Charles Fisher is one of the world’s leading experts in spine oncology. His winning approach owes much to his love of athletics—applying teamwork, leadership and work ethic to deliver the best outcome for patients.
Why did you choose to go into spine surgery? Did you always want to be a surgeon?
No, I didn’t always want to be a doctor. I initially studied general sciences, but then drifted into kinesiology and human anatomy, and that was really my first step towards medicine. I had always been involved in athletics too, so sports medicine was my first interest, and that directed me towards orthopaedic surgery. I gravitated toward spine because the patient population is very challenging from a decision-making perspective, because I liked performing the surgery itself and because I felt it had the most room for growth.
When did you start focusing on spinal oncology?
When we looked at building the spine program, we were considering what our potential strengths could be. We were the major spine referral center for the province of British Columbia, so “It’s important to look at the patient population and infrastructure you have available at your institution when choosing a research direction.”we got a lot of trauma, spinal cord injury, and cancer cases. This unique and large concentrated patient population gave us the opportunity to gather the experience and numbers to do good research. Today, about 40% of my cases are oncology, 30% degenerative and 30% trauma.
You went to UCLA on a soccer scholarship. Do you still play? How did your interest in sports help you in your career?
I don’t play competitively anymore but I still coach. Athletics had a big role in my academic direction early on. I learned the rewards of hard work and dedication and the importance of leadership. Also, the teamwork and camaraderie aspects are needed. The understanding that you can’t do this alone and need to work together are the principles of success in spine surgery.
Three tips for young surgeons beginning clinical research?
In terms of research advice, it’s important to look at the patient population and infrastructure you have available at your institution when choosing a research direction. I would also advise to do some additional education or an advanced degree in a discipline that will facilitate your research. Last but not least, try to be innovative and anticipate where the next phase of your clinical discipline is going. “Projects over the next year include qualitative research on patient expectations for treatment of metastatic spine tumors. We also have several projects related to cost effectiveness and modifying the SINS classification.”For example, healthcare economics and value-based medicine have come to the forefront in spine surgery. In oncology, molecular sequencing is now directing a lot of treatment.
The new frontier is probably all around evolving technology and software. Analytics, machine learning, surgical and imaging technology are coming on to the scene at a frantic pace and young surgeons need to sensibly embrace it, but most importantly figure out how to evaluate and study it.
How do you personally evaluate new technologies?
I think one needs experience to do that. You have to be in the trenches and operating a lot to know what’s effective and what isn’t. The other side of that is that sometimes with experience you risk becoming a bit of a dinosaur and not wanting to try new things. There has to be a blend. New surgeons are much more open to things like navigation and robotics. I try to keep an open mind and challenge myself to consider how it could be made better. In terms of more formal assessment, it’s about seeing the technology at work, talking to people to ensure the science is sound, and ensuring it’s economically viable.
You are the Knowledge Forum (KF) Tumor chairperson. Can you tell us more about projects that you are currently working on?
Our work can is simply divided it into primary and metastatic tumors and in both of these groups there’s ongoing data collection; the metastatic and primary tumor research outcomes network (MTRON and PTRON). These both function as registries for ongoing data collection, especially important in primary tumors because of how rare they are. The network’s most important role however is to provide a framework on which to do prospective studies.
With all centers using the same data fields and software, multicentre prospective studies are easier to do because we already have the infrastructure in place. This is very attractive to peer “It’s really important that we collaborate more with medical and radiation oncologists, as well as partnering with professional societies in oncology. That multidisciplinary approach is crucial in terms of advocacy and research.”review funding agencies.
Specific projects over the next year include qualitative research on patient expectations for treatment of metastatic spine tumors. We also have several projects related to cost effectiveness and modifying the SINS classification. Finally we are directing resources to genomics and linking them to clinical outcomes.
Generically we continue to encourage mutli-disciplinary participation and new ideas and research from the next generation of surgeons.
Do you see any differences in treatment approaches internationally?
With primary tumors the treatment principles have been well disseminated. There is less surgical variability, but there’s still some differences on whether the patients get radiation before or after surgery.
