MS. WINFIELD CUNNINGHAM: Good morning. I'm Paige Winfield Cunningham, a health policy reporter here at The Washington Post and author of the Health 202 newsletter. Welcome to our program, Chasing Cancer, where we speak with some of the most influential names in oncology.

Today I'm delighted to welcome my first guest, Dr. Carl June. He's one of the world's leading immunologists, a pioneer of CAR T-cell therapy, which was first approved by the FDA in 2017.

Dr. June, welcome to the program, and thanks for joining us.

DR. JUNE: Thanks for having me, Paige.

MS. WINFIELD CUNNINGHAM: Today we're going to talk about cutting-edge treatments that, of course, you pioneered, but first, I want to talk about the coronavirus. And I know that you yourself have had the virus and recovered. Can you tell us a little bit about that experience and what it was like?

DR. JUNE: You know, for me, it was early on. It was before actually widespread testing was available, and I didn't require hospitalization. So, I was lucky, and I've had a complete recovery.

But I'll say it's had a major effect on our cancer therapies, just the pandemic, and we could talk more about that.

MS. WINFIELD CUNNINGHAM: Well, absolutely. And recovering from the virus, I know that you're joining the fight to find a drug therapy to try to combat it. Can you talk a little bit about that progress?

DR. JUNE: Sure. One of the main issues with COVID is not just--it's the number of people who actually require hospitalization and that advanced care. So, the asymptomatic or low-symptomatic patients who stay out of the hospital, actually, then most of them become immune and contribute to herd immunity.

So, the problem we face right now, as you know, is overcrowded hospitals and lack of beds and intensive care units. So, if we could give a medication to people as an outpatient that could keep them from ever getting hospitalized, that could have a huge--relieve a big burden on the medical care system.

One approach is to prevent the inflammation that causes secondary damage in the lung, and so tuning down--it's counterintuitive, but tuning down the immune system appears in several models to decrease the need for hospitalization and death.

The RECOVERY Trial that came out this summer showed a 40 percent reduction in death using an immunosuppressant, that pill dexamethasone, which is an immunosuppressant, which is really counterintuitive. Everyone thinks that when you have an infection, you need to jazz up the immune system, and so now it looks like what we need is a balance, not too much and not too little.

MS. WINFIELD CUNNINGHAM: Well, this idea that the immune system can actually be so revved up that that is the thing that can cause death, I remember reading about the 1918 flu, and this seemed to also be one of the causes of death. Can you explain to our audience a little bit more about how that works?

DR. JUNE: Yeah. That's exactly right, Paige. They've now found--so this is pretty amazing. They've been able to reconstruct the 1918 virus using molecular biology and sort of paleo molecular biology techniques, and then they took what we think is a standard flu virus--so this is influenza A--or put in the reconstructed 1918 pandemic virus into monkeys. Those monkeys had a much more severe infection and died compared to monkeys who got the standard flu that we face pretty much every year that's not a pandemic.

So that virus killed actually more young people than old. The traditional flu virus mostly kills older people and the frail. But the virus back in 1918 was very severe in people in their 20s and 30s. It turns out that it was because it actually turned on too much immune response, and then that led to damage in the lungs above and beyond what the virus itself caused.

So, this is similar to what we're seeing with some of patients who get COVID-19. A subset of them, not everyone, but a subset overreacts, and then this leads to more damage than the virus itself causes.

MS. WINFIELD CUNNINGHAM: And what are some of the drugs or treatments, then, that can be used when you're seeing this effect in patients, in COVID patients in particular?

DR. JUNE: Sure. There are a number--I mean, first of all, the best thing would be not to get the infection. Wear a mask, and stay--you know, until we all have vaccines, but there are people, as you know, getting infections and damping down the immune system.

So, one, right now, standard of care, emergency use authorization by the FDA is dexamethasone, which is cheap and off patent, and another now that we're testing is cyclosporine. This has been used in more than a million transplant patients and people with autoimmune disease such as psoriasis since the 1980s. So, it's very inexpensive, and we are testing that at a trial at the University of Pennsylvania. And there's a trial that is just opening at Baylor College of Medicine in Houston.

And in Europe, they have studied this retrospectively in Spain and found that it's very effective. It was the best drug to reduce mortality.

MS. WINFIELD CUNNINGHAM: So, while we're talking about this idea, I think it's called the "cytokine storm." So, we know that this can happen in COVID patients but then, of course, also in patients who have received this immunotherapy.

Can you explain a little bit how that works? And these drugs that you're talking about giving to COVID patients, are those drugs that are also being used for cancer patients who have received immunotherapy?

DR. JUNE: So, yes. So, this is called "cytokine storm," and it was first--you know, cytokine storm was first recognized with infections, so, as I mentioned, 1918 pandemic flu. Back in the Middle Ages, people got bubonic plague, and that also caused a cytokine storm. So, infections--and now some of our cancer immunotherapies are known to cause this, and the one that my lab developed, CAR T-cells, can cause a very severe form of cytokine storm.

