 ThinkTek Hawaii, civil engagement lives here. Aloha and good morning ladies and gentlemen. I'm Pauline Schachmacher and your host for We Like the 1%. We Like the 1% is about individuals and entrepreneurs and today we're going to concentrate on entrepreneurship and technology within the healthcare sector. Hawaii is proud to be home to one of the 69 NCI-designated cancer centers across America and my guest today is Dr. Randall Holcomb, director of the University of Hawaii's Cancer Center. Good morning Dr. Holcomb. Good morning, it's a pleasure to be here this morning. Wonderful, thank you, it's great you could make it today. So what we're going to discuss is slightly abstract, a little bit esoteric because we're looking into the future of healthcare and patient care and we're going to focus on oncology in the area of cancer. So before we get to all the technical things and these futuristic ideas, can you please just tell the viewers and listeners a little bit about yourself first? Certainly, I've been in Hawaii for about a year and a half now as director of the University of Hawaii Cancer Center. I came from Mount Sinai Medical Center in New York where I was for the past six years and I've been an oncologist and in academic centers really for the last 30 years. Okay and what drew you to the study of medicine? Why did you choose this subject yourself? Well I was very interested at the time in immunology and how the immune system affected different diseases and I found that the study of the immune system and cancer was very interesting. At the time that was a pretty hot topic, it then waned and wasn't such a hot topic and now is a very hot topic again so it goes in cycles but that's really why I went into oncology and went into research and the study of the science of oncology. I also really enjoyed taking care of cancer patients. I think that as a physician you can just do so much for patients who are going through a difficult journey with cancer and it was very rewarding to be able to care for patients. Yes that's good. You have that immunology interest as well. My guest yesterday was also a doctor and he's an immunologist by training so there's something in common there for this week and also you still see patients. Is that correct? You still actively see patients in Hawaii. I do. People can come to you Dr. Holcomb not just at the cancer center but also as a physician. That's absolutely true. We work at the cancer center through the Hawaii Cancer Consortium which involves Queen's Medical Center, the Hawaii Pacific Health Hospitals and Kua Kini Medical Center and I have started to see patients through the HPH system and shortly through the Queen's system as well. Okay and you're licensed to practice in Hawaii and New York? At the moment in Hawaii and New York. Okay brilliant. Two wonderful places extreme sides of the American country. So let's get to these futuristic ideas about cancer detection, prevention, awareness, eradication hopefully completely and one of the things that for example Mitio Kaku when he does these futuristic talks he brings up in the cancer arena liquid biopsies this idea about liquid biopsies being able to detect the cancer before you even have to go to the physician so if you go to the Lou there'll be this kind of technology that can tell you whether you have cancer or not and how does this work, this idea of a liquid biopsy? It might not be quite as simple as going to the Lou and getting your liquid biopsy done. We have always diagnosed cancer by finding some kind of tumor growth or mass and then biopsying it and looking at it under a microscope and that is still the standard way to do it at this time. What we have found is that we can detect minute amounts of cancer cells that are circulating in the blood so people who have cancer have some cancer cells that can be found in the blood but they're very few so we've needed to develop the technology to isolate those few cells among the millions of cells that are within the bloodstream to try to determine whether there's cancer in the body or not. That's really what a liquid biopsy is. At the moment it's used mostly for people who have been diagnosed with cancer to try to follow their cancer while they're undergoing treatment and then after they finish treatment to see if there might be a relapse or early signs of relapse. I think that in the future we might be able to use liquid biopsies as we refine the technology for cancer detection even in the general population. We're not quite there yet though. We mentioned liquid biopsies but is this the primary method in the future for the detection or are there other ways besides liquid biopsies that you can see? Liquid biopsies have the advantage of sampling the blood or potentially the urine but most likely the blood and finding some cancer cells that you can do some studies on, genetic studies for example. It's not the way we diagnose most cancers now. Certainly now we diagnose them by physical examination and also by radiographic tests such as a CAT scan or an MRI scan and then followed by some kind of biopsy. Okay great. Now we're going to slightly move away from the liquid biopsy and we're going to automation in the medical arena. So on a couple of other occasions when I've had guests we've been talking about this topic about robot revolution and how automation is going to take over 70 to 90% of jobs fulfilled by people at the moment probably in about 10, 20 years down the line. So I always tell people the study of medicine is always safe because you always still need a human person. Even if you have the robotic surgeon known as Da Vinci or even if you have these elaborate technologies there is a level of judgment, a level of care, a level of compassion that is associated with being a physician that a robot cannot completely replace, that an algorithm cannot completely replace. So is that a fair thing to say that if somebody is a little bit confused about what they want to study or what career they want to pursue because they're frightened that a robot or an algorithm might take their place in 10 years? Healthcare is one of the safer options would it be fair to say? I think that's fair to say. I think my job is pretty safe right now. We do use a lot of technology and technology is coming into healthcare. Every year there's something new. We do use robots for surgery but the robots don't