Dr. Charles Lynch is an influential, long-time faculty member and epidemiologist at the University of Iowa, perhaps best known as the medical director and principal investigator of the State Health Registry of Iowa/Iowa Cancer Registry.

This week’s episode is a wide-ranging conversation with Dr. Lynch, hosted by Alex and Radha. They chat about his career, the many research projects he’s been involved in, his impending retirement, and advice for current students.

Find our previous episodes on Spotify, Apple Podcasts, and SoundCloud.

Alex Murra:

Hello, everyone. Welcome back to From the Front Row, brought to you by the University of Iowa College of Public Health. My name is Alex Murra and I’m joined today by Radha Velamuri. And if this is your first time with us welcome. We are a student-run podcast that talks about major issues in public health and how they are relevant to anyone, both in and out of the field of public health. Our guest today is Dr. Charles Lynch. Dr. Lynch received his MD in 1979 and PhD in Epidemiology in 1984 from the University of Iowa. He is currently a professor who, through most of his career, had a joint appointment in the Department of Epidemiology in the College of Public Health and the Department of Pathology in the College of Medicine at the University of Iowa. In addition to teaching, from 1990 to 2020, Dr. Lynch served as the Medical Director and Principal Investigator of the State Health Registry of Iowa, which is an Iowa statewide cancer surveillance program that is part of the National Cancer Institute’s Surveillance, Epidemiology and End Results Program.

Alex Murra:

Additionally, from 1992 to 2018, he was the director of the Iowa Field Station for the Agricultural Health Study. And for over 25 years has been the leader of the Cancer Epidemiology in Population Science Program of the Holden Comprehensive Cancer Center. His research interests include cancer epidemiology, cancer surveillance, and environmental epidemiology. Today is a bittersweet episode as after 36 years as a professor here at the University of Iowa, Dr. Lynch will be departing the University of Iowa and heading into retirement. However, before doing so he’s here to talk with us about his impressive career and give us all some words of wisdom. Welcome to the show, Dr. Lynch.

Charles Lynch:

Thank you.

Alex Murra:

So to start us off, our first question, we’d just like to ask you a little bit more about what motivated you to pursue your career in medicine and public health and just how you ended up in your current role.

Charles Lynch:

Well, when I was growing up, I guess I have to admit I’ve lived in Iowa, my entire lifetime. I was born in northeast Iowa in the Decorah, Iowa, area and went to high school in that area as well. And then pursued my undergraduate degree at Loras College in Dubuque, Iowa. Now, as I was growing up, I would go to my family doctor and I found medicine to be a noble profession. And I thought that would be something worthwhile to pursue. So when I was at Loras, I pursued a degree in chemistry and with, with the hopes that would be a sufficient undergraduate Bachelor of Science degree to get me into medical school. And I was admitted to medical school and came to the University of Iowa in 1974. So that was what, 26 and 22, 48 years ago. I didn’t come here with the intention of remaining in Iowa City for the rest of my life, but rather to go to medical school and be a family doctor, like I had experienced back in Decorah. But as I got into my medical school training, I was not attracted to clinical medicine.

Charles Lynch:

And that’s what the University of Iowa was really interested in putting out at that time. So the first lesson I was learning is what do you do when you’re pursuing a career that you thought you were interested in and finding out, “Well, not so interested in this.” But what I did learn during this time is that a medical degree is one of the most flexible degrees that we have in this country, as a professional degree. You can do all kinds of things with MD behind your name. And I was in the process of realizing that, and the way I approached it was if I was going to do clinical medicine, what was I going to do? And I thought I could go in and do basic science research. So I got a job with Dr. Tom Conway, who was a professor in Biochemistry. So the Bowen Science Building still stands today.

Charles Lynch:

And I was working as a research assistant in his lab on the fourth floor of the Bowen Science Building. And that worked out fine. And I was watching what he was doing, in a sense. He wasn’t an MD, he was a PhD. But within the Department of Biochemistry, they had MDs that were doing research on cholesterol and this type of stuff. So I was seeing firsthand what was happening there. And then the other thing I decided to do was to start taking some courses in what was then the Department of Preventive Medicine and Environmental Health. Now this department is what the College of Public Health grew into in 1999. But back in the 1970s, this was considered a basic science department in the College of Medicine. And as I said, it was named Preventive Medicine and Environmental Health. So I started taking courses and I liked that.

