Center of Gravity
Washington State has one of the highest rates of breast cancer in the country. Steve R. Martinez, an award-winning surgical oncologist at the Everett Clinic, wants to uncover why.
He zeros in on Snohomish County’s large population of rural poor. Disproportionately higher rates of breast cancer there elicit questions, underscoring the challenges of eliminating health disparities.
Is it radium exposure? Something in the groundwater? Scarcity of vitamin D-rich sunlight?
“Nobody knows—and without delving into it, we’ll never find out,” says Martinez, mindful of the complex factors driving disparities.
Solutions, he adds, require probing beyond race, ethnicity, and socioeconomic status.
Martinez has studied the impact of disparities on cancer treatment. “We looked at a range of conditions, including age,” he says. One study found that elderly patients with melanoma are less likely to receive aggressive therapies, and even evaluative procedures, typically offered to younger people.
“Geography also plays a role,” he says. “Breast cancer survivors in rural areas don’t have comparable access to breast reconstruction following a mastectomy.”
These days, Martinez spends most of his time in the clinic. But he continues to develop new research programs, as the quest for disparities solutions exerts a strong gravitational pull.
Audacity in Action
Martinez sensed early on that his future was in medicine. “My parents revered physicians, and I had a great relationship with my pediatrician, who I saw until I was 18 or 19,” he says. “I knew I wanted something to do with science, and I was interested in medicine as a possibility.”
The youngest of five, he was the first in his family to make it through college, earning a bachelor’s degree from Cornell University. “Cornell was completely different from Long Beach, Calif., where I grew up, in every way: different climate, different geography, different culture of people, and more rigorous academically,” he recalls.
At Cornell, Martinez learned how to study and how to focus, skills that continue to serve him well. He also learned about the Robert Wood Johnson Foundation’s Minority Medical Education Program (MMEP, now SMDEP) from his Cornell mentor, who encouraged him to participate at the University of Washington (UW) site.
In 1992, when Martinez attended, MMEP’s acceptance criteria included college juniors and seniors; they would later change to accept only freshmen and sophomores. “I went after my junior year,” he says. “I had already taken my MCAT and was happy with my score, so I wasn’t interested in the MCAT component.” He was, however, attracted to research being conducted at UW.
“I was taking a genetics course at the time, and I’d read about researchers at UW who were doing a clinical trial of a new drug for kids with cystic fibrosis,” he says. “I was very interested in that.”
Arriving on the UW campus, Martinez took an audacious step. “I called the pulmonary medicine department and brazenly said, ‘My name is Steve Martinez, I’m here for MMEP, and I was wondering if you’d have any interest in letting me help out on this research program.’ And they said, ‘Um…no,’” he laughs. But rather than dismiss him entirely, the department staff invited him to work on another project, examining insurance difficulties encountered by cystic fibrosis patients.
In describing MMEP, he says, “I can narrow it down to a single word: opportunity. Opportunity to meet people that would play a part in my future career and career development, people who were like minded and of similar backgrounds. Opportunity, in my case, to mold the program into something that I needed it to be, doing research with people who acted as mentors to me. Opportunity to get involved in community activities and be exposed to all sorts of new things. It was opportunity in every regard.”
Walking with Giants
The exposure to UW through MMEP weighed heavily in Martinez’s choice of medical school. “I can honestly say that I wouldn’t have considered applying to UW before that,” he says, adding, “When you interview for a job, how much time do you spend there? A day? Maybe they bring you back for a second visit, but at no point are you ever there for an entire summer. I got to see the whole picture, and working at that fabulous research facility got me excited about it. I could have gone to UCLA. I could have gone to Tufts. I chose the University of Washington.”
His MD in hand, Martinez once more headed east—this time to Long Island, where he did his medical internship and residency at the State University of New York at Stony Brook. During his six years there, he completed his general surgery training and managed to squeeze in a year-long research fellowship.
Another fellowship, this one in surgical oncology, brought him back to California. At the John Wayne Cancer Institute, and later as an associate professor at the UC Davis Comprehensive Cancer Center, he amassed impressive research credentials, co-authoring upwards of 70 studies on issues ranging from the management of colon cancer patients to disparities in breast cancer treatment. The latter study found that Blacks and Hispanics were less likely than whites to receive radiation therapy (RT) following a mastectomy—and that Black patients had a lower breast cancer survival rate overall, regardless of whether they received RT.
The recipient of a long list of honors, including two American Society of Clinical Oncology Foundation Merit Awards, Martinez has worked with giants in the field. They include one of the John Wayne Cancer Institute’s founders, Donald Morton, MD, who transformed treatment of melanoma and breast cancer by developing a widely used technique for detecting whether cancer had spread.
”What we used to do routinely with skin cancer is take a wide area of the lymph nodes around the melanoma and remove them all,” says Martinez. “It’s a great operation for finding out if any of those lymph nodes were involved, but a crummy one for most of the folks who come in with melanoma, because only 20 percent of them have involvement of the lymph nodes.”
“You don’t get to where you are on your own, even if you think you did. There’s always someone there behind the scenes or out in the open, helping you out.”
The technique Morton developed, the sentinel lymph node biopsy, narrowed the focus to the lymph node closest to the tumor. “You find it by injecting a radioactive dye and a blue dye, and make a radioactive map of where the dye goes,” explains Martinez. “So instead of making a big incision and removing all of the lymph nodes, you can make a small incision and just remove the lymph node identified with the dyes. If that node is clear, the patient doesn’t need additional surgery.” The same procedure is now done with breast cancer as well.
“People like Don Morton took me under their wings and were nice enough to train me and show me everything they’d learned,” says Martinez, reflecting on the many mentors who have guided him in his career. “That apprenticeship was invaluable. You don’t get to where you are on your own, even if you think you did. There’s always someone there behind the scenes or out in the open, helping you out.”
Back on the Case
After a decade of splitting his work evenly between the clinic and the lab, Martinez now devotes 90 percent of his time to clinical practice and 10 percent to administration and research.
“My clinical practice is about 80 percent breast surgery, primarily breast cancer, and the additional 20 percent is either endocrine surgery or melanoma and soft-tissue cancers,” he says. He sees patients two to three times a week and operates twice, carving out additional time here and there for research.
It’s unlikely that his investigative prowess will be on the back burner for long, however. In fact, Martinez is already developing protocols to get local oncology surgeons involved in research.
“There’s no history in this area of any research being done,” he says. “I need to get people thinking about it, get them involved with clinical trials and following patient outcomes more closely.” Among his areas of focus are new forms of surgery and treatment for breast cancer.
“That’s what I’ve had most of my training in,” he explains. “It’s what I do best.”