Jessica Kandel, MD, is the new section chief of pediatric surgery and surgeon-in-chief at the University of Chicago Medicine Comer Children’s Hospital. A surgeon, educator and researcher, Kandel came here from Columbia University College of Physicians and Surgeons in New York where she served as the R. Peter Altman Professor of Surgery and Pediatrics in the Institute for Cancer Genetics and co-director of its Pediatric Tumor Biology Laboratory.
An internationally recognized authority in the surgical treatment of childhood cancers, Kandel’s vast clinical expertise includes the development of groundbreaking treatments for vascular anomalies in children. As an active researcher, much of her work is focused on regulation of angiogenesis in pediatric solid tumors, including Wilms’ tumor, neuroblastoma and hepatoblastoma.
Science Life spoke to Kandel recently about her research, what she looks forward to about leading the surgical programs at Comer and how she and her family are adjusting to life in Chicago. The following is an edited transcript of that conversation.
What are your primary areas of research?
I think the best way to understand my research interests is that they pretty much all have their roots in my fellowship with Judah Folkman, who was my mentor at Boston Children’s Hospital, where I completed a surgical research fellowship. His interest was in tumor angiogenesis, or the idea that tumors couldn’t become established and grow beyond a certain size, or metastasize, without having blood vessels to feed them. Because he was interested in this process in oncology, he actually began to understand a lot about blood vessels and how they might be normally or abnormally formed. He developed a secondary interest in what are called vascular anomalies, which are congenital disorders of blood vessel formation that sometimes form things called vascular tumors of infancy. So like him, I came to this because I was interested in children’s cancer broadly, and then became trained in tumor angiogenesis.
“The requirement for multidisciplinary care for patients with complex disorders has become increasingly recognized as necessity.” – Jessica Kandel, MD
When I got to Columbia, I started a clinical and research program to understand better how blood vessel development contributed to the growth and progression of children’s tumors. I made models of pediatric solid tumors, Ewing’s sarcoma, neuroblastoma, hepatoblastoma, etc, and then explored how changing the regulation around blood vessel growth changed patterns of primary tumor growth and metastasis. Over the years, we’ve come to recognize that blocking new blood vessel growth in primary tumors can block both primary growth and metastasis, but it’s really dependent on the tumor type. Some tumors are really susceptible to this, and other tumor types are completely resistant. Understanding what those differences are is very interesting to us.
We’ve also recognized that the trafficking of cancer cells in and out of blood cells is obviously a critical mechanism of metastasis, and engraftment of these migrating cancer cells in different target organs also has interplay with angiogenesis and the regulation of how blood vessel cells control their immediate environment. So our current interests in pediatric oncology are understanding what we call intravasation, or the trafficking of cancer cells into blood vessels; extravasation, how they get out in their target organs, and then how angiogenesis in each of those target organs might control how those metastases would grow. To do that, we look at different growth factor families. We have an interest in what are called the Notch family of proteins, which seem to be particularly important in how liver metastasis gets established, grows and locally invades. We’re also interested in the angiopoietins, which signal through a receptor called Tie-2, which seem to be pretty important in controlling how neuroblastoma cells metastasize to the bone marrow.
What sparked your interest in vascular anomalies in children?
When I got to Columbia, my boss then said to me, “You’re a pediatric surgeon and you’re interested in angiogenesis, so you’re going to see all the patients with vascular anomalies.” So sort of like Judah Folkman, because of my interests in cancer, I got to see a whole group of other patients. This has become a major interest of mine clinically, and in the research domain because it’s a really underserved area of pediatric medicine.
Patients with vascular anomalies really need multidisciplinary groups to take care of them, because their malformations extend into a whole bunch of other domains. They need dermatologists, cardiologists, GI specialists, hematology, oncology and lots of interventional radiology help, so putting together those big multidisciplinary groups is really important for the care of these children. Before, they were research orphans. Nobody understood the mechanisms that caused these malformations to form in the first place, what made them expand, what made the regress. Recently we’ve been able to characterize the cells from lymphatic malformations to make the first mouse model, and begin to understand the molecular mechanisms that drive these particular malformations to become problematic. I see this now as an equivalent part of my research work. It’s actually a very large part of what I do clinically, because there are relatively few places that have a clinical focus on children with vascular malformations. It’s a really big unmet need in the pediatric community.