It's actually associated with a leukemia being killed, but that we have patients sometimes who have pounds of tumor. And when all that tumor gets killed by the immune system that's basically jacked up, if you would, that hyperimmune response that's necessary to kill a lot of tumor can lead to very high fevers. We've seen fevers as high as 106 or 107 degrees Fahrenheit and is managed now very effectively with drugs that damp down the immune system during this time. And there's a number of them being tested.

The one that's FDA-approved for the treatment of CAR T-cell into cytokine storm is called tocilizumab, and there are a number of other experimental therapies that are being tested as well.

MS. WINFIELD CUNNINGHAM: I want to talk more about CAR T-cell therapy because, of course, you've done so much work on that, but just to stay on COVID for a few more minutes, of course, Pfizer announced earlier this week, a very high rate of effectiveness it's seen in its vaccine, more than 90 percent effective. What do you make of this news given that we haven't actually seen the data yet?

DR. JUNE: Well, you know, I haven't seen the data either. So, it will be given close scrutiny by the FDA and the National Institutes of Health.

The top-line results of 90 percent efficacy in a randomized trial are stunning, I have to say. The standard flu vaccine that we get, that I get every year and that you probably do, has only--if you're above age 65, which I am, it only has a 50 percent, at best, efficacy rate. That's a flu vaccine that we use.

So, this vaccine, the COVID vaccine, appears to be very highly efficacious, and from what we've seen--and there is an article in the New England Journal of Medicine published yesterday on the phase 1 and phase 2 trials. It's very safe. So, it looks to be highly promising.

I think the thing that we don't know at this point is--or really two things. One is durability. How long will it last? The vaccine that was just reported required two doses, so it takes two months to get fully immune, and then there are vaccines being tested that only require one dose. So, durability is going to be an issue. How long does it last? Do we need revaccination every year, for instance, like flu?

The reason, though, that we need flu vaccines every year is that virus changes. It's called "reassortment." So, the flu virus itself changes, and it's basically a coat, if you will, so that it becomes blinded to the immune system. And you need revaccination to the new strength.

As far as we know, the COVID--the SARS-CoV-2 virus, which causes COVID-19, does not do this. So, it's likely that when a vaccine may be long lasting with COVID and that virus and not require every year a vaccine like we have to have with flu, but that remains to be tested.

MS. WINFIELD CUNNINGHAM: Well, and that would certainly be encouraging news.

I think one other thing a lot of Americans are wondering about is who is going to get the vaccine first, and we know that the federal government has recommended that frontline health workers should be among the initial population. But what about people who have had cancer, who are, of course, immunocompromised because of that, who may currently have cancer or be in remission? Do you think that they should be next in line, or where should they kind of fall in the line-up of who should be prioritized for getting vaccinated?

DR. JUNE: So those are principles that have been done, for instance, routinely during triage, so during mass casualties. You know, ethics have been developed over the years on who to treat first and when you have a limited resource.

So in a case of--if you have organ transplants and there's a big waiting list for heart and liver transplants, they have a worked-out ethics of who gets that precious resource, and the same principles apply, in this case, with a vaccine, which is initially going to be limited in dosing and also an ability to distribute it and we have worldwide population at risk. So, it both needs to be looked at from low- and middle-income countries to ours, where we have the financial resources, but then there are the logistics. Do we have enough nurses and people who are trained to give the vaccines?

And then there are the recipients, which one--or as you just mentioned, people who have compromised immune systems and maybe where the vaccine would be less likely to die. There are people after organ transplants, bone marrow transplants who are unable to clear the virus right now. That was just reported recently. So, they become like Typhoid Marys. They can continue to shed the virus if their immune system isn't strong enough to get rid of it.

So, from a public health perspective, vaccinating those people as rapidly as possible to make them noninfectious would be important, but just so that they don't die from comorbidity, so patients with cancer, elderly patients, all the other comorbidities, obesity, diabetes, et cetera. Those people, I think, will be given priority first available.

We've seen an explosion, of course, in telehealth services as people have tried to avoid going to the doctor's office or hospitals if not necessary. How does that work for cancer patients, and are you worried that there is going to be a spike in deaths because of the inability of people to seek care at times?

DR. JUNE: So, yeah, that's been an unavoidable consequence of people afraid to go to the hospital. So, they're not getting screened. They're not getting their mammograms. They're not getting tested for symptoms. I think, without a doubt, that there will be shown to be retrospectively an excess burden not of just deaths during this pandemic from the virus but from cancer due to screening and then just delayed treatment. And we've seen that at our own institution where there's been a shift to people being treated with a more advanced cancer than we would traditionally expect. So, unfortunately, that's a side effect, I think. What we do have in that data is that PPE works. We have an extraordinarily low level of infection to our health workers in our hospital if they have appropriate training and access to PPE, and similarly for the people who come in, there is segregation now of people who are infected and who are not because of the availability of testing, which we didn't have, unfortunately, early on in the pandemic. So, it's now safe for people to come to the hospital, and they should be screened appropriately and get their care.