Charles Lynch:

And I got swayed toward public health because as a medical student, you get a pretty broad education. You take your basic science courses the first year and a half, and then you rotated into Introduction of Clinical Medicine and then did clinical rotations. So where you’re learning a lot about health throughout the human body. On the other hand, as my research assistant job in Biochemistry, I was seeing Dr. Conway running over to the Hardin Library once a week, looking at what’s the latest and greatest things going on with protein biosynthesis, which was his particular area. So as an individual, I saw myself really having to get to the cutting edge, if I was going to be a basic scientist. I was going to have to really be narrow in my thinking, but you don’t know a lot about a particular area. But I was learning a little bit about a lot of areas as a medical student.

Charles Lynch:

And I thought that seemed to apply much better to public health, because you can do many things in public health as well. And even in many of the jobs that we have, you work on one disease one day, one problem, and you’re working on another problem next day. So I decided that was probably the direction I was going to take. So as I got into my last year of medical school training, I pretty much continued to take courses with my elective time in Preventive Medicine, Environmental Health, and I lost a year of training. You should be able to get through medical school in four years. It took me five years. So in May of 1979, I got my MD degree. And then that following December, I got a Master’s degree in Preventive Medicine and Environmental Health. And I was primarily working in the Division of Epidemiology.

Charles Lynch:

There were actually three divisions in the department at that time, Epidemiology, Biostatistics, and Occupational and Environmental Health. So those are the same three departments that we have today. We added Community Behavioral Health and Health Management as two additional departments to qualify to be a College of Public Health. But prior to that, the other three departments were already existing in this basic science department in the College of Medicine. So that’s what happened to me. It wasn’t anything I had planned, and I had done five years of additional training. And as soon as I finished that and got the MD degree, I was able to qualify for a fellowship. And my mentor for that fellowship was Bob Wallace, who is a professor emeritus in the department now. But he was, I think, an assistant or an associate professor at that time in the department. And the fellowship I qualified was in cardiovascular disease.

Charles Lynch:

But I remember telling Bob, “I’m interested in cardiovascular disease, but I’m even more interested in cancer.” So I was going to continue to do some work in cancer under this fellowship as well. The other person I met at that time was Peter Isaacson. Peter was the Head of the Department, but he had a personality. I don’t know if you run into faculty like this, but I was fortunate to get to know Peter. And he was like a grandfather. He was a person who had a lot of experience. You could go in and sit down and talk with him and it was just a very basic level conversation. So he was a very great mentor in that regard. And I think he saw me as a person who potentially could be of service to him in his activities at a later point in time, as I gathered more education.

Charles Lynch:

So with that interest, I continued to take courses for the PhD degree. Now, the other thing that happened to me was I had four years of medical education, which qualified me for a MD degree, but I was also interested in getting state licensure as a medical doctor. And it turned out at that time in order to do that and qualify for that, I had to do one more year of training, so-called internship. And I couldn’t figure out what I wanted to do an internship in. We all go through these, we stop and we have a fork in the road. And we have to decide, are we going to go to the right fork or to the left fork? We need to make that decision. And these are big decisions at the time. And the serendipity for me was I was playing basketball three times a week over at the Old Field House.

Charles Lynch:

And I was doing it with some faculty members from different departments. And one of the people that was playing on with us on a fairly regular basis was Dr. Michael Hart, who was a neuropathologist. And he worked in the Department of Pathology. And I remember talking to him one day coming off the court. And I said, “I face this dilemma. You have to do an additional year of training and I don’t know what to do it in.” And he said, “Well, you took pathology as a medical student, didn’t you?” “Yeah.” “Well, did you like it?” “I don’t know.” I said, “I did okay in it.” And this was in 1981 and I had been out of medical school roughly for three years, because my last year of training. I said I was mostly taking courses toward my master’s degree. And I said, “I’m rusty on medicine.

Charles Lynch:

I haven’t been seeing patients. I haven’t been doing anything like that for three years.” He said, “Don’t worry about it. Because the Department of Pathology pretty much services all the patients in the hospital with blood work, with tissue work, this type stuff.” And I didn’t realize this at the time, but he was telling me this. He said, “The first six months of your residency is going to be a review of medicine.” He said, “We’re going to take you around to all of our divisions in the department. And you’re going to see that the only thing they didn’t cover, for the most part, was eye pathology. But everything else went through this department.” So I said, “Okay.” Now I have four children and three of them have gone to medical school at the University of Iowa and received their MD degree. And every one of them, when they applied for a residency would put in 40 applications to different schools around the country in the hopes of getting admitted to one and they were all successful.