function by themselves. They function with a physician who's guiding the robot. And the advantage of a robot is that they're very steady and can sometimes do surgery in very close quarters and areas where it's difficult for the surgeon to actually manipulate tissues. So the robots are exceptionally helpful in that circumstance. We use a lot of technology also for outreach to rural areas for instance. We certainly have lots of rural areas here in Hawaii and also other remote areas where there may not be healthcare providers or a physician of particular expertise present. And we do that. We can use robots to do physical examination. We can use them for telecommuting. I think that on the other end of that robot is always a person. And so I think there's going to be a need for physicians and other healthcare providers as we move forward because you really need that. You need the judgment that comes from a human as opposed to just the robot. We do use a lot of technology though for trying to review medical records. For example, there's new technology such as IBM Watson that reads physician notes and tries to discern patterns from that. This is an algorithm, is that right? This is an algorithm that's used. And this can be very beneficial, but in the end it always comes back to a person to try to make the final determination about what should be done for a person. This is a little bit similar to what's being done with the legal profession as well because in law they said the algorithm just detects the casework looking for keywords and patterns and it doesn't get tired like a lawyer does and it doesn't stop. It's 24 out of 7 whereas a lawyer has to take breaks. And it's much faster. Yes, that's right. And it doesn't enjoy a drink or two like a lot of lawyers like to enjoy. So it will be faster. And one of the other elements is the 5G technology that's due to come out around 2020. That's when they're predicting. So we're in 4G world at the moment with the smartphones. But it's moving to 5G world where there's greater demand for data and what's going to be relevant in the medical field is that you would be able, one surgeon who is a specialist in a very tricky area can remotely help another surgical team in another country with a patient. Is that my understanding? I think there'll be those opportunities. 5G certainly allows for a much greater bandwidth for data streaming and could be utilized for surgery, for instance, so that someone could be stationed remotely while someone else is in an operating room at a different location. Also, the transmission of radiographic images is still rather difficult with 4G because of the amount of data that's included in each of those images. And with 5G, I think that should be much improved. And one of the other things about the relevance of the health care professions in the future is not only because there'll be one of the few percentage-wise jobs that a human is needed at, Michio Kaku said it's the garbage man also. You need garbage man and people like the people in the health care professions because a robot can only see in squares and circles. It cannot discern trash, for example. So you still need a human to point out what is the trash in the room because the robot does not understand that concept, at least currently the way they're making the robots. So it's the extremes, not necessarily just the professions but things that are very helpful and useful in society like the dustbin man. So I'm not sure that I took those two things right next to each other. But they're both very important. They're both very important. And I think certainly in health care, what's important is that you do need a human connection. So when people are sick, they need that sort of human connection to understand and process. The holding of the hand, especially in trauma. You should really process the whole situation. And especially for individuals with cancer, it's very important. So I think that we're not going to be outsourced to robots any time soon. I think we'll be needed. But technology does help us quite a bit. Yes. And also on the point about manual dexterity, surgeons have to have very great amounts of manual dexterities, as do most doctors, but particularly an ER physician. They have to sort something out very quickly and very delicately. It's very delicate work. So the comment always made in romantic novels and films is that doctors have very beautiful hands. Like in the killing of the sacred deer, there's the same director as the person who made the lobster. So it's a slightly strange film. It's a bit quirky. But it is about doctors. So the problem with the robots as they currently stand as the testing is done is that even to it's the grasping mechanism that's tricky to get a hold of. Because I did go to one robotic summit where I think it takes 800,000 grasps to pick something up, and it only has an 82% success rate on average. So what is very simple for a human to do, to replicate it in a robot or a machine, is quite complex. So on that level as well, it's a slightly more simplistic level, but you still need the manual dexterity of a human hand. I think for robots, they're very good in being directed by visual cues. So if someone is looking at a screen and seeing what's there, you can move the robot to the particular location and do things. What we haven't really perfected yet is the tactile sensation through a robot. So to understand what things actually feel like. So when you pick something up, you feel it. And that makes it much easier to pick it up. If you didn't feel it, you wouldn't be able to pick it up. And transmitting that tactile sensation through a robot is much more difficult. But people are working on that. So I think that in the future, that will get better as well so that the operator may be able to put their hands into a glove and actually somewhat feel what the robot is feeling. But we're not there yet. Yeah, I don't want to get too science fiction-y on you, but I think one of the ways you can overcome that problem is eventually when you combine man with machine and you create human clones. Because then you can replicate physicians, couldn't you? Presumably so, but I think that's too much Blade Runner, isn't it? I think we're a ways away from that. That's 2049, like in Blade Runner. So it's a little bit too abstract as a concept. So we'll get into a little bit more