We have now much better telemedicine, as you referred to, capability so that some of our cancer care now is done remotely, both administrations of chemotherapies, et cetera, blood draws. So, there's much more flexibility than we've had in the past.

MS. WINFIELD CUNNINGHAM: You've really revolutionized treatment for blood cancer, and we know earlier this year, the FDA authorized or approved a third CAR T-cell therapy. Can you explain to us a little bit about how that works?

DR. JUNE: Sure. You know, it's been a dream of mine that we could take the immune system out of the body and then basically redesign it, using gene transfer techniques, so that you have T-cells in your body which normally they evolve to kill viruses. In fact, they're essential for clearing the SARS-CoV-2 virus that causes COVID. So, if you don't have T-cells, you won't clear that virus.

Now, in addition, you can take T-cells and give them a new job, if you will, with genetic engineering, so that also they become professional cancer killers. So, this has worked very effectively in leukemia, then lymphoma, and there's a number of diseases now. Basically, all the blood cancers will be treated with these kinds of engineered T-cells called CAR T-cells.

And right now, those are made by taking cells from your own arm and then they're manufactured at a manufacturing plant and come back a few weeks later and given to the patient.

Our first patient was treated in 2010, in August actually of 2010. He came back during the pandemic in August of 2020 here to the University of Pennsylvania, and we found two great things. One is he no longer has leukemia. It looks like we can say he's pretty--that with some confidence now that he's cured, but also, we found he still had those CAR T-cells. And they're still on patrol in him, 10 years later, after a single infusion. So, what that shows is that these cells are long-lived. They can last a decade and stay on patrol and prevent recurring cancer.

MS. WINFIELD CUNNINGHAM: How do you see immunotherapies fitting into the future of cancer treatment? Is there reason to believe that it may ever be kind of on par with the amount of people that receive chemotherapy or radiation?

DR. JUNE: Well, I think so. That's clearly the $64,000 question. I think it will happen. The question is really how long it will take.

A Nobel Prize was given out in 2018 for the invention and discovery of so-called "checkpoint antibody therapies," and those treat about 20 percent of all patients with what was previously uncurable cancer, from melanoma, the worst of the skin cancers, and now to lung cancer.

And now CAR T-cells, which we call them a form of "synthetic biology," because rather than just jacking up the natural immune system that checkpoint therapies do, with synthetic biology, gene engineering, we can actually make an immune system, if you will, into basically an Olympic immune system to do things it never was capable of doing as you were born with.

So, both of these together, I think, will lead to the treatment and cure of more and more cancers, and the big issue now for CAR T-cells is making them work in solid cancers, you know, the common so-called epithelial cancers. Most cancers people die of are in the GI tract, colon cancer and pancreatic cancer and so on that are really very hard to treat unless they're found early.

MS. WINFIELD CUNNINGHAM: Well, all this seems so promising, but what would you say is the next big barrier to expanding this treatment for people?

DR. JUNE: Well, right now, the most common blood cancer is myeloma. There's about 30,000 advanced cases a year diagnosed in the U.S., and it's generally incurable. It's really an awful disease if you've ever seen anyone suffer with it, and it looks like two or three companies will now--that will probably be the next big forefront where they will get FDA approval to treat myeloma.

So, what that brings out now is we need the infrastructure. Whenever you have a brand-new technology--this happened with IT, computers, and so on--initially, you have something that's really good, but it can't go out to the masses because it takes a while to scale that. We're seeing that very much.

I make CAR T-cells, but the car automobile industry is having exactly that issue with electronic--you know, electric battery-powered cars. They're much better for the environment. They're cheaper on maintenance, and all have many kinds of advances, but they need--it's taking time to make enough of them to get the demand. And it's similar to that with these CAR T-cells because there's an entirely new manufacturing process that's much more complex, The cells are made from your own arm, and then unlike the standard drugs we get where one of them works for everyone, it's the same drug for everyone, these are your own personalized cell therapy. So, it's a much more complex logistic, but the advantage is it's curative in most cases, and it's a one-time therapy. You don't have to keep getting it over and over like many kinds of chemotherapy.

So, the patients prefer it, but it's not ready yet for prime time for everyone. It's going to take time, like all new technologies.

MS. WINFIELD CUNNINGHAM: Well, unfortunately, we're out of time, so we'll have to leave things there. Dr. Carl June, thank you so much for joining us for this fascinating conversation.

DR. JUNE: Thanks very much, Paige. It's really been a pleasure.

MS. WINFIELD CUNNINGHAM: We have much more of our program coming up. We'll be back with Wajahat Ali and Dr. Sarah Kureshi in just a few minutes. Please stay with us.