How has research and clinical practice in these areas changed during your career?
I think that the requirement for multidisciplinary care for patients with complex disorders has become increasingly recognized as necessity. Just the volume of information required to safely care for patients has grown hugely. When I was doing some background research for a talk I gave this spring, I used PubMed as a way to measure that. I looked at the number of instances that the phrase “pediatric surgery” was mentioned in the year that I graduated medical school (1985), and then I measured it in 2012. Just the number of those mentions has gone up 2,900 percent, so that could mean that I’m actually supposed to know 2,900 percent more about pediatric surgery than I did when I graduated from medical school. Maybe there’s also more publishing, but even if the knowledge had only doubled, the likelihood that any one individual can wrap their mind around the amount of knowledge needed to care for a patient is increasingly remote.In all domains, especially in pediatrics where the subspecialties are small and there are relatively fewer people, you need each other even more. I think pediatric oncologists have been leaders in this. The Children’s Oncology Group has included multiple specialties for decades, put them in the same cooperative group and created a structure that allows them to interact. I think that was pretty well established in pediatric oncology, but in other areas of pediatric medicine it’s relatively newer. There are fewer pediatric vascular anomalies groups, for example. More are forming because it’s a real need in pediatric health care, but they’re relatively few. But as a theme in medicine generally, and in pediatrics in particular, yes, collaboration has been of increasing importance in the last 10 years.
The University of Chicago focuses on that kind of collaboration between disciplines, and between basic science research and clinical practice. What were some of the other things that appealed to you about coming here?
It’s exactly that. Universities could exist by themselves without a hospital, and a hospital could exist without a university, but to give the best kind of care to patients, which involves not only living up to the currently established standards but having a view toward the future, what you want it to look like tomorrow and 10 years from now, you have to have a university and a hospital married to each other. That tradition of being on the cutting edge of both knowledge and health care is one of the things that happens here, and I think that would be exciting to anybody. Certainly to me in particular, there were all the pieces and all the traditions here that are needed to put together the kind of surgical care that I think is best for children.
What direction do you see pediatric surgery heading? What do you look forward to tackling now that you’re here?
One of my personal projects was to recruit the incredible talent that was already here and have a formal arrangement for a pediatric vascular anomalies group. That has been remarkably easy; everybody here was very enthusiastic. We have all the people, and the patients are really crying out for this. For me, that was very rewarding and very straightforward.
The pediatric oncology group here is outstanding and has been for a long time. They’ve been very welcoming to me, and so I’m delighted to be a part of that existing collaboration. I would like to build out that effort into other multidisciplinary programs.
Other things that are exciting to me are the potential for a program focusing on the upper aerodigestive tract, so thinking about congenital problems of the esophagus and gastroesophageal reflux disease in children. I also want to think about the other parts of the GI tract like colonic disorders, dismotility and anal/rectal malformations as another programmatic effort. I think the same truths about complexity are making it increasingly important to weave in different specialties into critical and acute care. I’m thinking about ways to build a pediatric surgical critical care trauma and ECMO program, which again takes advantage of everything we have here and just weaves it together a bit more.
One of the humbling themes in medicine is the recognition that you have to focus proactively on patient safety. We haven’t learned that much since Semmelweis. We know we’re supposed to wash our hands, but getting people to actually do that and then measuring what happens when they do it better is something people are thinking about in a systematic way. I would really like to have a programmatic approach to patient safety and outcomes here, and be able to measure our pediatric surgical outcomes by national benchmarks. I want to create ways to make it safer and better to have surgical care here for children.
What do you do when you’re not being a doctor?
I have two kids and a husband, so I guess I’m a family person. One of the things that I totally love about being a parent is you get drawn in to the things that your children discover of their own. One of the things that they’ve loved about living in Chicago is that you can ride your bike a whole lot of places, so we ride our bikes and we’re exploring the museums here. My daughter has developed a passion for astronomy, so we’re devoting a lot of time to thinking about that and going to the planetarium, which is fascinating for us. My son is a tennis player, so we are learning about junior tournament tennis in the Chicago area. My husband and I also have a longstanding love of music—totally as amateurs, I don’t have any talent myself but I’m a very willing ear—and we like to go to chamber music concerts. We really look forward to doing that here too.