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Dr. Onyinye Balogun: I was born in Nigeria and at the age of seven and a half my parents decided that we should immigrate to the United States. Their goal was to ensure that we had more opportunities, so I'm very grateful to both of them. I went back to visit Nigeria for the first time in 1992 around Christmas time, you know, around that time maybe I was 10. One of the things we wanted to do during that trip was to visit my father's only sister, my godmother, my aunt. Her name was Miranda. My aunt was beautiful, known as, like, the beauty in our community. Kind, wicked sense of humor…
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I have pictures of her holding me at my baptism. I was a chunky baby, so, you know, she probably had a lot of strength. In particular, what I remember is that I was
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doing a photo essay about my trip to Nigeria. I was busily snapping away and my aunt saw me taking pictures and she requested that I take pictures of her. She unfortunately had been diagnosed with breast cancer, and my father hadn't traveled with us at that time, and she wanted a way to just show him: this is what I'm going through, this is how I'm doing, and I was happy to, you know, indulge her request, but I was not prepared for what I saw.
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Dr. Onyinye Balogun: From her supraclavicular area, um, down onto her chest it was just so, so dark, very much, you know, in contrast to the rest of her skin. I thought my aunt had had a mastectomy and that's why her skin looked so dark, and, uh, her skin just looked marred and it was shocking for me.
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But I think I didn't let the shock register. I knew that I should just kind of be stoic about it and just take the pictures. I, I can only remember that interaction with her. I remember the feeling I had and how she made me feel at that visit. And it was that she was full of warmth, that she was caring, that she was tender, um, that she loved me and my siblings a lot. And I always wondered if she knew that that was gonna be our last time together. My aunt died, um, Thanksgiving day in 1993. I was really upset because to my mind, if I make a request, if I make a prayer, then magically, everything should get better. That was my thinking. And when
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she did not get better, it really, I, it, it, it rocked my world.
INTRO MUSIC
All I knew was that I hated this disease. I wanted to do everything I could to make sure other people did not suffer from it. So from that time forward, I decided that I had a vendetta against cancer. It was just, I hate this thing and I am going to be part of the solution.
Catherine Price: I'm Catherine Price, and this is Advances in Care. The photos that Dr. Onyinye Balogun took of her aunt were stored away in her parents’ house sometime after she returned home from her trip to Nigeria, but she says they always stuck with her. Today, she is a Radiation Oncologist at NewYork-Presbyterian/ Weill Cornell Medicine. In the course of her career -- so far -- she has worked to improve access to better radiation
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technology globally, initiated genetics research, and has even dipped her toes into venture capitalism for medical devices. If I were to summarize her career, I'd describe it as an exhaustive and multi-faceted attack on cancer. But she describes it like this:
Dr. Onyinye Balogun: I'm multi-passionate. I love to do many different things.
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Dr. Onyinye Balogun: I think it was in college when I started thinking, what can this look like tangibly? Which avenue am I going to use to be part of the solution?
Catherine Price: Dr. Balogun realized there were many ways to wage her vendetta against cancer. There was drug development, of course, and medical oncology, surgical oncology...
Dr. Onyinye Balogun: And I remember the first time I shadowed a surgical oncologist and I said, ‘okay, prepare yourself. You're going to see a mastectomy.’ And so when we got into the operating room, I kind of steeled myself for this moment where when they removed the breast, I thought the skin would just become really dark and it didn't. So
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I started asking myself why didn't, you know, this patient's skin become really dark? It was after I decided to become a radiation oncologist, had already done my interviews, that I went to visit my parents and my mom said, ‘Hey, these pictures, you took them a while ago.’ And it was the pictures I'd taken of my aunt and with the knowledge I had gained, I realized, oh my goodness. Those are the side effects of radiation. That's what I saw.
Catherine Price: Timing can be funny that way. The moment when Onyinye realized that her aunt's darkened skin was in fact damage from radiation was mere days after she decided to become a radiation oncologist.
Dr. Onyinye Balogun: It's just always so interesting to me how things come full circle and how even without knowing it, I ended up being in the field that basically had impacted her. I felt I'd really found my niche.
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I felt, I want to learn these skills. I want to learn how to harness the power of radiation. I'm just really happy with what I do.