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MS. HERTZKA: Good morning. My name is Camille Hertzka, vice president and head of Oncology U.S. Medical at AstraZeneca. We are delighted to be here today as part of AstraZeneca's YOUR Cancer program, which spotlights those in the community working to really fund cancer car with an emphasis on medically underserved patients.

We've invited one of the foremost experts in cancer genomics and precision medicine to join us for this discussion, Dr. Lincoln Nadauld, vice president and chief of Precision Health and Academics at Intermountain Healthcare.

Our discussion today will explore how the COVID-19 pandemic has disrupted cancer care and brought to light challenges within the health care system that we must address together. We'll look at how we can work to identify cancer earlier to improving screening and testing capabilities, leveraging digital platforms, and prioritizing personalized medicine, all in which will help realize our mission to redefine find cancer treatments to ultimately one day eliminate cancer as the cause of deaths.

Dr. Nadauld, I want to take our time today to talk about the state of cancer in America. We know that immunotherapies have transformed the way cancer is treated, extending survival rates, improving quality of life, and clearly bringing new hope for the future. However, many patients are not treated use with the precision medicine approach. In your view, what are some of the most urgent barriers to implementing the broad adoption of precision medicine, and what are some of the solutions?

DR. NADAULD: Well, you know, Camille, the advent of precision medicine and immune therapies have really transformed the treatment of cancer. We are seeing patients do well and live longer in ways that we never anticipated.

The biggest barrier currently for patients to get access to that care is getting the right kind of testing. We simply need their physicians to use precision medicine testing. That really means using comprehensive genomic testing to know which treatment a patient should receive. It's only when we know what kinds of genes are present, what kind of biomarkers are present in a patient's cancer that we can really give them the appropriate, targeted, tailored therapy that is individualized for them. And when we do that, which is the essence of precision medicine, then we really see the best outcomes.

MS. HERTZKA: Thanks for that.

And, actually, earlier this month, you were recognized with the Cancer Community Catalyst for Precision Medicine award for your work with Intermountain Precision Genomics. Can you tell us a little bit more about your work?

DR. NADAULD: Yes. Well, the Cancer Community awards are sponsored by Scientific American and AstraZeneca, and they are given annually to innovators and researchers who are working to advance cancer care. And I was awarded for the Catalyst for Precision Medicine, and it was a complete surprise, totally unexpected, very flattering. And I'm very grateful, and it really was given in recognition for our efforts to identify how precision medicine improves outcomes, and what we found is that applying precision medicine to patients with advanced cancer can nearly double their survival, and it can happen in a way that it costs less to health care systems overall. So that combination of improved survival at lower overall health care costs is really innovative, and that was the reason for that award.

So, we're thrilled that it's working for patients, and we need it to be available more broadly for more patients everywhere.

MS. HERTZKA: Well, thank you for that, and congratulations again. It's extremely important work that you are doing.

Can I ask you also what are you the most excited about when it comes to innovation on cancer care?

DR. NADAULD: I'm just so excited about the pace and acceleration in change. We have seen advances, as I mentioned, in precision medicine and immunotherapy, and we're seeing patients experience results that we never would have guessed, patients with advanced cancers who go into remission. We would not have seen that five years ago. So, it's very exciting to be in cancer care right now, and I believe this is only going to continue.

So, it's really important for patients to advocate for themselves. A patient could ask their doctor, "Am I a candidate to receive precision medicine? Am I currently receiving precision medicine? Have we done the right kind of testing on my cancer? Have we looked at all of the genes in my cancer?" As patients and doctors work together to advocate for each individual patient, that's when we see the best results.

MS. HERTZKA: Thanks. I agree. This is a really important approach. Thanks for raising this.

Anything else you would like to share in closing?

DR. NADAULD: I just want to congratulate all of the doctors and care providers out there who are working so hard every day to help patients be as healthy as they can, and I am cheering on all those patients out there. So often, cancer patients can sometimes feel alone or like they're in a fight, and they don't have the support they need. When we come together as a community to really help cancer patients, we can help them fight through their treatment and have outcomes that they wouldn't be able to achieve on their own. So, we all need to work together as a community.

MS. HERTZKA: Yeah. I cannot agree more. It will really take all of us, the entire community, to come together to ensure all patients have an opportunity to benefit from the latest innovative medicines and to ensure that we can identify the right patient for the right treatments, as you mentioned earlier.

Because of the COVID pandemic, we continue to see declines in the rates of cancer diagnoses across the country, and of course, we know that it doesn't mean that fewer patients or fewer people are getting cancer. Rather, many are going undiagnosed until their cancer will reach a later stage, and they might have a poor prognosis at a later stage and potentially also less treatment options.

We're working to ensure that all of us will prioritize our health and hope to continue to convene and amplify the work for those supporting the cancer community.

You can learn more about these efforts at newnormalsamecancer.org and at yourcancer.org.

Please join me in thanking Dr. Nadauld for his participation here today and his tireless work on behalf of those living with cancer.

