Mountains, Marathons, and Motivations: Julie R. Gralow, MD, Gets Giants of Cancer Award in Community Outreach/Cancer Policy

Julie R. Gralow, MD

In 1995, Julie R. Gralow, MD, sat down for lunch with a group of patients and survivors of cancer at the Danskin Women’s Triathlon in Seattle, Washington. Members of the media walked around the room with microphones and cameras, asking attendees about their motivations for participating.

When they stopped in front of Gralow, she told them she wasn’t participating. She was only there to support those who were.

A patient turned to Gralow, her head bald from her recently completed chemotherapy treatments, and asked, “Dr Gralow, why aren’t you participating with us?”

Gralow paused before finally answering, “You’re right. Why aren’t I?”

Afterward, she left to buy a swim cap and goggles, registered for the triathlon, and participated the very next day. That moment represented the birth of Team Survivor Northwest, a group Gralow cofounded with fitness and therapeutic exercise specialist Lisa Talbott that aims to provide female patients and survivors with a range of fitness and health education programs to help women play an active role in their physical and emotional recovery.

“I could see what it was doing; it was giving hope,” Gralow said. “It was giving a process [through which patients] could take control of what [they] could—with cancer, you cannot control everything. I nominated all these patients to train for the triathlon, a few of whom said, ‘Well, if Dr Gralow thinks I can do it, I guess I could do it.’ They had never thought of themselves as athletes or anything. I did not train with them, but I supported and encouraged them.”

The idea that eventually became Team Survivor arose when Gralow was just a fellow beginning to specialize in breast cancer. She noticed that as treatment concluded for patients with breast cancer and their visits became less frequent, they were not receiving the advice and support that they needed, despite having difficulty coping with the lingering adverse effects (AEs) of therapy.

That observation inspired her to take a more proactive approach in helping patients manage AEs and led her to partner with a few of her patients to launch a series of lectures at the University of Washington called “Living Well With Cancer.” The series focused on helping patients live a healthy lifestyle, deal with the emotional and physical effects of cancer, and take control of their lives.

“At the end of the training and the triathlon, [the patients] got special recognition as they crossed the finish line,” Gralow explained. “All of the women who had participated said, ‘We cannot let this end here, and we cannot just have it be about one event a year. We need to have this opportunity exist for all women with cancer.’”

She recalls one patient named Belinda whose doctor denied her request to participate in the triathlon because the disease had metastasized to her bones, leaving her at risk for fracture. Gralow managed to persuade the doctor to allow Belinda to participate, much to her joy. She died within the year.

At Belinda’s memorial, her husband explained how her participation with Team Survivor brought her life such hope and meaning. Her family members continued to volunteer for events for years after her death.

“Stories like that really helped convince me that this was absolutely the right thing to do. The best way to prove that I really believe it is important...is to get out there and do it with them to show that I am walking the walk and talking the talk,” Gralow said, adding that while out of the clinic and training with them, “I’d hear a lot of patients’ stories and a lot of the personal piece, and sometimes the fears and a lot of hopes as well. That really helped to shape my perspective on what my job was as an oncologist.”

Gralow’s work with Team Survivor took her and her patients from competing in triathlons to walking, biking, dragon boating, and even climbing mountain peaks in the Pacific Northwest. The first mountain they climbed together was Mount Rainier, the highest mountain in Washington state, and they eventually scaled the 5 tallest peaks of the Cascade Range. The adventures gave Gralow a love of the outdoors. For her 50th birthday, she scaled Mount Kilimanjaro in Tanzania. For her 60th birthday, she went trekking in Bhutan and climbed to Tiger’s Nest Monastery.

From Seattle to the World

Gralow’s globe-trotting adventures and efforts extend to her professional life as well. She has dedicated a good portion of her career to advocating for patients and health equity on a global scale.

In 1997, the nonprofit global health organization Program for Appropriate Technology and Health (PATH) approached her about their application for a United States Agency for International Development–funded grant for a Ukraine breast cancer assistance project. The goal was to improve breast cancer expertise among multiple disciplines in the country.

After PATH won a 3-year grant, Gralow served as a consultant for the organization and went to work collaborating with her colleagues on a chemotherapy trial in Odessa, the third largest city in Ukraine. She provided guidance on clinical trial logistics and explored whether Ukrainian women could tolerate doses of chemotherapy commonly used in the West. During her time in Ukraine, Gralow found that communication between physicians and patients about cancer diagnosis and treatment was limited.

“When I was met on my first visit in Kyiv, Ukraine, by the press there, they said, ‘Please describe this American project, but do not use the word breast and do not use the word cancer,’ ” she said. “Then when we were working, for example, on the chemotherapy trial, it became apparent [that this was a problem]. I mean, how do you give informed consent if nobody has even talked to you about your cancer diagnosis or your treatment options?“In many cases, [this was done] in a very paternalistic way, which is how they were all taught. They wanted to protect patients. The teaching was [that] if somebody knows they have cancer, they will lose all hope and they will commit suicide. Part of this was because, as cancer care was not good and a lot of people did die quickly, they did not know cancer survivors. That was the teaching.”