Catherine Price: In the years after medical school, Dr. Balogun began working abroad in Armenia and Gabon. She designed a curriculum to teach oncologists about better radiation technology--- like 3D-conformal radiation therapy, for example --- which allows oncologists to direct radiation beams to conform to tumor shapes, so that they can avoid damaging healthy tissue. Her hope is to improve the quality of cancer care in middle and low income countries. But like she said – she is multipassionate. And while doing this work, cancer data began emerging that was telling a confounding story. In recent years, common cancers like breast and lung cancer have seen a decrease in cancer mortality. But some cancers were getting more deadly.
Dr. Onyinye Balogun: The two cancers that are trending backwards are cervical and uterine cancer.
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We're not decreasing in morbidity, we're not decreasing in incidence. Everything is just going up both incidents and mortality of uterine cancer, especially among Black women.
Catherine Price: Dr. Balogun made the decision to zoom out. Improving the landscape of cancer care required more than just better radiation therapies, or better-trained oncologists. Cancer rates and mortality rates were rising disproportionately for Black women, and Dr. Balogun realized more research was needed to figure out why.
Dr. Onyinye Balogun: I wanted to take a look at cancer disparities within New York City, and in my mind, the big story was going to be cervical cancer disparities are still present. I didn't know if they were getting worse, but I wanted to basically, if they were, shine a light on that or if they were still in existence, shine a light on that and I just said, you know, why don't I just take a bird's eye view and look at everything? Let me look at ovarian cancer, cervical cancer, vulvar, uterine
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cancer, and my eyes nearly jumped out of my head when I was looking at the statistics for uterine cancer.
Catherine Price: Black women's uterine cancer incidence has been increasing at a faster rate than other races. So much so that in the mid 2000s the incidence surpassed that of White women. Not only that, Black women are dying from their diagnoses twice as often.
Dr. Onyinye Balogun: If you look at the five year survival for a White woman living in the United States, it's about 84%. If you look at a Black woman with endometrial cancer diagnosis, her five year survival probability is 62%. And the trends are going in the wrong way. Why?
Catherine Price: Finding answers to these questions is understandably not straightforward. An analysis of patient histories doesn't often take into account "softer" data - like access to healthcare, medical literacy, and systemic racism.
Dr. Onyinye Balogun: When it comes to the causes of cancer disparities,
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we know that there are social determinants of health that contribute to these disparities. It involves health literacy. If you see postmenopausal spotting, do you know what it is in order to go to the doctor quickly enough that we can catch the cancer hopefully early? Do you have health insurance? Are you in a location where you have the ability to get to a healthcare center easily? Do you have the money to pay for healthcare? And we also know that it involves your environment because there are environmental risk factors that contribute to an increased risk of cancer.
Catherine Price: But Dr. Balogun isn't certain that these social determinants can account for the disparities on their own. There may be something genetic at play. Enter: The Polyethnic 1000 study.
Dr. Onyinye Balogun: Basically we are recruiting underrepresented populations into genomic studies because they are usually not
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included in the numbers that they should be.
Catherine Price: This is an initiative of the New York Genome Center in partnership with research hospitals like NewYork-Presbyterian/Weill Cornell Medicine to advance genomic cancer research in underserved populations. Now, as a part of this study, Dr. Balogun is overseeing an effort to search for clues about the uterine cancer disparity in the biology of Black cancer patients.
Dr. Onyinye Balogun: We’re looking for potential mutations or polymorphisms specific to a certain group of individuals that may increase their risk of certain cancers.
Catherine Price: Black women with diagnoses are offered an opportunity to participate if they qualify. As a part of the study, patients are asked a slew of questions about potential social determinants, and then the geneticists at Polyethnic 1000 sequence the patients' genomes.
Dr. Onyinye Balogun: We know race is made up. It's kind of an arbitrary means of classifying people according to their skin color, right? Up to today,
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people have relied on self-reported race: just Black, White, which doesn't tell us much. When you say Black, they could be of Caribbean heritage, it could be someone who's Afro-Latina. There's so much that's under the umbrella of “Black.” What we're looking to do is to say, ‘okay, yes, this person said they were Black, but we see in their genome that they have 90% African ancestry.’ Some of the colleagues that I worked with, like, um, Melissa Davis and Lisa Newman have done this kind of teasing out of African ancestry and its relationship to breast cancer. They've shown that the patterns for breast cancer and the genomic expression for breast cancer in East Africa is, is different from that in West Africa. And so I want to do the same for endometrial cancer – to be able to kind of break down the percentages
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and the relative contributions from different backgrounds. That's the beauty of this research: we're not just saying, ‘oh, you're Black,’ because that doesn't give the granularity that we need in order to really figure out, is there a different risk factor for people who are from South African heritage? So we're going to be able to have that level of granularity.