And I'd like to now turn it over to The Washington Post.

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MS. WINFIELD CUNNINGHAM: Welcome back. If you're just joining us, I'm Paige Winfield Cunningham, a health policy reporter here at The Washington Post.

And my next guests are Wajahat Ali and Dr. Sarah Kureshi. Waj is a journalist, author, and TV news commentator. Sarah is a family medicine practitioner and assistant professor of family medicine at Georgetown, and together they're parents of three children, including five-year-old Nusayba Ali who underwent a liver transplant last year and is a cancer survivor.

I'm honored to welcome you both to the program. Thanks so much for joining us.

MR. ALI: Thanks, Paige.

DR. KURESHI: Thank you for having us.

MS. WINFIELD CUNNINGHAM: Waj, I want to start with you. I know that you spoke with my colleague, Libby Casey, about a year and a half ago, and this was just a few months after Nusayba was diagnosed with Stage 4 cancer. We know a lot has happened since then. Would you update us?

MR. ALI: Yeah. So Nusayba had Stage 4 cancer when she was two years old, right before her third birthday, and we were looking desperately for a liver donor that entire summer. And thanks to Shawn Zahir, who was an anonymous donor at the time, she had a full liver transplant because the cancer was all over her liver. So, we couldn't just simply do a surgery.

She went to do two post-transplant chemos, and last January, she rang the bell. And ringing the bell, for those of you who know anyone who's endured cancer, means she was officially cancer-free.

Fast forward, we literally two days ago got the results of her liver biopsy, because you have to do multiple tests to make sure the cancer hasn't come back. All the blood tests came back negative. The liver biopsy came back negative. So, knock on wood, fast forward a year later, she is cancer-free, doing well. Her hair is coming out. She's watching TV right now with her brother, and apparently, she got another toy in the mail from her grandparents. And we have bribed them that we will open the toys if they just stay quiet for the next 25 minutes.

MS. WINFIELD CUNNINGHAM: Well, as a parent of three kids myself, I will totally understand if small children appear in your background.

We know that more than--you had said more than 500 people applied, most of whom are strangers, applied to be liver donors for your daughter, and that seems particularly amazing because more than 100,000 people in the U.S. are on the wait list for organ transplants. Were you surprised by the volume of applications?

MR. ALI: Yeah, we were very surprised. Not only was I surprised, Dr. Fishbein, who was her lead doctor at Georgetown, who did the transplant, said it was the first time they had noticed that supply outmatched demand, and as a result of seeing how so many people stepped up for one girl, they have invested in trying to create a center in the name of Nusayba, a center for living donors. And they just started it, and they're seeking to basically get some money, any donors out there who are interested in donating to a good cause, because they realized that if you actually give the resources and the services and do exactly what we're doing right now, just to raise awareness, that people step up, because most people--just like myself.

I'm not a doctor. I had no idea the liver grows back. I had no idea, and so Shawn Zahir, who is the anonymous liver donor, he's doing perfectly fine. He's now a family friend. The liver grows back, and his small piece of liver is now growing inside of Nusayba as her liver.

So, I had the privilege--we had the privilege that--I write for The New York Times. I used to be on CNN at the time, and by sharing the story of Nusayba and by informing people what happens in Stage 4 cancer and by telling people, "Hey, did you know that you can give a piece of your liver and save a girl's life and your liver grows back?" People didn't know.

And 500 people, overwhelmingly, people we've never met, we found out from Georgetown that they actually stepped up, and there are a multiple battery of tests. And at the last second, thankfully, Shawn Zahir's liver was the Wagyu Grade A liver.

But one of the beautiful, I think, positive stories about this is not only did Nusayba get saved, but we found out that some of those anonymous donors who stepped up, they got matched with other people. And so, I've been receiving messages in the past three months saying, "Hey, I signed up, but guess what? My kidney was great, and I just gave a kidney," or "Guess what? A piece of my liver was great, and I matched up with another girl." So other lives have been saved as well, and they're trying to invest in this and expand the center for living donors, because it was the first time that demand outstripped--supply outstripped demand. And it's amazing.

MS. WINFIELD CUNNINGHAM: So, Sarah, I want to ask you. So, I know as a mom, of course, going through this must have been incredibly difficult, but you're also a doctor. Can you talk a little bit about what that was like? So, on the one hand, of course, you're a mom, but then you also have a deeper medical expertise than most moms do. Do you think that made it easier or harder as you went through the process of treatment?

DR. KURESHI: I think it can go either way for any individual, depending on probably their personality.

For me and for our family, I think it made it easier. For me to be able to advocate for Nusayba in a way where I understood a lot of the medical jargon and what the physicians were talking about and be able to make sure I was on top of every little thing, I think it really helped me ask some of the tougher questions and just really, really follow everything closely and make sure that Nusayba--I mean, her doctors from Children's National Medical Center to MedStar, Georgetown have been incredible.

