Summer 2021 (Volume 31, Number 2)
The CRA’s 2021
Distinguished Investigator:
Dr. Sasha Bernatsky
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What was your first thought when you learned that you
would receive this award?
I am so grateful!
Why did you become a rheumatologist? What or who
influenced you along the way to do so?
When I entered medical school, I did not have the faintest clue
that there was a specialty like rheumatology. . . I wanted to be a
psychiatrist! But I became captivated by internal medicine; it was
so challenging, and I felt that if I conquered internal medicine, I
would know everything. Early in my internal medicine training,
I did a rotation in rheumatology. This exposed me to some very
wonderful people, including Drs. John Thompson and Janet Pope.
When I learned more about rheumatology, I found that all the
things I liked best about internal medicine were what typified
rheumatology: the challenges, the knowledge, and the opportunity
to develop long-lasting relationships with patients. My love
of rheumatology was strengthened by contact with the wonderful
rheumatologists at the Arthritis Centre in Winnipeg, especially
Drs. Hani El-Gabalawy, Christine Peschken, and Kiem Oen.
What do you believe are the qualities of a distinguished
investigator?
If you look at people like Marvin Fritzler, Paul Fortin, Diane Lacaille,
and John Hanly, and so many others, you notice not only that they are
brilliant and hard-working, but that they are truly kind people, who
really care about others. They are fun to work with. They have a vision
beyond themselves, they work to accomplish goals that focus on improving
the lives of people with arthritis, lupus, etc. They are determined,
but they don’t force their own way. They inspire everyone around them.
They are great leaders who create opportunities for others.
You have been nominated Principal Investigator (PI) of CAN-AIM,
the Canadian Network for Advanced Interdisciplinary
Methods for comparative effectiveness research, funded
by the Drug Safety and Effectiveness Network (DSEN), a
collaboration between the Canadian Institutes of Health
Research (CIHR), Health Canada, and other stakeholders.
Can you tell us about your work?
DSEN was established to address knowledge gaps on the safety
and effectiveness of drugs used in real-world settings in Canada
and worldwide, to help regulators, policymakers, healthcare
providers and patients. Since 2012, CAN-AIM researchers have
collaborated with policymakers in the Marketed Health Products
Directorate, the Biologics and Genetic Therapies Directorate,
and the Pharmaceutical Policy Division, Office of Pharmaceutical
Management at Health Canada's Strategic Policy Branch. We have
built bridges with many other stakeholders such as the Canadian
Agency for Drugs and Technologies in Health, the Pan-Canadian
Pharmaceutical Alliance, and provincial formulary bodies. Our
research is based on clinical and population-based cohorts and
administrative data to produce timely answers to queries. Currently,
CAN-AIM investigators have created a biologic registry
with the intent of providing real-world information comparing
the safety and effectiveness of biosimilar drugs versus their originator
biologic drugs. This five-year study of adults with inflammatory
rheumatic disease or inflammatory bowel disease relies
on the work of many investigators, including Denis Choquette,
Walter Maksymowych, Gilles Boire, Vivian Bykerk, Robert Inman,
Claire Bombardier, Carol Hitchon, Carter Thorne, Claire Barber
and many more. For more information, please contact Autumn
Neville at autumn.neville@rimuhc.ca or visit canaim.ca.
Can you tell us about your experience with the Systemic
Lupus Erythematosus (SLE) International Collaborating
Clinics (SLICC) and the Canadian Network for Improved
Outcomes in SLE (CaNIOS), as well as your work in cofounding
collaborative networks such as the Canadian
Rheumatic Administrative Database Network (CANRAD)?
As a rheumatology trainee, I had the great fortune to join CaNIOS,
founded by Paul Fortin, who led me to begin post-graduate training
in epidemiology. He introduced me to Dr. Ann Clarke, who
was co-director (with Christian Pineau) of the McGill University
Health Centre (MUHC) Lupus Clinic, originally founded by John
Esdaile. At the time, Len and Judy Funk introduced me to the patient
group Lupus Canada. Without the CaNIOS network, and the
support of Lupus Canada, I wouldn't have been able to begin my
epidemiology training; the result was my PhD research on cancer
in SLE, a multi-centre effort that brought together SLICC and
CaNIOS lupus researchers. This effort ultimately clarified that
lupus patients have an increased risk of certain cancers (such as
lymphoma) but a decreased risk of others (such as breast). The
reasons for this may be multi-factorial: SLICC and CaNIOS investigators
have banded together over the years to clarify how drugs
might shape this risk. For example, while we saw no clear effect of
most lupus drugs on cancer risk, hydroxychloroquine decreased
the risk of some cancers, while cyclophosphamide increased it.
Regarding my association with CANRAD, Drs. Claire Bombardier,
Diane Lacaille, and Lisa Lix were some of the masterminds
behind the Canadian Rheumatic Administrative Database
Network. CANRAD first came together as a coalition of researchers
linked with policymakers and other stakeholders to produce
guideline statements for rheumatic disease research and
surveillance using Canadian administrative data. Through the
years, it has been funded by the Canadian Arthritis Network,
CIHR, and other agencies. The CANRAD network has continued
to attract brilliant investigators, like Jessica Widdifield, Carol
Hitchon, Lihi Eder, and others, who have greatly increased research
capacity in Canada.