Catherine Price: It's important to say that doing this work is uncomfortable at times. People are understandably wary of blaming poor cancer outcomes on the genetics of Black people.
Dr. Onyinye Balogun: I don't want to, um, discredit the fact that there has been a lot of research done to show that a lot of these cancer disparities are attributed to, you know, systemic racism and issues with access to care, but specifically with uterine cancer research, there have been studies conducted by the GOG that hold certain factors equal–socioeconomic level equal, educational level equal and yet still Black women come out
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with worse outcomes. We have to attribute some of these differences to genomic factors that have not yet been studied. There is, unfortunately, a school of thought that says, don't look at genomics. You know, 99% of our genome is the same, but you cannot deny that the percent, even though it's less than 1% that's different – it makes a difference in terms of how we look, in terms of our risk for certain diseases. It matters.
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Dr. Onyinye Balogun: I'm not here to say, ‘oh, it's our fault, or it's, it's our bodies.’ I don't ascribe to that, but we need to explore all aspects of it. And so that's why as part of the Polyethnic 1000 project, we are not just collecting tumor samples, you know, sequencing them and saying, ‘oh, these are the genes that we see that are
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upregulated or downregulated.’ We're also taking care to collect socio demographic information. So we want to see what's the interplay, what are things maybe that are coming together to drive up your risk of developing an aggressive uterine cancer. I don't see it as a this or that. It is both and and.
Catherine Price: Once the study is complete, Dr. Balogun hopes to have a clearer picture as to who has higher risk -- and what exactly is causing that risk. With that information, it could be possible to make huge improvements to cancer mortality rates.
Dr. Onyinye Balogun: Can we find new strategies for screening? Can we find new strategies for treatment? Right now, there's no way that's widely used to screen for endometrial cancer. We haven't found that modality that makes it cost-effective,
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you know? What age do we start at? Who do we screen? Maybe there's a genomic mutation that puts you at higher risk, then is that a population that we should be screening regularly so that we can catch the cancer earlier? And then also if we do find a genomic mutation in a number of these cancers, that of course leads to, is there a way we can have a drug that exploits that mutation?
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Dr. Onyinye Balogun: It can't, it can’t stay like this. We have to find new strategies because endometrial cancer just continues to skyrocket. So we need better strategies, and I'm really excited about what we're going to find out and hopeful that it will, you know, move the needle when it comes to changing, um, the likelihood of survival, especially for Black women.
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Catherine Price: The Polyethnic 1000 data
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is coming, but in the meantime, more patients than ever are undergoing treatment for uterine cancers. That’s why another area of passion for Dr. Balogun is finding ways to improve the quality of patient care given during cancer treatment.
Dr. Onyinye Balogun: In 2020, I met Eve McDavid. She, at the time, was a tech executive, 33 years old. You know, she had one daughter and was 34 weeks pregnant with a son, and um, when I met her, she had just been diagnosed with stage two B, um, cervical cancer. We started treatment right away.
Catherine Price: Eve had a seven centimeter cervical tumor and it was growing fast. She needed aggressive treatment, which meant that her son needed to be delivered early by C-section in the days after her diagnosis.
Dr. Onyinye Balogun: Eve's story was particularly meaningful to me
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because I knew she had a young daughter at home. I knew she’d just delivered a son, and I wanted her to go home and have the opportunity to create memories with her children. I felt that this woman has a chance at cure.
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Dr. Onyinye Balogun: In order to cure cervical cancer that has gone beyond a certain stage, so if something is larger than four centimeters or it's adherent to certain structures inside the body like the pelvic side wall or the parametria, or if it's, if cervical cancer has spread to the lymph nodes, we know that surgery alone is not going to be enough. And in her case, we needed to proceed with chemotherapy and radiation.