about the genomic items right after we take this quick break. So we'll be right back. Climbing all week for the day of the big game. Watching at home just doesn't feel the same. But on the list is who's going to drive. It's nice to know you're going to get home alive. Planning for fun and responsibility. Captain of our team is the DD. For every game day, assign a designated driver. Well, I'm Dave Stevens, host of the Cyber Underground. This is where we discuss everything that relates to computers that's going to scare you out of your mind. So come join us every week here on thinktecawaii.com, 1 PM on Friday afternoons. And then you can go see all our episodes on YouTube. Just look up the Cyber Underground on YouTube. All our shows will show up. And please follow us. We're always giving you current, relevant information to protect you. Keepin' you safe. Aloha. Aloha, and welcome back, everybody. So we're speaking with Dr. Randall Holcomb at the University of Hawaii's Cancer Center. And we're going to move into the realm of personalized medicine and personalized prevention. So one of the things that fascinates me, even though we just had this discussion before the break that the health care professions are lesser likely to be taken over by robotic or automation, robotic functions or automation, is that one of the things that are envisaged is that the smart home will have many, many features. So it's almost as if you don't have to leave the house to do anything, including having your annual checkup at the physician. Because there is this idea about having a sort of AI within the walls of your living room. And a holograph or a hologramic doctor come out that may or may not look like you, for example, if it's your patients or just a general doctor in a lab coat. And the house will actually analyze the health of the inhabitants of the house. So what do you think of that idea? Is that strange to you? Or is it something practical? Or what do you feel about, how do you feel as a physician about that? It lacks the personal touch, but it's interesting, don't you think? I think it has no personal touch, but I think we may be able to do many things remotely like that. I think that radiographic imaging, such as X-rays, CAT scans, ultrasounds, we may be able to perfect these things so that they can be done from home as opposed to going to a particular location to do that. I think that analysis of blood could potentially be done as well. People certainly check their glucose at home if they have diabetes all the time. And they put a little drop of blood into an analyzer. There's no reason that analyzer could not connect into a more robust testing system that could test for lots of things and could avoid a trip to the physician, for instance. So I think the smart home may bring a lot of things to home, but it won't bring that personal touch. And I think that many times that's fine for screening for people that are healthy, but may not be so good for people that are actually ill and need to see a physician. Would it make them feel a little bit better if the hologram looked like you, for example? I'm sure it would, of course. If it was their own doctor and it looked as opposed to a generic image of a doctor with gray hair or something. There's no reason that they couldn't have their own doctor projected. Or they can design it how they wish they could look. So the possibilities are limitless with that sort of thing. So the other thing is wearables. So it reduces the need to go actually physically see a physician because there are gadgets that are being created and already in the market that check your heart rate, your blood pressure, things of that nature that people just have on them all the time or is attached electronically to their smartphone. So what do you think of those ideas? Are they pretty handy, especially if somebody does have a serious medical condition? I think they're good for some conditions, certainly for testing and monitoring blood pressure, heart rate, heart rhythm. These are great because you can get a recording of what's going on over time that is really much better than just going to the physician and getting a single determination at one point in time. So I think the wearables are great for some things in my field in oncology, probably not so great because we have to monitor many other things. But some of the things that we do monitor and have people come into the office for all the time are things like blood counts after chemotherapy. There's no reason that that couldn't be done at home that people couldn't test it just like they do their blood sugar at home and send those results into the physician. And that would really dramatically change how we practice oncology today. Okay, so what's very trendy that everybody's seeing the commercials for is Ancestry.com, 23andme.com. It's this personalized genetic testing. And from the commercials and the information, the appeal of it, the marketing seems to be so you know where your ancestors came from geographically wise. They don't focus on the medical elements so much. But it does cover that as well. So the way they market it is more like somebody thought they were Irish all along and then they're half black or whatever. They don't seem to touch upon the medical detection or the ability to detect any diseases within that person's DNA. So is that something that could lead to eventually being cancer free if the cancer can be detected early on and eradicated? So most of these tests are looking for genetic abnormalities that are inherited that might predispose someone to develop cancer. It doesn't mean they have cancer. And it doesn't mean that they are necessarily going to get cancer, but it might indicate that they have an increased risk of developing cancer. 