Your research on air pollution has been described by Health
Canada’s Air Quality Assessment Section chief as “the first
indication that air pollution could be tied to such a specific
disease state, which influenced our thinking about the
inflammatory potential of air pollution.” Can you describe
your research findings in this area and its significance?
I feel very lucky to have been the first researcher to uncover trends
linking road-traffic density and fine particulate matter (PM2.5)
exposures and systemic autoimmune rheumatic disease prevalence.
I was mentored by incredible people like the wonderful
Dr. Audrey Smargiassi. The biologic plausibility of links between
air pollution and rheumatic disease was supported by our very exciting
paper suggesting links between PM2.5 levels and anti-DNA
antibodies and other key manifestations of SLE. As further “proof
of principle,” we published a cross-sectional study indicating that
industrial emissions of PM2.5 and SO2 correlate with other autoantibodies
important in rheumatoid arthritis. To ensure that
knowledge from my research is used by policymakers, we collaborate
closely with the chief of Air Quality Assessment within the Air
Health Effects Division of Health Canada, and the Science Advisor
for Health Canada. These individuals are responsible for updating
review documents on the health effects of air pollution, which
form the basis of negotiations between federal, provincial and
territorial government stakeholders in partnership with the Canadian
Council of Ministers of the Environment. These documents
are used in decisions related to national air quality standards and
are also consulted by the US Environment Protection Agency and
other international bodies. Our successes inspired others, such as
Michelle Petri’s group at Johns Hopkins to study air pollution and
SLE. It’s a very exciting time.
Are there other areas of interest you would like to
investigate in the future?
I’m very interested in personalized treatment for SLE patients—
beginning with hydroxychloroquine (HCQ). Although HCQ is a
key drug, there are increasing concerns about side effects. Uncertainty
about the balance between the risks and benefits of
stopping or continuing HCQ is a primary gap voiced by SLE patients
and their doctors. Almost all rheumatologists in the world
prescribe HCQ on a daily basis, but we do not have evidence on
how to best use it. I have been working with wonderful SLICC
and CaNIOS investigators to identify subgroups of SLE patients
at particular risk of having flares or developing adverse events
associated with HCQ use. However, truly personalized treatment
must consider patients’ preferences, and Glen Hazlewood
is helping me design a discrete choice experiment on that topic,
with other CaNIOS investigators. Ultimately we need pragmatic
trials to understand outcomes related to reducing HCQ in select
groups (considering their risk profile and preferences).
What have been the most rewarding aspects of going into
the field of rheumatology and what have been some of the
most challenging aspects?
I love the relationships our patients develop with us. I love helping
a patient find the right combination of therapies to make
them feel the best that they can be. This was something that I
think Hani El-Gabalawy first taught me. The most challenging
thing is that most of my patients don’t have easy access to physiotherapy,
occupational therapy, social work, or counselling.
It also scares me when my patients are hospitalized with life-threatening
complications. But one of my first rheumatology
mentors, Dr. Barringer, told me that we can’t allow ourselves to
feel overwhelmed; our patients may feel overwhelmed but it is
our job to be strong and do all we can to help them overcome
every setback along every part of their journey. This is made easier
by the wonderful comradeship of my fellow rheumatologists
who work so hard for our patients, especially my colleagues at the
Montreal General: Chris Pineau, Evelyne Vinet, Ines Colmegna,
Beth Hazel, Fares Kalache, Arielle Mendel, Michael Starr, Michael
Stein, Mary-Anne Fitzcharles, and Pantelis Panopalis (plus
our very hard-working staff).
What is your proudest accomplishment?
I don’t feel that I should be proud of any accomplishments. I have
been given so many opportunities and have been so inspired
by special people like Cheryl Barnabe, Jessica Widdifield, Evelyne
Vinet, Glen Hazlewood, Stephanie Keeling, Murray Urowitz,
Carter Thorne, Dafna Gladman, Susan Bartlett, Michel Zummer,
Debbie Feldman, and so many others.
What advice would you give to someone looking to pursue
a career as an academic rheumatologist?
Be grateful, be mindful. Always remember that you were placed
on this earth for a reason (www.desiderata.com/desiderata.html). For
me, the greatest academic rheumatologists are people like Marie
Hudson and Ines Colmegna who live to serve others and strive for
excellence. Unfortunately, academia can feel like a “rat race.” We
must look to the example of people like Marie and Ines and others
who never seem to forget the reason we are here: to find answers
for our patients, to help them live better lives.
You are handed a plane ticket to anywhere in the world
(once the pandemic is over). Where do you go?
Well, I am crazy about Vienna, such a wonderful city…but I can’t
wait to see my mom again, so I guess I would pick Winnipeg over
Vienna this time.
You are marooned on a desert island. What book would you
like to have on hand with you?
I would choose the scriptures… I need to be reminded every day
that I am loved, I am forgiven, I am free…and I need a constant
reminder that since I have been shown so much love and mercy, I
must try to show the same.
Are you more of a morning or night person?
I grew up on a farm so… Early to bed, early to rise.
How many cups of coffee does it take to make a productive
day?
I love green tea and I drink several cups a day but have
to swear off it by 1 or 2 pm. Sometimes l have a little
espresso after lunch. Dark chocolate helps too.
Sasha Bernatsky, MD, PhD
Professor,
Department of Medicine,
Division of Rheumatology, Faculty of Medicine
McGill University
Research Institute of the McGill University Health Centre
Centre for Outcome Research & Evaluation (CORE)
Montreal, Quebec
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