Catherine Price: Eve started with 6 rounds of weekly chemotherapy, which was quickly followed by a radiation treatment plan.
Dr. Onyinye Balogun: First from the outside for about five weeks
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on a daily basis, Monday through Friday, you're going to give external beam radiation therapy focused on the pelvic lymph nodes, the cervix, the uterus, um, the vagina. She had a great response to the initial first phase of treatment. And then, this is the crucial part: You have to give internal radiation called brachytherapy.
Catherine Price: Brachytherapy is radiation administered internally in the uterus, directly aimed at the tumor, and while this step is extremely important, the standard brachytherapy device is unconscionably outdated.
Dr. Onyinye Balogun: The tools that we use right now -- the template for them, the originals were approved before women were included in clinical trials in 1976. The tools can be excruciatingly painful. The pain is likened to childbirth, and this is from the lips
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of cervical cancer survivors. There have been women who say, ‘I would rather take my chances with dying than to put myself through this cervical cancer treatment.’
Catherine Price: Dr. Balogun does have the good fortune to work with anesthetists while she’s implanting the brachytherapy device, so she does her best to limit that excruciating pain, but in many other countries, patients are left with nothing more than an oral painkiller.
Dr. Onyinye Balogun: Imagine getting through childbirth with a pill of Xanax or Tylenol. I could not do it. And you know, it just, it made me think of my, you know, my aunt.
BEAT
Catherine Price: Even though Eve McDavid had the best possible care scenario for her brachytherapy, she says she found the procedures “impossible.”
Dr. Onyinye Balogun: Eve started asking me, she said, ‘do you think we can do these procedures better, these brachytherapy procedures?’ And I told her ‘I know we can do it better.’ In the midst of the procedure,
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she'd be talking to me and saying, ‘Hey, can I see those, those devices?’ She's very motivated.
Catherine Price: Dr. Balogun wanted Eve to focus on getting better first. But, a year later, once Eve was in remission, Dr. Balogun called her and they began working together to bring brachytherapy into the twenty-first century. Dr. Balogun and Eve are now exploring how to design a brachytherapy device that’s better suited to women’s bodies, less painful, and that can deliver better treatment.
Dr. Onyinye Balogun: A lot of the devices we use are quite rigid, so with the device that we're building, we want to improve upon its adaptability to the female anatomy. We also want to solve for the limitations that physicians face. So one of the limitations is the ability to alter the configuration of the device after you've put it in place. So that's what we want to do is to provide that kind of flexibility
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and ability to change things if needed, so that we can always get the optimal plan. When it comes to medical device research, it feels like devices are brought to the patient population and they say, ‘here you go, this is what we’ve created’ and Eve and I are trying to reimagine how that process goes. Eve is a survivor, a patient advocate; she has insights that I could never possibly have.
Catherine Price: Dr. Balogun’s and Eve’s women’s health venture is backed by Weill Cornell Medicine, Cornell Tech and Cornell university – and they’re combining Eve’s tech background and patient experience with Dr. Balogun’s expertise in radiation oncology and gynecologic cancers to improve the experience of patients undergoing cancer treatment.
Dr. Onyinye Balogun: How do I ensure that the technology I use as a radiation oncologist is optimal, and that it, it, it, it achieves its goals while being patient centered, while making sure that people are not left traumatized from their treatments and choosing to walk away from it.
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I spoke with a group of endometrial cancer survivors and they said ‘a risk factor for death is a physician who doesn't care about you,’ and I never heard anyone say something like that, and it just struck me to my core. I know many of us, most of us, come to medicine to do a good job. And it, it's not easy. The days are long. You give a lot, especially as an oncologist, you give a lot, but it, it behooves us, when people are bringing concerns, to sit up and listen and, and, and do your part to really take notice of what they're trying to tell you. And I will say especially, especially for Black individuals because we know that there
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is a tendency to not acknowledge their pain or to underplay their symptoms. The voice of the people we take care of matters.
Catherine Price: So many thanks to Dr. Balogun for speaking with us.
I’m Catherine Price; Advances in Care is a production of NewYork-Presbyterian hospital. As a reminder, the views shared on this podcast solely reflect the expertise and experience of our guests. To find more amazing stories about the pioneering physicians at NewYork-Presbyterian, go to nyp.org/advances.
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