23andme is approved for testing, I think, for 10 different genetically inherited diseases. Most of them are not really related to cancer. Most of them are very rare blood disorders that occur in an inherited fashion. There are many tests that we can do for looking for cancer risk, inherited mutations that may increase somebody's cancer risk. Most of those are not available through either ancestry.com or 23andme, but could be done by seeing a physician or genetic counselor if the family history warrants such testing. I think that we can identify many things that may predispose to the development of cancer, but cancer's really complex. And it doesn't occur just because of genetic predispositions. It occurs in the context of genetics as well as environmental exposures. So you need to know what is happening to people and what they're being exposed to and what they've been exposed to over time to understand if those genetic abnormalities may actually lead to the development of cancer or not. So I'm not sure that the testing is going to identify and eliminate cancer, but I think it will identify individuals who may be more at risk for certain environmental exposures. For instance, work that we're doing at the University of Hawaii Cancer Center looks at different genetics that may predispose people to development of cancer when exposed to cigarette smoke. And so this may give an indication to people that they shouldn't be smoking because they have a particular genetic predisposition to developing lung cancer. That sort of information I think we can now reasonably determine by very complex testing. And that complex testing may become more commonplace in the future. And have you done one of these test kits yourself? I have not. Oh, OK. I was wondering. I wanted to ask anybody or particularly a physician, if you did both tests, if you took a kit from Ancestry.com and you took a kit from 23andMe, if you get the exact same result. I'm very curious about that. It is unlikely. Because they use different methodologies? People have looked at that. Well, not only, and they use different algorithms. So they really try to determine what your ancestry is based on a collection of information that they have by having tested people in different areas of the world and looking at what the genetic profiles are and then using that information and comparing it to your genetic profile and seeing where the likelihood is that you got most of your genes from. The different companies use different algorithms. They have a different database. So you're going to get slightly different results. Actually, if you use the same company and you send the testing in twice, you may get different results as well. So it isn't that precise. It gives an indication of where some of your genes may have come from. But the actual percentage is pretty much an estimation. I see. OK. But it might be fine-tuned in five, 10 years time. Oh, I think it's going to get better and better. As more people do the testing, I think it's going to get better and better. The databases will get larger and it will become more precise. But right now, I think that you get an indication of where your ancestors may have come from. But knowing that it's 13% or 18%, that's probably not precise enough to really make that determination. So hopefully within five to 10 years time, it'll be more accurate. And the medical assessments will be more accurate from each person's DNA. And you're going to have longer living people because you're going to have eradication or prevention at a higher level. So people will live longer lives, is that correct? We hope so. We hope so. Now, the problem with that is that it's the care of the elderly. So unless we overcome, which some companies are trying to overcome, the fact that even if you're aging, they still, even at 70, you can have the body of a 30-year-old. So they're working on technology related to that. But let's assume you just become more decrepit but you live longer. So there's going to be a high amount of high population of very elderly people. So elder care is going to be another branch within the general group of health care professionals that are going to be needed. And there are companies working on robots that can care for the elderly because they did. I did go to another event where they were talking about this issue. And when they asked elderly people, they took a sample survey. I don't know how many people it was. But they did say, because it's such an intimate thing, this kind of elder care, that they would actually feel more comfortable if a robot was doing it. It is impersonal, but in this case, perhaps, that is preferred. I think the robots can help. I think that as people live longer, there certainly is a greater need from a societal level for care of the elderly. And particularly if we don't make the same kind of progress related to elderly dementia and Alzheimer's disease, which, of course, is a terrible problem for people as they age, they're going to need help. They both physically and mentally things decline with age. And I think robots can really help quite a bit, especially because we have such a mobile society so that the family is not always where the elderly person is. And it used to be everybody was in a single unit, and there were people there to care for you as you got older. That was the purpose of having children in the first place. That was one of them, Brad. And looking after the farm. That's why I had to have 12 of them. But nowadays, people are scattered. So I think that technology will help. It's not a guarantee that your child will necessarily look after you. So it would be nice to know that, but I think that's not always the case. So there's always a robot to look after you in the future. A robot to help. Yes, a robot to help. And the Japanese are very advanced on this because they already deploy robotic nurses. So they're particularly advanced in this area. So one last thing is because you've only been in Hawaii a year and a half, we expect you to be here a very long time. So what are your impressions of Hawaii? I'm just curious because you haven't been here for very long. It's fabulous. It is, isn't it? We love it here. My wife and I have really enjoyed the culture here. It's a great place to live. The people are so welcoming. It's been a wonderful time here. And the work at the Cancer Center has been extremely rewarding. There's a tremendous amount of great research that's going on there. And I think that the faculty that we have at the Cancer Center are really contributing tremendously to advancing the science of cancer care. Yeah, it really is top notch. So that's why you have that NCI designation. That's exactly right. Thank you so much, Dr. Holcomb, for being here. It has been great to be here and talk to you about some of these things that are gonna happen in the future. It's been a lot of fun to think about. It's exciting. So we'll see everybody next Thursday at 11 a.m. for We Like the 1%, aloha.