Charles Lynch:

But I would joke with them. I applied to one institution for my residency training University of Iowa Department of Pathology and I was accepted. And so I started that in the summer of 1982. And with my elective time, I was able to complete my thesis and obtain my PhD in Epidemiology in December of 1984. So I’ll go on and tell you how this ended up in my current role then. Because it’s 1984, I have a year and a half left of my pathology residency training. It’s a four year training period. And I successfully ended that in the summer of 1986 and the culminating event of that is to pursue board certification. And I was pursuing it in Anatomic Pathology. And I was successful in doing that. And immediately the Department of Pathology was short staffed on the faculty side and said, “We’d like to hire you as an instructor.”

Charles Lynch:

So I started out with a faculty appointment as an instructor. Now, the other advice I have for students is early in your career, I advise you to keep as many doors open as possible. So I liked Surgical Pathology, which is part of Anatomic Pathology. So is Autopsy Pathology part of it. And Cytopathology, those are three major disciplines under Anatomic Pathology, but I like Surgical Pathology, which just basically means I’m dealing with the surgical specimens that are coming out from the surgeons as they operate on people, they need to have a diagnosis. And they send that through Surgical Pathology in order to obtain that the bread and butter of Surgical Pathology is cancer. Almost in every case, you’re asking, “Is this cancer, is it not?” And if it is cancer, then you’re working to classify what type of cancer it is, and also staging it.

Charles Lynch:

What is the extent of the disease in the specimen that you’re looking at? So I wanted to keep that door open. So I talked with the Head of the Division of Surgical Pathology and said, “If this instructor position doesn’t work out, I’d like to do a fellowship in Surgical Pathology.” And said, “You’ve been a good resident. We’ll take you as a fellow. Do you have to apply? Just let us know.” But the other people that came calling in January of 1988, I was contacted by Peter Isaacson and Bob Wallace and said, “We’d like you to consider coming over to our department and taking an Assistant Professor position.” And being I’d gone to the 12 years of work to get an MD, PhD. I thought I probably should try and see if I can be successful in an academic career as opposed to a service career.

Charles Lynch:

But I still had in my back pocket, if this didn’t work out, I was going to go and do a surge-path fellowship, because I knew I liked Surgical Pathology. I didn’t know if I would be successful as an Assistant Professor because I would have to do service research and teaching the three legged stool of being a academic faculty member at least at that time. And you’ve got to publish and you’ve got to bring in grant funding and this type stuff. And was I going to be successful with that? And was I going to like it? But anyway, it was comforting me to have that in my back pocket. That other opportunity sitting there with the door open, it was just for me to decide if I wanted to do that. So I would advise students to do the same thing, keep as many doors open.

Charles Lynch:

As you move on your career, you have to close some doors. It’s just inevitable. You can’t keep everything open. But try and do it as long as you can so that you get into something that you enjoy and you feel good about and appreciate what you’re doing. And for most people in public health, it’s the feeling that I’m doing something to improve the health of the population and that’s what makes you feel good. It’s generally not the amount of money that you’re making. You’re making enough to live this type of thing. But it’s the fact that you’re doing something good for mankind that appeals to you. But there’s a lot of things you can do that are good for mankind. So that’s why I say try to keep those doors open.

Radha Velamuri:

Well, yeah. You told us this amazing story about how you got to where you are today. Lots of twists and turns that I’m sure a lot of students can relate to. But I was curious, is there something that you’re particularly proud of? One achievement, one key moment where you’re like, “I made it.”

Charles Lynch:

Yeah. I think for me it would be the Statewide Cancer Registry. I mentioned Dr. Peter Isaacson, he happened not only be the Head of the Department, but also to be the Principal Investigator of the Statewide Health Registry in the 1980s. And he came to me in 1988 and said, “I’d like you to replace me. You’ve got the educational background particular with your pathology training.” And a big part of cancer registration is getting the morphology or the histology of the tumor correctly classified. And that’s really something that pathologists do. He didn’t have a degree in pathology, but he felt it would work good to me. So he mentored me essentially to take this over, which I did in 1990. And so in retrospect, the thing I’m proudest of is that I was able to maintain full funding of the cancer registry. You’re evaluated every so many years to renew your contract that you have with the federal government in our cases, coming from the National Cancer Institute at NIH.

