We hope you enjoy the following conversation with EIPM Member Dr. Ravi Sharaf.
Ravi Sharaf, M.D., M.S., is a Member of the Englander Institute for Precision Medicine, an Associate Professor of Medicine (Gastroenterology) with a secondary appointment as Associate Professor of Population Health Sciences (Epidemiology).
He was born and raised in the Washington, D.C. area, where he did his undergraduate training. He did the majority of his medical training in New York City, then spent four years in Palo Alto where he completed a Gastroenterology Fellowship, and his research and genetics training. He and his wife returned to New York City in 2011 and Ravi has been at Weill Cornell Medicine for the past year and a half.
We hope you enjoy learning more about Dr. Sharaf and his current research interests.
Did you always want to be a doctor?
The short answer is yes. I’m the first-generation product of Indian immigrants, my parents came to the United States during a unique period of recruitment during the 1960s and 1970s of engineers and physicians. That vocational value set was transferred to their children, whether consciously or subconsciously, and medicine was always a presence in my life. My sister and my mother are physicians. So I do think there was an inherent desire to become a doctor from a young age.
Your clinical focus is on the care of patients with hereditary cancer syndromes. Can you tell me about this work?
The niche of genomic medicine is the fastest growing and most rapidly evolving subspecialty of medicine. The human genome project which finished in the early 2000s, for example, was a herculean, multinational, multi-year, multi-billion-dollar endeavor to sequence a handful of individuals. Today we can do the same work in a few hours for about $1,000.
My interest in genetics developed in college where basic science research I was conducting with a mentor led to a pre-doctoral position at the National Institutes of Health with the current director Dr. Francis Collins, who’s a geneticist by training. The experience in genetics, combined with an interest in gastroenterology that developed in medical school, led to a career focus of gastrointestinal cancer genetics. I was very interested to learn that up to 20% of cancer has an underlying germline genetic predisposition, and I wanted to be part of the revolution in medicine to diagnose and treat patients based on their hereditary predisposition.
Are there hereditary cancers that lend themselves especially well to clinical genomic research?
In the end I think it will be that all cancers have some degree of germline predisposition, though our clinical focus so far has been on solid malignancy. I do think that for all malignancies we should be pursuing germline genetic testing at diagnosis to determine etiology and management.
Can you tell me about your specific research?
I combine health services research with clinical cancer genetics. Specifically, I use comparative effectiveness research methodologies applied to the germline cancer genetics. Comparative effectiveness research helps us determine what the most effective strategies are for delivering healthcare, for personalizing healthcare, for meeting the needs of persons at risk, and for providing value-based care- making sure we’re improving patient outcomes given what we spend.
So, thinking about health care as a return-on-investment?
Correct, absolutely right. In cancer genetics I want to study how we apply a given test, or a given medical paradigm, to a population for patient benefit and for the systems’ benefit, in a sustainable way.
This, very broadly, is where my research lies. What I specifically try to look at is how we best implement genomic medicine on a population-level, how we best identify those at increased genetic cancer risk in the population, and how we take care of those patients longitudinally.
For example, for people with a specific genetic disease like Lynch syndrome, we’re trying to figure out how to best manage and screen people based on their individual genetic mutations. People who are affected have up to an 80% chance of developing one of several malignancies. But, pending which gene is affected, the cancer risk can vary between 10-80%. So using comparative effectiveness research methodologies, we’re creating computerized models to mimic the natural history of a Lynch syndrome patient, and then superimposing screening strategies on top of that natural history model. For certain genes with certain cancer risks, we hope to be able to determine that maybe we can do a colonoscopy on a specific patient once every five or ten years, as opposed to the current one-size-fits-all patient and resource-driven approach we have now of a colonoscopy every year.
What we’re trying to do is affect the true personalization of medical care and the delivery of value-based care. That value means clinical benefit for the patient, that is also associated with prudent expenditure of resources.
Are there countries that do a good job with comparative effectiveness research?
Every nation with a single payer structure has comparative effectiveness research incorporated into their fundamental mechanism of healthcare delivery. In the UK or Canada, they make the determinations up front on which healthcare technologies, tests, or pharmaceuticals meet certain values-based criteria and that’s how they govern reimbursement decisions. That’s why their general population-based health metrics are better than ours. I think there are important lessons to learn from such infrastructure. It’s why we’re trying to apply value-based assessment to care delivery in clinical cancer genetics.
How unique is the work you’re doing in New York City and across the country?
It’s unique and novel, and it’s an exciting time to be in this field because historically there hasn’t been a focus on looking at comparative effectiveness research and value-based care in cancer genetics specifically. This is broadly permeating cancer and cancer care, but only recently. What I’d love to do is form a cancer health policy center here at WCM so we can become a nucleus for this type of research in the United States.
Is that challenge what drew you to Weill Cornell Medicine?
What drew me to WCM was multi-factorial. The institutional culture values academic research and clinical care. We have a preeminent population health sciences department, as well as world-class gastroenterology, oncology, and precision medicine programs. It’s also great to be in close proximity to the other academic centers in Manhattan- ultimately the proximity fosters collaborative work.
What makes the EIPM a special place?
What EIPM and Cornell are doing is unique. It takes intellectual and pragmatic foresight as well as a tolerance of risk to develop new technologies and push frontiers in medicine.
The EIPM is on the forefront of developing clinically actionable genomic technologies. I think the bottom line is that EIPM is really a testament to Oliver Elemento’s of vision and leadership and drive and savvy to make precision medicine a routine part of clinical care
Is there anything else about your work that our readers should understand?
I want people to understand that we’re building clinical cancer genetics at Cornell and trying to bring a standard of population-based sequencing to our patients. Not in the future; but today. We’re trying to establish a standard that all of our patients have access to cancer germline predisposition testing. We’re trying to integrate the clinical and the research enterprises so each of our patients have access to unique clinical trials, translational research, and epidemiological studies, in a manner that’s commensurate with care delivery at the top-notch academic center that we are.
How has the global pandemic affected your work and your personal life?
Overall, the pandemic has reaffirmed things that I already knew, or should have known, about what’s important in life. It’s reminded me of the value of being both a clinician and a researcher, someone who can care for patients as well as affect health system change. It’s made me reflect on how fortunate I am to work with colleagues, and for an institution, whose values I share. It’s reiterated my identity as a New Yorker, and as a healthcare worker. Fundamental to both is a belief that there is strength, and unity, in our diversity. And last, the pandemic has reemphasized the deficiencies of our national healthcare system, the need for truth, accountability, compassion, and leadership. Now more than ever, there is a moral imperative to do right. And that transcends the personal and professional.
What do you like to do when you’re not working?
I think I’ve lived long enough, and have practiced medicine long enough, to have perspective on what’s important in life–all of which is further emphasized by the pandemic. Health and family and friendship are what it’s about. That basically shapes what I do outside of work. Hang out with my wife (a physician at MSKCC) and our two daughters, aged eight and six. I’m also really into working out with our Peloton. I’ve become a sucker for group-motivational classes as I age.
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