am very excited about the possibility of establishing that program here.

Did you personally develop this new technique?

IHP was tested back in the 1950’s, but the technique was largely abandoned for many years. The initial reports indicated that it was difficult to do, there were a lot of side effects associated with it, and no one had really looked carefully at whether or not it was of significant benefit. At the NIH, we thought that it deserved a second look, so we’ve been refining the procedure and have performed it in several hundred individuals. The data indicate that it deserves continued development because it has the ability to cause regression of very advanced cancers, even in people who have already been treated with standard chemotherapeutics. The results are now encouraging enough that other centers are beginning to do it. I look forward to starting new clinical trials at the University of Maryland to continue to develop this technique.

The University of Maryland is partnering with the state of Maryland to use tobacco settlement monies from the Cigarette Restitution Fund Program to conquer cancer and other tobacco-related diseases. Was this a factor in your decision to come here?

Yes, very much so. Maryland is fortunate to have a state legislature that has made the commitment to use tobacco settlement funds for cancer research, prevention and health care, especially for those without adequate insurance coverage. This program allowed the University of Maryland to attract a leader of Dr. Cullen’s caliber, and he was, in turn, able to recruit other talented clinicians and researchers, such as Dr. Sausville (Edward A. Sausville, M.D., Ph.D., associate director for Clinical Research at UMGCC). The opportunity to do important work with these individuals in an atmosphere that supports and encourages new research into cancer diagnosis, treatment and prevention was a huge draw for me. With the field of oncology poised on the verge of important advances in the next few years, Cigarette Restitution Fund monies will go a long way in helping to make the promise of new discoveries a reality in the lives of the people of Maryland.

What trends do you see developing in cancer treatment in general, and in surgery in particular?

The field of cancer treatment is moving fast, and the role of surgery is constantly being redefined. For example, as a surgeon, I’m being asked more and more to remove cancers that have metastasized, or spread to other parts of the body. In the past, this was not considered to be a standard or routine application of surgical treatment for patients.

Now, with more effective chemotherapeutics, we can take advantage of the strengths of two different disciplines: surgery to remove the bulk of all visible tumor, and then chemotherapeutics to attempt to eradicate any microscopic metastases that may be left behind. This kind of approach is going to be used more and more in the future.

Certainly, when people have localized disease that’s potentially curable by surgery, it’s almost routine now that they receive preventative chemotherapy. So, it’s important that those patients go through their surgical treatment without complications that would delay them from receiving potentially lifesaving additional therapy. The expectation that we bring them through their procedure safely and quickly and allow them to recover and move on to the next phase of treatment is very important. In that context, minimally invasive procedures have generally been underutilized in cancer treatment and need to be used more routinely.

What advances in cancer treatment do you see on the horizon?

We are moving into an area that I believe is going to be a reality in my own professional lifetime, which is that of personalized oncologic medicine. This is where treatments are tailored based upon a fundamental analysis of an individual’s tumor — known as gene expression profiling. Instead of treating entire classes of patients identically when they have one type of diagnosis, this new technology will allow us to look at the tumor on the molecular level and tailor the treatments more effectively.

This approach involves characterizing what specific types of genes or protein pathways are activated in a tumor that are necessary to sustain its malignant characteristics. In that context, surgery will have an important role, because obviously harvesting the tumor so that it can be analyzed on the molecular level is very important.

Another area that I think is very interesting is that of prophylactic, or preventive, surgery. As we understand more and more about how cancers develop, we recognize that there are certain types of genetic alterations that occur early on in tissue, before it actually becomes malignant. Having an understanding of how those processes work allows us to engage people and talk to them about removing organs that are at high risk of developing potentially lethal cancers if left in place. This is already being done routinely in patients with breast, colon and thyroid cancer and I think it is going to expand.

As an example, there is an inherited form of thyroid cancer that, when an individual has the gene mutation, guarantees that they will develop the cancer. And, if the cancer is allowed to develop and spread to lymph nodes, 100 percent of patients will die from it. So, when the gene mutation is recognized, a prophylactic thyroidectomy is recommended. This is a very good example of how, by understanding the particular pathways that result in a malignant transformation of the tissue, we can offer an intervention to prevent that cancer from even developing.

What are your goals in the areas of cancer prevention and early diagnosis?

This is an area within the field of oncology that we really need to develop. The cost to an individual and to society of treating one cancer is enormous. If we could take that money and direct it towards the prevention of another one or two, ultimately that’s going to develop into a huge cost savings, not just in terms of money, but in terms of time, emotion, and lives saved. I would like to see us focus on developing really robust screening programs for the community that we serve to help identify these conditions early on when they are curable, or even preventable.

As sophisticated as they are, our diagnostic and imaging technologies are not perfect. There are ways now that we can use complementary types of screening tests to help identify those who need to receive further evaluation. I am very interested in the field of serum proteomics. This is a fascinating field that’s really in its infancy but that has huge potential. Basically, it’s predicated on the understanding that within the body, whenever there’s any kind of pathological condition, the presence of that condition results in the release of minute amounts of protein debris in the bloodstream. We are now learning how to identify those minute amounts of proteins and understand what they mean in any one individual patient.

I think it will not be too far into the future where we may see an individual who has an abnormality on a CT scan of their chest or abdomen who would normally be recommended to undergo invasive diagnostic procedures. Soon we might be able to do a blood test and a proteomic analysis of their serum and tell whether or not that finding on CT scan is benign or malignant, possibly saving them further invasive procedures. I think this will become a reality very quickly.

In the future, with a blood test, we will be able to confirm whether a vague abnormal finding on some other kind of screening test is one to really worry about and do further testing or one that could be safely left alone.

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This page was last updated on: February 5, 2009.