Charles Lynch:

And we have to show evidence that we’re doing well in our position. And we were able to renew that for 30 years with me as the PI. I think I’m particularly proud of that because that really created my career. The Registry is a rich resource. It’s documenting all the newly diagnosed cancers, excluding the nonmelanoma skin cancers that are diagnosed among Iowans. So it’s a very rich resource and it has high quality. And so with that, you can do research. So I’ve been able to do projects on children and adolescents and what’s happening with cancer in them. We did a large case control study, the largest case control study, I think that had been done at the University of Iowa, on cancer and drinking water contaminants. We had over 4,000 cancer patients and over 2,000 controls in that study. We did a population-based study called the Iowa Radon Lung Cancer Study, where we looked at residential radon. A very good study, one of the better quality studies that has been done on radon.

Charles Lynch:

It turned out to be highly productive in the sense that our study was pooled with other studies in the US and Canada and became a pooled report of what were the findings from that study. That database went on to be pooled with studies in Europe and other places on the planet. And rose all the way to the WHO, where they created a handbook for all the countries about how they should be handling residential radon. So to me, that was an example of a project that went all the way up to the World Health Organization. And the information was utilized for the welfare of the planet. I also got involved in an Iowa Women’s Health Study cohort of 40 some thousand Iowa women, but it wasn’t actually led by anybody at Iowa, it was led by a professor at the University of Minnesota. But throughout my career, I’ve collaborated a lot with people outside of the University of Iowa.

Charles Lynch:

Again, because I have this rich resource called the Iowa Cancer Registry. So our funding agency is we’re part of the Surveillance Epidemiology and End Results Program at the National Cancer Institute. So we’re one of several SEER Registries there. But we pool our data and do special studies as well. So every year, every other year, we do a Patterns of Care Studies. I was contacted by the Radiation Epidemiology Branch at NCI. They were interested in looking at the risk of second cancers in people who receive chemotherapy and radiation therapy for their first cancer. So it’s interesting that we treat cancer with carcinogenic agents. Chemotherapy and radiotherapy are agents that actually can damage cells and they can turn into cancerous cells. So they were interested in what is that risk? And so we got involved with several second cancer studies. Another big one was the We Care Study, which is a study of contralateral breast cancer.

Charles Lynch:

So women developing breast cancer in one breast have about a 6% to 10% risk of developing cancer in their contralateral breast. Because of that, one of the treatments that some people take with the first breast cancer is a double mastectomy to reduce that risk, but many people don’t. So we’re interested and have been for the past 20 plus years in identifying a population of women who’ve had contralateral breast cancer where the breast cancers were separated by at least one year. So it wasn’t like it was metastatic disease from the first breast cancer. We we’re pretty sure there are two independent primaries and we studied that. But this study was different in a sense, not only were we looking at lifestyle and environmental factors like smoking and alcohol consumption and the role of mammography this type of stuff. But as well, looking at genomics. So we collected blood samples and did genome wide scanning of those.

Charles Lynch:

And we’re looking at, are there certain genetic traits that lead women to be at increased risk of contralateral breast cancer, that study is still going on today. It started in 1998, 1999. Again, I couldn’t have done this without the Registry, because that was the source of the cases for this. Then I also got involved with tissue. As a pathologist I found out that laboratories in the State of Iowa, they’re destroying their tissue blocks for patients. So I don’t know if you realize this, but when you have surgery or you have a biopsy, that material is sent to pathology for examination and to render a diagnosis. But only a small amount of that tissue is generally needed to render the diagnosis. So if you have part of your colon resected, for instance, most of it never gets examined under the microscope, just the critical parts.

Charles Lynch:

But that piece of tissue was held onto for probably 30 days until you’re certain there’s no questions about the diagnosis. You don’t have to go back to the specimen and then you can’t hold onto this forever. Where are you going to put it? So it’s incinerated and is destroyed. And the same thing was happening with tissue blocks, the College of American Pathologists, which accredits labs, stated that you should hold onto those blocks for 10 years from the time of diagnosis. But after that, you can destroy them because they take up space and people run out of space. And it also costs money to maintain space. So labs were doing that and we decided for the cancer patients we had at the Registry, we would attempt to intercept that process and say, “Don’t destroy those blocks for that cancer patient, send them in to us.” So we started building what we called a Residual Tissue Repository.

Charles Lynch:

And today that repository has over a half a million tissue blocks for over 60,000 cancer patients. So we created another research resource utilizing that. Recently I’ve been involved with the Transplant Cancer Match Study. This is a linkage between two national databases. The SEER Program, right now, many of the registries, every state has a population based cancer registry now and pretty much has had since 1995. So we’ve linked to, at this point, about 37, 38 of those registries. And then linked it to the national database that exists for solid organ transplants of which the most common one is a kidney transplant. So there’s a registry of all these people who are donors, as well as, the people who are recipients of organs and that’s tracked. So we merged those two databases and called it the Transplant Cancer Match Study. So we’ve been publishing on that. What is the risk of cancer associated with transplantation?

