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INTERVIEW: April Salama, MD

Dr. Chadi Nabhan recently caught up with Dr. April Salama, Associate Professor of Medicine, Associate Medical Director, and Director of the Melanoma Disease Group at Duke University. Dr. Salama is also a member of the Caris Precision Oncology Alliance™ and is the Chair-Elect for the Cutaneous Tumor Group. The interview took place in October 2020.

Here are the excerpts of the interview: 

NABHAN: What got you interested in melanoma and cutaneous malignancies? How did you end up where you are right now?

SALAMA: It will surprise many, but I knew I was going to be a doctor when I was in the first grade. No one in my family was a doctor and no one in my family knew where this was coming from, but I knew that’s what I wanted to do. All along I’ve had great teachers and great mentors going all the way back to high school. I was a biology major in college and to me that’s what medicine was, molecular biology. In my first year of medical school in 2000 and 2001, that was the year the early trials of Gleevec® were being announced. When these early Gleevec trials were introduced that’s when I believed this was the next wave of oncology and that we were turning the corner in terms of new types of therapies.

My initial interest was actually not in melanoma, but in lung cancer. A personal note about me is that I’m originally from North Carolina, where tobacco is king. When I was a teenager, my grandfather was diagnosed with small cell lung cancer and that was something that really touched me. At that time kids at my high school were allowed to smoke with a note from their parents! That’s when I thought this was something we have to fight as it was going to be a problem for generations to come. I didn’t want others to go through what my family went through.

When I came into my oncology fellowship at the University of Chicago, I was fortunate enough to pair with Drs. Ravi Salgia and Everett Vokes as my mentors. I also worked in the lab of Dr. Salgia who focused on translational research in lung cancer.

As much as I loved my time in Chicago, having grown up in North Carolina, attending public school through college and medical school, I felt it was a mission of mine to serve the people here, so I came to Duke after I completed by fellowship.

Duke did not have an open lung cancer job at the time in 2010. What they did have was a position in melanoma, which had been vacant for five or six years. I took a leap of faith at the advice of my mentors who advised me that this was a great time to pursue this opportunity and get into this field as there were new therapies coming out. So I accepted the job. It was hard at the time to leave the lung cancer world and transition but at the same time and given my interest in clinical trial development, and combined modality approaches, I thought it could be a good fit for me. I was able to get involved in some of the early studies and early combination trials and the rest has just built from there.

NABHAN: What does the day in the life of Dr. Salama look like? How do you divide your work up with everything you’re involved in?

SALAMA: First and foremost, I view myself as a clinician. That’s how I would define myself – a clinician researcher. It’s about the patient, it’s about the people. That’s where the passion is for me. So those couple of days a week that I’m in clinic that’s really my focus and really, it’s the drive and mission to get folks in, get them on trial. I’m lucky to have a really great team that makes all of that possible. Other days it’s juggling the administrative piece. I lead the melanoma disease group here, so I think strategically about how we need to continue to grow, especially as Duke is now expanding its reach beyond just the main campus with a campus in Raleigh. My passion is clinical research so I’m really fortunate in that respect because it requires key collaborations with our physician scientists. I am also invested in training the next generation of oncologists, so I take the mission of education very seriously.

NABHAN: Do you have a lab right now or do you collaborate with folks in the lab?

SALAMA: I don’t have a lab, but partnering with scientists and physician scientists is really integral to the success of any program. At Duke we have a motto: “Bench to bedside. Bedside to bench.” It has to be a full circle, so from bio-banking protocols, looking at pathways particularly of adaptive resistance to PD1, novel strategies, of course molecular diagnostics and markers, it’s really really important in terms of how we shape care right now. But then it’s also about what are we going to do next, and what are we going to look at in the future to continue to move things forward.

NABHAN: When you look at melanoma, it’s such a rapidly evolving field. You’ve been doing this for 10 years at Duke. When you look back, what have been the major advances in the disease and where do you see us heading in 5 years?

SALAMA: I think about this a lot. It’s really hard to think about a solid tumor that has had more change for the better in the last 10 years than melanoma, a disease that was revolutionized. Patients used to have a median survival of nine to ten months, but now, there are some studies where we haven’t reached the median OS at five years of follow-up. We’ve had tremendous progress of course with targeted and immune therapies. The work is certainly not done yet, so the big challenge is the development of resistance to both of those – what I’ve really taken an interest in is how the molecular BRAF story in melanoma has expanded to other tumor types. In the future, we still have to figure out the mechanisms of resistance to those therapies.  We’re still looking for the right combination immune strategies and both primary and acquired resistance is an issue there. Toxicity is a challenge as well. So, as we move forward we really have to look at these factors as we design combination strategies- which we can’t do without the scientific rationale and preclinical data. One of my former mentors at Duke said, “It can’t be like throwing spaghetti at the wall to see what sticks.” It has to be founded in science and we need to look at those combinations and ask how do we balance that risk/benefit to move forward.

The other answer to this question is in five years, or even sooner, I’d love to be able to more accurately characterize these patients – what are the biomarkers… we still don’t really have a biomarker, for example, for immune therapy. There are things out there that are predictive, but there is no one sort of clear winner that we can use in a reliable fashion as we do for selecting targeted therapies.

NABHAN: Where do you see sequencing tumors for melanoma?

SALAMA: I still think sequencing is an integral part of therapy for the care of advanced stage IV patients. Also, in stage-III, these are patients who are considering adjuvant therapy. Even if patients with metastatic disease are going to be treated with immunotherapy as frontline, sequencing might help as I think it’s something you need to know and I think the patients want to know. It helps you fully inform the discussion of therapy. I really think it should be included as part of the care plan for that cohort of patients.

NABHAN: Having pivoted from lung to melanoma, do you have any advice for the hemonc fellows right now who are interested in having an academic or translational career?

SALAMA: I’d say this advice applies less if you’re a physician scientist or basic scientist, but for clinical researchers I’d say to keep an open mind and learn the skillset of clinical trial development. I think if you have that skillset, you can pivot and learn a new disease. The clinic is your lab so you have to be a good clinician as well. I think you still need to be able to communicate with scientists, so I actually still tell our fellows to consider going into the lab even for a brief period of time. I did so myself and think it was tremendously helpful for me to understand what goes on there. And I’d also advise them to be open to new possibilities and be agile to explore new opportunities.

NABHAN: How do you spend your free time outside of the work?

SALAMA: I’m a big runner and love to run. I stick to half marathons because of my work schedule – maybe a marathon one day. I also have two young boys, 7 and 9, so the training for half marathons is more conducive! Pre-pandemic, my family and I loved to travel. Now with COVID-19 and not being able to travel, my new found time is spent relearning both tennis and the piano. I believe you need something outside of medicine to stimulate the mind and challenge yourself with and both of these have done just that and it’s been fun.