When the doctor is the patient

A kidney transplant and a cancer diagnosis helped shape the career of infection-control expert Steve Pergam
Dr. Steve Pergam, right, chats with a colleague.
As director of infection control at Seattle Cancer Care Alliance and an infectious disease researcher at Fred Hutchinson Cancer Research Center, Dr. Steve Pergam works to protect a subset of people who are particularly vulnerable to infectious diseases: cancer patients. Here he is shown with graduate research assistant Arianna Miles-Jay. Photo by Bo Jungmayer / Fred Hutch News Service

As a first-year medical student at University of Nebraska Medical Center, Dr. Steve Pergam volunteered for a vaccine campaign in Nicaragua, bringing basic childhood immunizations to squatters living in cardboard shacks. When he returned to Nicaragua the following spring to deliver a second round of immunizations, he found that local health care workers had already done so. His earlier efforts had helped put the impoverished community on the government’s radar.

“One of the things I really liked about infectious diseases was I actually felt I could make a tangible difference,” he said, reflecting recently on the experience that sparked his interest in what would become his life’s work.

Having seen firsthand the toll that such diseases take on developing countries, Pergam assumed that like many others in the field he would go on to work internationally.

Instead, as director of infection prevention at the Seattle Cancer Care Alliance and an infectious disease researcher at Fred Hutchinson Cancer Research Center, Pergam today works to protect a subset of people who are particularly vulnerable to infectious diseases, even in developed countries: cancer patients.

Infection prevention is an essential task at all hospitals and health clinics, but it is especially so at a cancer care center, where almost 100 percent of patients have weakened immune systems. Both cancer itself and chemotherapy can reduce the number of infection-fighting white blood cells, making it harder for the body to defend itself against viral, bacterial, and fungal pathogens.

“What’s really tragic is when you have patients who are essentially cured of their disease and need to recover from their chemotherapy but get a life-threatening infection,” Pergam said. “A simple infection for you and I, like the common cold, can be life-threatening for patients in our system. We have to do everything we can to prevent [infections] in the first place.”

If volunteering in Nicaragua first sparked his interest in infectious diseases, two very personal experiences led to the fork in his professional path that eventually brought him to the SCCA.

The first was needing a kidney transplant.

The second was getting cancer.

A double blow

Pergam developed an autoimmune kidney disease as a young man growing up in Omaha. For a while, he was able to control the condition with medication. But by age 32, he needed a transplant. His mother donated a kidney, and mother and son now celebrate the anniversary of the June 23, 2003, transplant as his second birthday. 

At that time, Pergam was working as an assistant professor at the University of New Mexico School of Medicine, where he’d done his residency in internal medicine. On the day he received his new kidney, he woke up from the surgery to learn that he’d been accepted as a postdoctoral fellow in infectious diseases at the University of Washington.

But already his career path was changing. With the transplant came the lifelong need for immune-suppressing drugs to prevent Pergam’s body from rejecting his new kidney. His plans for traveling and working in countries hard hit by infectious diseases “went out the window,” he said, because of the risks that would pose. 

Then came the second blow.

From the transplant, Pergam contracted Epstein-Barr virus, a type of herpesvirus that in most cases, at worst, causes mononucleosis. As a transplant patient, Pergam was not like most cases. He developed a rare condition called post-transplant lymphoproliferative disease, which in turn can – and did – lead to lymphoma nine months after the transplant and just months before his Seattle fellowship was supposed to start.

Pergam wrote to Dr. Larry Corey, the former head the Fred Hutch Vaccine and Infectious Disease Division, now Hutch president and director emeritus, saying that he needed to delay his start and offering to bow out so that the fellowship could go to someone else.  Corey replied by saying, “Just get better. There will be plenty of time for research.”

Pergam continued seeing patients as he underwent chemotherapy in New Mexico.

“It was really interesting to see patients I had diagnosed when I was on [clinical] service getting chemotherapy at the same time as me,” he said. “They would say, ‘What are you doing here?’ Well, doctors get ill too.”

Going through a transplant and then cancer may have halted Pergam’s plans to work overseas. But instead, as he became intensely engaged in his own therapy, he attained a different kind of dual citizenship: that of both doctor and patient.

“It does give you a particular insight that others may not have,” he said. “Going through that process made me appreciate what it’s like, the immune-compromised world. It really made me think about transplant and infections and cancer and infections. It was something that I really enjoyed and something that I sought out when I came here.”

Cancer-free for more than a decade

Pergam came to Fred Hutch in 2005. He counts himself lucky: The chemotherapy melted his cancer away. He has been cancer-free for more than 10 years.

He completed a master’s degree in public health and epidemiology from the University of Washington in 2008.  As an assistant member in Fred Hutch’s  Vaccine and Infectious Disease and Clinical Research divisions, he researches new ways to prevent infection transmission, findings that he puts to use in his job at SCCA.

Better infection control lowers both risks and costs. Treatment in a hospital intensive care unit for a major respiratory viral pathogen can cost as much as $500,000, twice the average cost of a marrow or stem cell transplant, Pergam said.

Among the accomplishments of Pergam’s infection prevention team is an SCCA staff flu vaccination rate of more than 97 percent. His team has also recruited and trained a core of nurses  – the first line of defense in infection control – to help better educate and observe basic infection control practices such as hand hygiene and environmental cleaning. Other centers are beginning to model programs after the SCCA’s.

“My goal – our division’s goal – is to do what we can to prevent infections in cancer patients,” Pergam said, “and to be be able to step in and help them when these infections do show up.”

Pergam and his Fred Hutch colleagues also are collaborating to study how a patient’s gut microbiome – the microbes and their genes that populate our digestive tracts – influences transplant recovery. They are particularly interested in how antibiotic use changes the makeup of the microbiome and leads to development of bacterial resistance and colonization with high-risk pathogens. They have developed a large cohort of patients and have characterized their infectious outcomes and post-transplant complications. These data will help to modify and manage how antibiotics are used in cancer and transplant patients.

What the research uncovers will have an even broader impact because the number of people with compromised immune systems is growing as treatments allow those with cancer and other diseases to live longer and as the general population ages. The list of immunocompromising conditions and those eligible for immunosupressive therapies continues to grow beyond cancer and transplant patients to include a much broader swath of the population and such diseases as rheumatoid arthritis, inflammatory bowel disease, chronic obstructive pulmonary disease, and those on kidney dialysis, among others.  

"Every hospital and clinic in 2015 has patients who are immunosuppressed," Pergam said. "What we learn here will help others."

Pergam may have moved his focus from the developing world to the immune-compromised world, but his work in infectious diseases continues to make a tangible difference.  

“Immuno-compromised patients,” he said, “are everywhere.”

Mary Engel is a former staff writer at Fred Hutchinson Cancer Center. Previously, she covered medicine and health policy for the Los Angeles Times, where she was part of a team that won a Pulitzer Prize for Public Service. She was also a fellow at the Knight Science Journalism Program at MIT. Follow her on Twitter @Engel140.

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