Charles Lynch:

And the big issue that we’re studying there is immunosuppression because anyone who gets a transplant has to be immunosuppressed so your natural immune system does not reject that organ. And that immunosuppression is for a lifetime. It’s intense initially for the receipt of the transplant at organ, but it continues after that with maintenance therapy. And we’re finding out, as you know, right now that the immune system is pretty important in protecting every one of us from developing cancer. So if you suppress it, not surprisingly transplant patients have fairly high risk of developing a cancer after their transplant. And that’s what we’re studying in probably the largest database to do this in the world. So that’s been a very productive study. And then I think a study you want me to talk about a little bit is the Agricultural Health Study that you mentioned that I was the Iowa Director of.

Charles Lynch:

So let me just go on and tell you a little bit about the Agricultural Health Study. This is a prospective study. So we’re following people into the future and we’re particularly interested in chronic diseases, such as cancer, but we’re also looking at other health outcomes. In epidemiology, if you want to study something in the environment, the best place to do it is where you have high exposure. You don’t want to go do this in a low exposure group. That minimizes your opportunity to identify the exposure as a risk or protective factor. You want to identify people who have a lot of that exposure. So we thought a great way to do this would be to go after a cohort of licensed pesticide applicators. We went after both private and commercial applicators. Now private applicators are essentially farmers.

Charles Lynch:

They’re called private applicators, because they’re applying restricted use pesticides to their own farmland. So that’s going on right now with pre-emergent herbicides in that to cut down on the number of weeds in the fields so that the soil can primarily nourish the plant, which in Iowa was likely either corn or soybeans that were growing. I was just out on I-80 yesterday and it looks a lot of brown out there right now. But shortly, we’re going to see these rows of green growing and it’s going to be corn or soybeans for the most part, occasionally have a green field of alfalfa or clover. But this is Iowa and this is what we do. So we went after these and the goal here for us in Iowa was to bring in and enroll 50,000 people. This is a huge study.

Charles Lynch:

And initially we were going to do this. We were going to do this over a five year period. And it took us a year to develop a questionnaire that people could fill out. And we decided at that time to take a fairly novel way to collect this data, we had to collect it for so many people. Prior to this, when I would send out a questionnaire to people, I would just have them fill it out. Usually they would do a checkbox or something, we’d get it back and then we would enter it into the computer system. And we used double key entry to enter it once and then enter a second time to make sure that you had keyed it in correctly. But with this study, it was going to be so many people. We decided we would use a sustainable questionnaire. So it was like, you take an exam on a bubble form, this is how the questionnaire was set up.

Charles Lynch:

And you would circle the bubble that was your response. And then we sent it up to a firm in the Twin Cities that was going to scan these. And we thought this was going to be great. The flaw in our thinking was that some questions left a box for people to write in, to comment on. And the scanner was set up to collect what was in that box. But some people would write and the margins outside of the boxes type thing, there was no way to collect that data. Some people didn’t fill out the oval very well, so it wasn’t recorded. So although it worked well, we enrolled people, we spent another year or two just editing the scannable stuff to make sure that it was correctly recording the information that was provided. So that was a painful process to go through.

Charles Lynch:

But we achieved our goal. We enrolled over 58,000 Iowans into the study. Most of them were farmers at 32,000. Another 20-some thousand were their spouses. And then we enrolled about 5,000 commercial applicators. These are the people you can hire from farm service to go out and apply the pesticides rather than buying the equipment yourself to do it on your own farmland. So that was the group of people. On average, the spouses and the applicators were about 47 years of age, was the average age. And the commercial applicators. They were about 10 years younger, 38 years of age. So the first enrollment was in December of 1993. It took us till the end of 1997 to get our 58,000 people enrolled. And after that, we’ve just been following them ever since. We did a good job of getting personal identifiers from these people. So that every other year, we link them to the cancer registry to find out about their health outcomes regarding cancer.

Charles Lynch:

And then we follow them to death. So we do linkages with the National Death Index from the National Center for Health Statistics, as well as the death certificates from the State of Iowa and get information about their underlying cause of death. But most of the cohort is still alive today. So in some cases with rare diseases, we’re waiting for things to happen yet, so that we can actually have enough cases to have the statistical power, to do a good study of agricultural exposure. So pesticides is the exposure we studied the most and we probably in the study have the highest quality pesticide exposure data of any epidemiologic study that’s been conducted to date. We have a sister state that got involved with the study. It’s North Carolina, they enrolled 30-some thousand people. So we have a cohort of almost 90,000 people that were following, and there were many special studies with this.

