Drake Lecture to address 21st century controversies in transplantation

Nancy L. Ascher, MD, PhD
Nancy L. Ascher, MD, PhD

This year’s Charles G. Drake History of Surgery Lecture will address some of the social and ethical issues surrounding resources and disease burden as they relate to modern transplantation.

Nancy L. Ascher, MD, PhD, FACS, professor of surgery, University of California, San Francisco, will present Transplantation in the 21st Century at 1:00 pm CDT, Monday, October 5, during the virtual ACS Clinical Congress 2020. The lecture will be available for on-demand viewing through the virtual Clinical Congress meeting platform through December 31.

“The advances in transplant have completely changed our idea about what transplant should be, what it is,” Dr. Ascher said. “Generally, it’s accepted as optimal therapy for many of the causes of end-stage organ disease, which has elevated this miracle of transplant to everyday care. But what it has done at the same time is create terrible problems that have to be addressed on a local level, a national level, and a global level.”

Transplantation success is high, but a shift in disease burden from infectious diseases to noncommunicable disease has created new challenges for the field. COVID-19 is an exception to this repositioning, but Dr. Ascher explains the ongoing pandemic does not override the evolution that has taken place over the past 20 years.

“As countries develop, noncommunicable diseases such as heart disease, lung disease, chronic liver disease, chronic kidney disease, and diabetes are the diseases that cause deaths and disability,” she said, drawing on data from 150 different countries in the Global Burden of Disease Study. As these diseases become more prevalent, the steps before transplant—prevention, management, and treatment—also increase in importance.

“Transplant is at the end,” Dr. Ascher said. “Once your heart has failed, you can get a heart transplant. Once you are on dialysis, you may be able to get a kidney transplant, but the truth is that it’s the obligation of us, the surgeons, to think about disease prevention.” She challenges surgeons to approach noncommunicable disease prevention in ways that are both economical and able to be widely dispersed.

With a growing number of people who could benefit from a transplant, there are simply not enough organ donors available, making organ distribution the focus of multiple debates. Some question the fairness of wealthy international patients coming to the U.S. for organ transplants. Dr. Ascher’s own research has delved into the equity and transparency of organ distribution in the U.S. using data from the Scientific Registry of Transplant Recipients.

The practice of multiple listing—where someone is on more than one organ waiting list in different parts of the country in an attempt to shorten their overall wait time—reveals some inequities.

“The people who can do that have to be wealthy enough to get on a plane and wealthy enough to be able to stay in another place at a hotel or Airbnb,” Dr. Ascher said. “You have to have insurance that will cover you to go to another place, and you have to be well enough to go to another place to get listed.”

Her research has shown that the majority of multi-listed patients are white men who are well-educated and have above average financial means.

“There’s this disparity that’s going on right under our nose,” she said. “I’m not saying we have to change the distribution scheme, but I want people to be aware of it.”

Dr. Ascher’s call to action for surgeons and other medical professionals is to examine the unintended consequences of the health care they are providing to evaluate whether it is being administered fairly.

Dr. Ascher is the first woman to present the Drake Lecture. Throughout her career, she has been committed to advancing women’s opportunities in surgery. During her 17 years as chair of the department of surgery at UCSF, female representation on the faculty grew to 40 percent and more than half of the residents are now women.

The Advisory Council for Neurological Surgery established the Charles G. Drake History of Surgery Lecture in 1992 to explore the historical development of surgery and to honor this leader in neurological surgery.