I mean, hearing Dr. June talk about the research, I just want to put a plug in for research because Nusayba wouldn't be here today if it wasn't for all the research that was done for chemotherapies, the appropriate chemotherapies, to treat the type of Stage 4 hepatoblastoma that she had. And if this was five to ten years ago, she wouldn't have been living because the chemotherapy likely wouldn't have been effective, and living donor research, you know, it wouldn't have been there in terms of a living transplant.

So, we have so much to thank in terms of the physicians, the researchers who have done all this work to help it be possible for Nusayba to have been treated in such an amazing say.

So, as a physician, it was--I think it helped, and I feel like it's helped me be a better physician also to be on the other side and to, I think, teach medical students also. We each a lot about navigating the health care system, and I think it's a whole different experience when you're actually having to do that yourself. So, I hope that this has helped me be a better physician to my patients and understanding then system and the complications.

MR. ALI: Paige, I can say I'm a lowly English major, a failure to my South Asian ancestors. So, to have a doctor in the family and also a super-star, rock-star mom, I mean, I sit there and I think about it. I'm like for those poor parents who don't have a doctor in the family, just to navigate this with not just the emotional pressure, trying to save your daughter who has a Stage 4 cancer, but also just trying to understand and keep up with everything.

And so, we were so lucky. I was so lucky as a parent that Sarah was there always as a resource for me, even now with the medications and looking at the test results. Like you just have a second set of eyes at home to make sure that everything is going well, and so I always just think about those poor Americans who don't have health insurance, our fellow Americans especially during coronavirus where over 240,000 Americanus have died. I just want people to sit with that number--240,000 Americans. It's profound. And those parents who don't have the resources--we were profoundly lucky every step of the way.

MS. WINFIELD CUNNINGHAM: What do you think is Nusayba's understanding of what she went through? I know she's five years old, and as a parent, it's so difficult to explain complex things to kids. So, what is her own understanding at this point?

MR. ALI: Four years old. She's four years old.

MS. WINFIELD CUNNINGHAM: Four years old. I'm sorry.

MR. ALI: So, Sarah, she made the parenting choice that she's going to--as a doctor, she's going to tell them everything. So, at the age of two, Nusayba and Ibrahim--

DR. KURESHI: Two and a half.

MR. ALI: Yeah. --knew all the private parts, the actual names of the private parts, which has put us in some hilarious situations in public.

But we told them everything. So, they're very sharp, and our experience is that--Ibrahim and Nusayba knew. I remember one time, Nusayba said to Sarah and right after she was diagnosed--she goes, "Oh, cancer. Didn't that one person that we know got the cancer and died?" and then my son, who I used to drop off at school, who is two years older than her, her was telling his friends, "Yeah. My sister, Nusayba, she has the cancer in the belly, and they're going to have to get rid of the liver. But then it will be okay." And so Nusayba and Ibrahim, sensitive, smart, they knew everything. She knew the names of her medications. She knew the names of her procedures. She knew exactly what was happening, and Sarah being the doctor was able to really, I think, do a wonderful job of informing her about everything that was happening every step of the way.

DR. KURESHI: Yeah. I'm going to echo what Waj said. I think, again, it depends on your child's personality.

MR. ALI: Right.

DR. KURESHI: But for the most part, I think it's really important to inform children, to inform any patients, but especially children about what's going on and for them to have some sense of control, because they're going in the hospital. They've having a port placed. They're constantly being accessed through needles. They're having all these procedures done, getting all these meds, and so for them to at least have some understanding, even if they're really young, to talk to them about it, I think, is really important to assess their understanding.

And I also have to give a shoutout right now to the child life specialist at both Children's and Georgetown. Nusayba just went for her one-year post-transplant liver biopsy, and she was getting the IV placed. And even though she is such a pro and she's used to getting stuck, they developed with Hope for Henry, a nonprofit--they developed this chart where she like put stickers and goes through every step. I think that those organizations are huge and a lot of the other children's cancer organizations in helping children just feel comfortable, feel at least some control of what's going on, and I think for Nusayba, that's worked out well.

In translating that to the pandemic that happened, we've been really fortunate in terms of the fact that she rang the bell January 2020, cancer-free, no more chemo, had some tests in February, and then March, the pandemic hit. So, she hasn't had to get chemotherapy at all during this year, and we have friends who have kids with cancer who have had to go in and out of the hospital during this challenging time.

But I will say for her and Ibrahim, they understand the pandemic in terms of wearing a mask. They wear a mask. They remind us about making sure we don't forget masks. They understand the virus, the pandemic. We've talked to them about it. So, I just think when you talk to kids and explain things, it's the best thing you can do for them.

MR. ALI: It also normalizes it, Paige, for the kids, right? And so Nusayba, thank God, so far, we have not seen her in any way, shape, or forum be self-conscious about the surgery, about the scar.

DR. KURESHI: Hair loss.