In metastatic disease we see more variability. I think that’s good because we still don’t know the best way to do things and the only way you will know is to look at that variability and study which patients had best clinical outcomes. Part of that is due to resources available—in certain regions you may not have stereotactic radiation, you may not have all of the surgical tools like navigation or minimally invasive surgery.
Where do you think are the main challenges and developments coming through in spine oncology?
It’s really important that we collaborate more with medical and radiation oncologists, as well as partnering with professional societies in oncology. That multidisciplinary approach is crucial in terms of advocacy and research. From a clinical perspective, the real challenge is to improve decision making in oncology. For both primary and metastatic tumors it’s about knowing the right thing to do. Looking ahead, one key area will be in demonstrating the value and cost effectiveness of what we do.
Looking forward to the next 2–5 years, where do you think the biggest developments in spine oncology are going to be?
Firstly, I think qualitative research in patient expectations will be a big area. The second domain will be in demonstrating value and cost effectiveness of what we do. To put it crudely if a payer says a patient is dying and treatment is a waste of money, we have to demonstrate that it’s cost effective to keep patients out of hospital, keep them walking and happy—that’s crucial.
Integrating genomics into decision making around treatment will continue to evolve. For example, a tumour with a particular genomic or molecular pattern will dictate the type of surgery we “Integrating genomics into decision making around treatment will continue to evolve.”perform and the type of treatments the patient gets. So instead of it just being a sarcoma it will have particular subtypes. New algorithms will develop because of the molecular discoveries we’re making. You see that in metastatic disease, because cancer patients are living a lot longer now. In certain types of lung cancer, we’re realising as surgeons we can operate on them now because the patients are living 18 months longer. Before, life expectancy was to short and the risk-benefit ratio unfavourable. So we’ve come full circle on why we have to become so involved with our oncology colleagues.
You’ve been honored as one of the top spine surgeons in north America. What do you consider your biggest achievement?
Improving patient care, especially in spine oncology. I am proud of the care I have provided to all my patients over the years. I feel I have positively impacted many patients through teaching residents and fellows. The biggest and broadest impact on patient care and surgery however has been through my clinical research.
What or who inspires you in your work?
It comes from within. I love challenges, and surgery is very challenging. We’re very lucky to be able to make an impact on someone’s wellbeing, and I enjoy the symbiotic environment of working in a team of smart, motivated people, and great organizations like AOSpine. My kids, Olivia, Anabelle, Charlotte and Zacharie, and wife Carolyn have provided the greatest inspiration through their love and support.
How do you unwind outside of work?
I love doing outdoor stuff—coaching sports, golf, skiing, gardening—especially with my kids. Although now that we are ‘empty nesters’ this is becoming less frequently.
“I learned the rewards of hard work and dedication and the importance of leadership. The understanding that you can’t do this alone and need to work together are the principles of success in spine surgery.”
Charles Fisher is Professor and Head of the Combined Neurosurgical & Orthopaedic Spine Program at Vancouver General Hospital and the University of British Columbia. His practice is confined to adult spine surgery with subspecialty clinical interests in trauma and oncology. He has a Masters Degree in Health Care and Epidemiology and is the former President of the Canadian Spine Society.
He has a special research interests in spine trauma, oncology and evidence based medicine. He is Chairman of the AO Knowledge Forum Tumour an international group of spine oncology surgeon thought leaders committed to advancing the understanding of spine oncology management through education and multi-center research. Charles Fisher is one of 5 spine surgeons on the steering committee for the Canadian Spine Outcomes and Research Network (CSORN); a multicenter research network and registry he initiated in 2013. Fisher, along with Alex Vaccaro author a regular article on Evidence Based Recommendations in Spine Surgery for the journal, Spine.
He has authored over 260 peer-reviewed publications and has co-authored 4 textbooks. He has been the special guest editor for two focus issues in Spine Oncology for the journal Spine. He formally sat on the Editorial Board of the Journal of Neurosurgery Spine and is an Associate Editor for the journal Spine. He is a regular guest lecturer at spinal events around the world and in 2013 and 2016 was honoured as one of the top 28 spine surgeons in North America.
Newsletter 19 | December 2018