Charles Lynch:

So with this particular study, the first time I went to IRB was in 1992, when we first got funding for the study. That particular IRB number is still open today. But in the interim, there were probably at least 75 other projects that were taken to the IRB that involved the Agricultural Health Study. Most of those have been closed out now. They were just sub-studies that were done, but we didn’t want to put them under just one IRB number because it would become too complex to follow this over time. And that was something that I just decided to do early on and I’m glad I did. Because this study probably still has the best days I’ve ahead of it. In the meantime, we have published 350 peer-reviewed papers from this one cohort thus far, and there’ll be many more to come. And our papers that we have published addressed the study design that we’ve used for the main cohort, as well as for some of the sub-studies that have been done. Issues related to measuring and classifying pesticide exposure.

Charles Lynch:

So we’ve done some studies to verify our algorithm that use to estimate individual exposure to pesticides as intensity weighted, lifetime exposure, accumulative lifetime exposure. We have this for over 50 specific pesticides. This is a strength of the data. But in order to document, we were getting pretty good estimates from this. We did a study with the research arm of the EPA, where they actually collected every type of exposure a person could have from the food that you were eating, the water you were drinking, in addition to, the application of the pesticide. But our feeling still is that most of the exposure for these people comes from the fact that they’re actually working with these chemicals in preparing a mixing of them on their farms, into a tank, and then actually going out and applying it in the field. And interestingly, about a third of our cohort members that were doing this reported getting headaches and feeling nauseous and this type thing after a day of applying these restricted-use pesticide they’re powerful compounds, but we weren’t so interested nos.

Charles Lynch:

We already had information about that from the existing literature. What we were concerned about was what were the long term effects of this? Does it put you at increased risk of cancer? We’ve also looked at reproductive factors. Does it impact that? Respiratory health as some of these chemicals can be breathed in. Although pesticides, a major route of absorption is through your skin. So they’re encouraged to wear protective clothing, to wear gloves, to have a hat on. And of course, they’re out there today doing this. It’s going to be 95 degrees. So it’s pretty hard to wear Tyvec overalls today. But you’re going to feel like you’re suffocating out there. So we also looked at how they repair their equipment and this type thing. Because many of them will say, “I wear gloves. But when I’m out there spraying, if one of my spray nozzles gets plugged up and I notice that I want to get off the tractor and go down there and fix it. I can’t do a good job with nuts and bolts and this type thing when I got gloves on.

Charles Lynch:

So I take them off. I mean, I have to do that to fix the equipment.” Well, they’ve just increased their exposure to that pesticide because they’re absorbing more of it now through their skin. We’ve looked at neurologic disease. This study still exists today. We’ve had students who have done their PhD thesis work on this cohort. Several of them, as a matter of fact. We’ve had faculty that have pursued grant funding through the existing data available in this cohort as well. So it’s not only been good for me. It’s been good for the department and good for the college as well.

Alex Murra:

Yeah. I’m actually going to ask a little bit of a follow up question. It’s so amazing that you’ve been able to work with these huge data sets and these really large projects like the Agricultural Health Center, the Iowa Cancer Registry. Thinking back about even with the Agricultural Health Study. I remember that was one of the first large cohort studies that we were introduced to in the epi-department as far as like, “Oh, well, what is a large cohort study of this nature?” But I actually wanted to go back to the Iowa Cancer registry and we actually really wanted to ask your opinion on some challenges that you think cancer surveillance is going to face in years to come. So we’ve seen with the most recent Iowa Cancer Report, that there were some decreases in cancer screening as a result of COVID-19. So just what other different things do you think we should look out for in this, I don’t want to say post-pandemic world, because we’re not really out of it yet, but moving forward at least.

Charles Lynch:

Yeah. Well some of that’s already happening. For example, so in terms of cancer surveillance, there’s going to be pressure placed on the surveillance programs to more thoroughly addressed and document changes in incidents in mortality and the reasons for these changes. In order to do this, they’re going to need to expand their data variable collection. So right now we rely a lot on what’s in the medical record, but we can’t collect everything in a medical record. I mean every variable that we decide to collect if we’re going to do in equality manner is going to take time and time is going to cost money. So we don’t have an unlimited budget. But the other thing that’s going on is there’s a lot more electronic data capture. Now there’s the electronic medical record, there’s these types of things. So we’re looking as part of the expansion to capture this electronic data, which if we have good linkage variables, we can link with confidence and feel we have the right person.

