The First Time

The First Time

Anees B. Chagpar, MD, MPH

@AneesChagpar
Jun 01, 2015

You never forget your first time . . .The sense of trepidation is overwhelming, the fear of rejection intense. You wonder about your own worthiness, but with some encouragement, you reach outnever anticipating reciprocation. But then it happens . . . almost out of the blue . . . the embrace you never thought you would receive. You remember exactly where you were, what you were wearing, who you were with . . . You remember the intense experience of euphoria that, in an instant, took over your being. You wanted to scream, but no sound came out; and you felt every molecule in your body quivering in excited Brownian motion . . . I’m speaking, of course, of your first publication in the New England Journal of Medicine. My first was just this month, with the manuscript of the SHAVE trial coming out concomitant with my presentation at this year’s ASCO Annual Meeting (Abstract 1012). 

This was, by far, one of the greatest days of my entire life, and as with all good things that happen to me, there are many people to thank. To begin with, I need to thank Tom Lynch, who is not only the Cancer Center Director at Yale, but a great friend and mentor. He encouraged me to do the study which by all accounts is a very simple randomized controlled trial. When others teased me about the study, Lajos Pusztai, my stalwart counterpart in breast medical oncology and the head of our translational working group, prophesied that this would be practice-changing as it compared two standard procedures to determine which would be better. My colleagues in breast surgical oncology, regardless of their personal views on which technique was better, enrolled patients in the trial, knowing that data should trump our preconceived notions. Everyone on the team did their part, and perhaps most importantly, patients participated in droves. This was one of the fastest accruing trials at Yale, and much is owed to the patients who helped us to find the answers. 

At the end of the day, when the data were in, and we found that taking routine cavity shave margins cut re-excision rates and positive margin rates in half, without compromising patient cosmetic outcome nor increasing complication rates, a few things happened. First, we changed what we were doing. I had long been a critic of this technique thinking it made no sense to simply take more tissue all the way around the cavity. Why couldn’t we just take out what we thought was sufficient, and use intraoperative imaging and gross analysis to see where we might be close and take more tissue there? Wouldn’t taking more tissue result in worse cosmetic results? I had been skeptical of the retrospective data to date, but now had level 1 evidence that I was wrong (mark this date on the calendar—surgeon admits she was wrong). Second, we needed to get the word out to the rest of the world. We submitted the work to ASCO, and were so pleased to have had the opportunity to present this year, but where to send the manuscript? 

While it had always been a childhood dream of mine to publish in the New England Journal of Medicine, I never really thought I would ever accomplish that–kind of like the dreams kids have of going to the moon or becoming President. Sure, some kids will accomplish those goals, but it certainly isn’t the norm. Here again is where great mentors come in—both Tom and Lajos encouraged me to submit to the top-ranked journal. I thought they both were being flattering (but delusional) . . . And then, as I sat in our conference room with Lajos and Malini, listening to a talk on circulating tumor cells, an email came through my iPhone from the New England Journal of Medicine that started “Dear Dr. Chagpar, We are pleased to inform you . . .” The rest of the talk was a blur, and my world was changed forever.

I must send a huge shout out to all at the New England Journal of Medicine who were absolutely incredible—they worked tirelessly to get the manuscript out in time for our presentation for ASCO, and were amazing to work with. To all my friends and colleagues who congratulated me, especially to people like Deanna Attai (a “Featured Voice” at ASCO) who supported me in the media and on Twitter, and Tari King our discussant who was so gracious, I cannot thank you enough. To the media relations people at the New England Journal of Medicine, ASCO, and at Yale, thank you for helping us get the story out about this work. Now the world will need to evaluate the data for themselves. I suspect, for many, this will be practice-changingit is very hard to ignore level 1 evidence showing a significant benefit, despite preconceived notions. For others, it may spur on further trials to see if we can improve even further in terms of margin clearance. Either way, it’s all good . . . and I am still in that state of beautiful euphoria and gratitude after one of the greatest climaxes of my life.  

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