MR. ALI: Yeah, hair loss. You know, and that's also parenting, affirming language, educate them about the process, and normalize it, show them other kids who are going through it. And that really helps them feel grounded and centered, and so we've been very lucky that at least what we've seen Nusayba and Ibrahim have just kind of--kids are resilient. They've just kind of moseyed along because we have tried our best to make them feel that this is normal. You're informed. You have some autonomy. Do you understand what's happening? And you just give them love. At the end of the day, you just give them as much love and comfort and attention as possible.

MS. WINFIELD CUNNINGHAM: Well, and we know talking about the pandemic, it's especially a huge concern for families with immunocompromised members. Are you more concerned about Nusayba getting COVID than, say, your other children, and how does your level of concern, say, compare to your friends who don't have immunocompromised children?

MR. ALI: Do you want to take it first?

DR. KURESHI: I'll start. We also have a baby who just turned one year old. So, when the pandemic hit, she was only about six months old. So, we had a newborn whose immune system obviously is still developing. So, we were worried about the newborn and definitely worried about Nusayba because of her--she's post-transplant. So, she's one lifelong immunosuppressants, and her immune system is suppressed because of the immunosuppressant, so that her liver does not get rejected, the new liver does not get rejected from her body. So, we have been extra cautious.

I'd like to believe we would be anyways in terms of protecting other kids like Nusayba, even if our kids weren't, but yeah, we've definitely noticed differences in family friends or other friends, colleagues, who have not been as stringent. But we've had our own bubble from the start of the pandemic and been really cautious.

My job has been amazing in terms of letting me to telehealth from home or precept residents from home, so that I'm not getting exposed myself to bring something home to Nusayba, because she worked so hard to live last year. It's been really scary for us. Honestly, every day just thinking, "Oh, my gosh, if she were to get it." She is on the list who would be at risk of more severe illness from COVID because of her status.

So, yeah, we've been extra cautious.

MR. ALI: I've been very blunt. I've been telling people, for love of god, please wear a mask and social distance and survive. And having an immunocompromised kid, I think Sarah--remember, like, January? So, Sarah is also--the fact that she's a doctor, she called it. She goes coronavirus is coming. This is going to be a huge pandemic. People are not taking this seriously. This country is not taking it seriously. The leadership is not taking it seriously. In late January, she said--she goes, "Everything is going to be shut down. Just watch," and I think that heightened awareness for us was as a result of the fact that Nusayba literally at that time had just rang the bell.

And so, what we were trying to tell people, save yourself, but also think about this child who is three years old, at that time, who literally fought like a warrior for a year, and think about all these other kids or elders who are immunocompromised, those who come predominantly from Black and brown communities. As more and more, you guys are going to learn about this, this is a pandemic, and no one is going to be immune to it.

And at that time, there also were some cases of young healthy adults, some of our friends, people who are public, and even New York Times editor Mara Gay, who is a runner in her thirties, wrote about it.

So, we have tried our best to not only protect our family but also educate people that, well, you don't wear a mask and you're being cavalier and you don't take it seriously, you are actually endangering Nusayba. And you are endangering your elders.

And so even now, slowly but surely, we've seen that some people are hesitant, resistant. There's disinformation. There's stubbornness, but I try to shamelessly use the example of my daughter. I'm like, "This girl lived through cancer. Are you telling me that you can't wear a mask to protect her? Come on." And so, for those of you who don't wear masks, please wear masks.

I'm not the doctor. Sarah, they'll listen to you. I'm an English major.

DR. KURESHI: Echoing Waj's message, absolutely. I mean, we--besides Nusayba, like he said, we have so many vulnerable communities, and Waj brought up Black and brown communities. And that's not because of anything genetic. That's because of racism and other socioeconomic factors that makes those communities more susceptible to COVID and higher mortality rates of COVID by far.

So, for all of our vulnerable patients, our vulnerable communities, please--we're researching vaccines. We're researching medications. That's great, and I love the work that Dr. June is doing. But we want to also put a plug in and say we know that--and he said this already. We know that masks work. We know that PPE works in terms of like hospital providers. We know that social distancing works. So, we should practice what works, and hopefully, moving forward with our new administration, we will have that model for our country and we will move in a more positive direction. But please think about all of these patients.

I'll just say as a family medicine physician, it's not about just mortality rates. It's also about people who get coronavirus and are living with long-term effects of it in terms of chronic cough, in terms of chronic fatigue, body aches. I see it all the time.

So, I think we talked about mortality rates, but we're not talking about really how people are unable to work, for some people are really affected by this, and these were people who did not have health conditions before. So, it's really for the betterment of everybody.

MS. WINFIELD CUNNINGHAM: Sarah, I want to--you mentioned a vaccine, and of course, we got really big news this week about Pfizer's vaccine. But as a family doctor, how do you think about that? Do you have any safety concerns? And if we do see the FDA give emergency use authorization, would you want to give this to your patients? Would you want to give this to your kids?