Charles Lynch:

We can capture this electronic data and it already exists. I mean, we don’t have to go and put it into the computer. It’s already in the computer. So that’s a big thing that’s going on. And then as a result of this, there are certain needs that people want us to fulfill. So one of them is for decades, we follow people to death. So we could look at overall survival and cause specific survival. But we could look at progression free survival, which is very important in clinical trials. Clinical trials, usually follow people and look at progression-free survival because if they have to follow you to death, the clinical trial never ends. It just keeps going on and on and on. And if it was required by the FDA for a new drug, the drug companies have to wait for years in order to be able to make the request to FDA for approval of their drug because not everybody had died yet.

Charles Lynch:

The study hadn’t concluded. So ability to look at progression free survival. We’re hoping we can capture that through electronic data. Another thing that we need to get is comorbidity information. So as you’re aware, because we grow older, there are many chronic conditions that we can be suffering from. We collect information on cancer. But people would like us to collect information on diabetes, heart disease, all these other conditions that people can have as well. We call those comorbidities. And the reason we want that data is they can impact survival of cancer patients. So they’d like to be able to control for that variable. That’s been a difficult variable to get a hold of for us, at least in the cancer surveillance arena. So there’s going to be more work done to try and capture that information. Another big thing that’s going on is biomarkers. So looking at a biospecimen and there are two major types of biomarkers we’re interested in cancer called predictive and prognostic markers.

Charles Lynch:

Predictive markers are ones that predict the type of therapy you should receive. So this is going on with lung cancer right now with PDL1, you look for a biomarker for this. They then qualify a specific type of drug that has been shown to be effective in clinical trials for lung cancer, but it’s not effective for all people with non-small cell lung cancer only for certain types. And that requires positive evidence of that biomarker. The other thing people are interested in is biomarkers that predict survival beyond what we have right now. They’re highly predictive of how long you’re going to live. So an example of that could be HER2 for breast cancer. HER2 positive people generally have a better prognosis than HER2 negative people. So you probably heard about triple negative breast cancer, you’re ER negative, you’re PR negative, your HER2 negative.

Charles Lynch:

These are very aggressive breast cancers that we don’t have a great treatment for right now. We do for estrogen positive breast cancers and for HER2 positive breast cancers, we’ve got a specific drug that has been developed. That’s effective. We don’t have a triple negative. So again, this is happening across medicine, these new biomarkers. So we have to be able to capture that information. And then of course the other big elephant in the room, the big data element is genomics. People would like you to collect the genomic data. Well, that’s a huge database. But it’s, what’s leading to personalized medicine. And so cancer surveillance is going to be under pressure to capture more of this type of information we’re going to lag behind what’s actually happening out there. Because usually we wait to see of the things that are happening out there, which are the ones that are going to persist over time that are really going to be good markers.

Charles Lynch:

Those are the ones in particular that we would like to capture. So as an example for HER2, we didn’t start collecting that in the registry until 2010, but it was initially approved in 1998 for metastatic breast cancer. And in 2006 it was further approved for more localized breast cancers. And then we start collecting it in 2010. So I’ve had some studies where people say, “Well, can you tell me about triple negative in the registry database?” I can, but I can’t really tell you about it till 2010 because that’s when we started collecting it. But I’m working with the study right now where I say we can go back to the past report and it’s possible it’s in the past report. It wasn’t something we were collecting, but that’s typically where it would be mentioned whether it was tested for or not. And whether it was found to be positive or negative. So anyway, that’s what I see happening down the road.

Radha Velamuri:

Yeah. I like how you gave us this temporal perspective about all of these changes that have happened in public health, specifically with the Iowa Cancer Registry and ones that you’ve seen in your career. Like you brought up electronic health record, you brought up biomarkers, genomics, and personalized medicine. Which is what we’re all working towards to improve the lives of every individual. And now that you’ve given us this historical perspective and with you retiring, which is, again, a sad note that we don’t want to end this podcast on. But there’s something we always like to ask our guests. We like to ask, “What is one thing that you thought you knew, but you were later wrong about?” And I think this is super valuable from your perspective because of your rich career and all of the amazing information you’ve told us today.

Charles Lynch:

Well, I think I’ve told you what I thought of that. When I first came to the University of Iowa almost 50 years ago, I thought I would become a family doctor. Like what I experienced as a child and adolescent. I really believe that. But I found out I had no idea about the complexity of medicine and there are so many subspecialties, this type thing. I didn’t do a good job of preparing myself for medicine. I didn’t shadow doctors. I didn’t do any of this type thing. I was just a student, went on, and I thought medicine would be a noble profession. Let’s look into it. And the only way that I had looked into it was seeing my family doctor back home. So because of that, I never thought back then that I would end up with the career that I’ve had.