In response, part of the project focused on identifying patients, doctors, and nurses who were willing to experiment with education and communication so patients could openly ask questions about cancer. The experiment sparked a major patient advocacy movement in Ukraine, with the group of patients referring to themselves as the Amazonkas, after the mythological female warriors who would cut off one breast to shoot better with a bow and arrow.

As the project came to a close in 2001, the group garnered a permit to shut down a street, and they filled it with pink balloons and brought in a marching band to raise awareness for breast cancer. Gralow notes that such a gathering was unheard of after the fall of the Soviet Union and that permits were very difficult to obtain.

She later returned to Europe in 2003 with the Center for Women and Democracy to rally support for Baltic advocacy groups in countries such as Estonia, Lithuania, and Latvia. This movement ultimately laid the foundation for the creation of the Women’s Empowerment Cancer Advocacy Network (WE CAN), a global organization working to strengthen the movement for women’s cancer advocacy around the world. The group connects medical professionals, patients, advocates, and policymakers to generate change in the developing world.

Because of her appointment at Fred Hutchinson Cancer Research Center as a member of the Clinical Research Division, Gralow was able to develop a relationship with the Uganda Cancer Institute, which frequently collaborates with Fred Hutch. She began traveling to Uganda to assist with education in addition to meeting with advocates and women with newly diagnosed cancer. These efforts helped inspire the first East African WE CAN meeting, which included representatives from 12 nations.

“We met every year because they wanted more help in getting up and getting connected and everything, but they just took off,” Gralow said. “I mean, the things that they have done—these are powerful women.

”Gralow continues to be involved with WE CAN’s global efforts, although the COVID-19 pandemic led to the postponement of a 2020 conference planned for Malawi.

Change on a Global Scale

As the current chief medical officer and executive vice president at the American Society of Clinical Oncology (ASCO), Gralow continues to ensure that a global focus on cancer care remains a top priority. One of ASCO’s strategies for increasing global engagement is to establish regional councils to ensure that voices around the world are being heard and taken into consideration.

ASCO initiated an Asia Pacific Regional Council in 2019 and launched a Latin America Regional Council in 2021.

“Within the Asia Pacific Regional Council, we are [establishing] a leadership development program that is a version of ASCO’s bigger leadership development program, tailored to their young professionals,” she explained. “We also put out [a request for applications] within our Asia Pacific Council to partner with our International Cancer Corps, which is where ASCO members can volunteer to go spend a couple of weeks at a cancer center in a low- or middle-resource country.

“It is a strong relationship where [you do not just] plop yourself down for 2 weeks and [then] you are gone; ASCO has an enduring relationship. We have people who know the site well and [local] partners. You really learn, and we have continuity there.” A cancer center in Sarawak, Malaysia, was chosen, with one of the first projects being a virtual palliative care course at the request of the local health care providers.

ASCO wants to ensure that its work can be applied to other parts of the world in a meaningful way. “We’ve made a strong case for [needing] advocates at the table in these regional councils as well,” she said. The organization plans to launch even more regional councils within the next year.

“It’s clear that partnerships and collaborations are key in making a global impact,” Gralow said. “At ASCO, we’re working on several memoranda of understanding with other professional societies and governmental organizations, including the World Health Organization [WHO]. I came in and said, ‘We need to be supporting the priorities of the United Nations and the WHO, as well as our own domestic agenda.’

“Within all our partnerships, it’s important that both sides are benefiting. It has got to be a 2-way street. If you are really going to partner, both sides need to see what they are getting out of it and feel like they are contributing. This is the kind of approach [and attitude] we are taking as we build out partnerships and collaborations.”

Gralow spoke to the thrill of being recognized by her peers for her efforts in global oncology, explaining that it took work to convert her global oncology efforts from a hobby to a formal field that is recognized and respected. All her global efforts took place outside of her primary job description and did not necessarily result in the classic recognition or contribute to promotions that one might expect.

She was often told that she was spending too much time away from her patients and institutions. Whenever this came up, Gralow remained steadfast and would explain how her actions were not unsafe for her patients. Whenever she would travel the globe, she would ensure she had a strong team caring for her patients and remained responsive through email. Her nurses even joked that she was better at responding than some doctors who never left town.

“Certainly, it was not easy to do what I did. There are a few more grant opportunities available now in this area, both in global oncology and equity, diversity, and inclusion more broadly. But there were not always a lot,” Gralow said. “It gets back to being recognized for this work and [to] the importance of partnering with patients...with Team Survivor Northwest, with WE CAN, [and] with all of the nonprofits that I have advised [as well as serving] on [their] advisory committees.

“With this award, it’s nice to know [that] somebody thinks this is important.”