DR. KURESHI: Yeah. So, I mean, I'm not a vaccine expert, but as a family medicine physician and based off what I've read, that the efficacy so far has shown really good, at least with the first trial with Pfizer, and the safety profiles seems really good.

So, the only issue is they tested it mainly on adults. They did not test it on breastfeeding mothers or pregnant women or children. So, if it is approved, I don't think it will be approved for kids, but I will absolutely advocate for anybody it's approved for to go ahead and get the vaccine, including ourselves. So--

MR. ALI: You first.

DR. KURESHI: I understand the safety concerns, but based on the other side of what I've seen in terms of coronavirus and how it can devastate the body. And right now, we don't even know the long-term consequences of how it can affect different organs and different parts of the body. So, I think, again, I know that the vaccine trials have pushed through more quickly than any other vaccines in the history of our time, but it appears to have been done in a safe way. So, I would be the first to actually take the vaccine. I would probably [audio distortion].

MS. WINFIELD CUNNINGHAM: Waj, you wrote about this, I believe, earlier this year, but can you talk a little bit about how this experience of going through cancer with your daughter prepared you perhaps mentally and emotionally for now this huge challenge we find ourselves in with the pandemic?

MR. ALI: Yeah. I mean, we have kind of a dark humor because you need dark humor during cancer. You need to find joy. You need to find release, and you need to find a perspective, because one of the things that happens when you're enduring a tragedy, such as coronavirus or when you find out that your innocent two-year-old daughter has Stage 4 cancer all over her liver is you can go to a very dark mental place very quickly. You can go into a mental quicksand, where you ask, "Why us? Why me?" You can ask God or the universe.

And we were very lucky, I think, Sarah and I being on the same page that we curbed that very quickly. We said like, "This happened. This happens to people. This is happening to us right now. We just have to endure it now. That's it." And I say that because if you can mentally keep yourself away from that quicksand, you give yourself a type of resilience and outlook to endure what is a challenging, brutal, uncompromising, unpredictable journey, right?

And I feel like that's what's happening with coronavirus, with 240,000 people dead, with millions now, 10 million cases, as many people are saying, "This is not fair. Why is this happening to me? Why did I lose my job? Why did I lose my health insurance? Why did my healthy family in America get sick and get killed?"

And what happens with cancer--Sarah can talk about it--is it plays for all the marbles. It doesn't care about your routine. It doesn't care about your Netflix queue. It doesn't care about your vacation plans, and so it mentally--just surviving and enduring Nusayba's cancer prepared us in a way, mentally, spiritually, and emotionally for coronavirus, because right when Nusayba rang the bell, a week later, coronavirus.

And so, our kids were dealing with basically lockdown six months before. They know everything about hand sanitizing. They had multiple trips to the hospital. Now all we were asked to do is, hey, just live the way you were living with that uncertainty, and keep your immunocompromised daughter safe, but now you at least don't have to go to the hospital every other day, right?

So, in a strange way, we were kind of prepared for the onslaught that we had to endure, and I always tell people--there's a beautiful saying in Islam. It's "Tie your camel first, then put your trust in God," which means you do everything in your power that you can, but then you have to let it go. And I think when you're dealing with a daughter with cancer or if you're living in a once-in-a-lifetime pandemic, there's only so much we can do. But there are things we can do. Wear a mask. Social distance. Educate yourself. But then after that, you have to let it go.

And you also--final thing I'll say is you have to be easy on yourself. Give up the routine. Find a new normal. With cancer, we're finding new normals every day because our routine was disrupted. So be a bit easy on yourself. Be gentle on yourself. Forgive yourself, and know that this too, inshallah, one day, God willing, will end, and you want to get through it with mentally, physically, spiritually, your soul and your mind intact and with your family members alive and well, and if you do that and you unburden yourself--and final thing I'll say is don't be afraid to unburden your pain.

We live in a community. People are experiencing this pandemic together. So, it's okay to share your pain and your sorrow. Other people are going through it, and I found out that once you share that pain, it's healing. We met and talked to other cancer survivors, people who are going through it, parents, and now as a result of being on the opposite end of it, we are in a small way, I think, lucky to provide solace to those parents whose children are enduring cancer as we speak right now.

DR. KURESHI: And if I--

MS. WINFIELD CUNNINGHAM: Well, unfortunately, we're out of time, so we'll have to leave things right there.

Waj Ali and Sarah Kureshi, thank you so much for joining us today. It was a great conversation.

MR. ALI: Thank you.

DR. KURESHI: Thanks for having us.

MS. WINFIELD CUNNINGHAM: If you’d like to watch highlights from today’s program, head over to washingtonpostlive.com, where you will also find our full calendar of upcoming events.

Please come back and join us here tomorrow at 1:00 p.m. Eastern, where my colleague, David Ignatius, will interview the CEO of Genentech, Alexander Hardy.

I'm Paige Winfield Cunningham, and thanks so much for watching today.

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