Charles Lynch:

Nevertheless though I can look myself in the mirror today and I can honestly say that and I feel proud of what I’ve accomplished. And that’s, I think, a good goal for everybody to say, “I want to have a career that I enjoy what I do. I enjoy getting up in the morning and going to work. I enjoy what I’m building, whatever that is. And I feel it’s doing good. It just makes me feel good to be able to do that.” And because of this, in my case, I was able to accomplish more than I ever dreamed as a youngster. I mean, I can honestly say, if you would’ve told me that I would done have done what I did back when I was at Loras College, I would’ve said, you’re crazy. This is not going to happen.

Charles Lynch:

I’m not going to go to the University of Iowa and be there 48 years later. There’s just no way that’s going to happen. And it did. And I allowed it to develop. I talked to my kids, you go to college, “You’re 16 years of education, maybe 17, if you want to count kindergarten, grades 1 through 12, then you go four years, get your degree. You’ve got 17 years of education. You’re a highly educated person.” I never dreamed I’d come to Iowa, have to add on another 12 years of education on top of that to get to where I was to be attractive as a hire. But it wasn’t something that I was pursuing all along. I don’t know if I would’ve been doing that I would’ve had the will to do it. It was just something that happened. And I guess another thing that I would tell students is as you get an advanced degree, I already mentioned this with an MD.

Charles Lynch:

I automatically qualified for a fellowship. And what happens after that is you continue on with education. It was 1979 for me. I still had seven more years to go, but I have to really tell you that was a job. I was getting educated on the job. I had work to do. As a resident, I was expected to be in clinics such and such and such and such a time every single day until I rotated off that and went to my next rotation. That’s just the way it was. You had duties, you had work, it was a job, but you were getting educated at the same time. I also need to conclude to deeply thank all of my collaborators who have assisted me during my career. I couldn’t have done it without them in a sense. And I’ve dealt with some very good people, many different people at NIH, at NCI, many different people at institutions across the country.

Charles Lynch:

And what’s allowed me to do that, if you look back, has been the Iowa Cancer Registry. That’s been the key resource that only not I was using, but all these other people were interested in tapping into. As well in epidemiology, it’s hard to publish without data. Everybody needs data. Now I just happened to be a person who was able to work my entire career with very rich data sources and to look for opportunities to apply that resource. At times I feel bad. I felt I should have done more than what I did with these resources. But nonetheless, I’m proud of what I was able to accomplish, but it wouldn’t have been possible with all these other people, including the 40, 50 people who I was responsible for working day in and day out as registry employees. And there’s been many of those who have come and gone.

Charles Lynch:

It’s going to be my turn to be gone now, but that’s going to happen for all of us. But for the students, your careers are just starting. So my advice is keep as many doors open as you can. Look for opportunities that you enjoy and appreciate. If you’re not enjoying your work, there’s many opportunities in public health, look elsewhere. Hopefully through one of those other doors that you’ve been able to keep open and find something that you really do like and enjoy and then prosper in that. Be able to look yourself in the mirror when you retire and say I’m really happy with what I was able to accomplish. And many of you will be able to say it was more than what I ever dreamed.

Alex Murra:

Thank you so much for that Dr. Lynch. I think that’s an amazing. And oh, I don’t know. I get a little emotional sometimes with these types of goodbyes, but you have a wonderful career that you should be very much proud of. And I think that your impacts on campus and even in medicine and public health will be felt for many years to come. So I wish you all the happiness and hopefully you get some time to relax in retirement. But thank you so much for coming onto this podcast with us today.

Charles Lynch:

And I wish all of you success in your careers. And fight for it. And at the same time balance your life. You’ve got family, you’ve got your own personal needs, and you’ve got your work needs. Figure out a way to balance all that. So that, as I said, you can look yourself in the mirror. You don’t have to do it at the end of your career. You can do it during it as well and say, I’m happy with the way things are progressing for sure.

Alex Murra:

For sure. Yeah. Thank you.

Anya Morozov:

That’s it for our episode this week, big thanks to Dr. Charles Lynch for coming on with us today. This episode was co-hosted and written by Alex Murra and Radha Velamuri and edited and produced by Anya Morozov. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, and anyone interested in public health. Our team can be reached at CPH-gradambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.