Cancer Stories: The Art of Oncology

Dr. Hayes interviews Dr. Norton. Dr. Daniel F. Hayes is the Stuart B. Padnos Professor of Breast Cancer Research at the University of Michigan Rogel Cancer Center. Dr. Hayes' research interests are in the field of experimental therapeutics and cancer biomarkers, especially in breast cancer. He has served as chair of the SWOG Breast Cancer Translational Medicine Committee, and he was an inaugural member and chaired the American Society of Clinical Oncology (ASCO) Tumor Marker Guidelines Committee. Dr. Hayes served on the ASCO Board of Directors, and served a 3 year term as President of ASCO from 2016-2018. TRANSCRIPT SPEAKER 1: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] DANIEL F. HAYES: Welcome to JCO's Cancer Stories, the Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insights into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org. [MUSIC PLAYING] Dr. Norton has stock and other ownership interest in Samus Therapeutics, Codagenix Inc, Martell Diagnostic, and Medaptive Health Inc. He's received honoraria from Context Therapeutics, Prime Oncology, the Sarah Lawrence Lecture, Context Advisory Board, Oncology Pioneer Science Lecture Series, Sermonix Pharmaceuticals, the Cold Spring Harbor advisory board, Codagenix, Agenus, and the Cold Spring Harbor external advisory board. He has served as a consultant or provided advice to Context Therapeutics, Prime Oncology, the Context Advisory Board, Oncology Pioneer Science Lecture, Martell Diagnostic, Sermonix, Codagenix, Agenus, Medaptive Health, and the Cold Springs Harbor Laboratories. He has received expense reimbursement for travel and accommodations from the Oncology Pioneer Science Lecture Series, the BCRP Programmatic Review Meeting, the Breast Cancer Research Foundation, the American Association of Cancer Research, and Cold Spring Harbor Laboratory. [MUSIC PLAYING] Today my guest on the podcast is Dr. Larry Norton. Dr. Norton has been instrumental in so many facets of oncology it's hard to go through, but particularly, in breast cancer, and especially related to applying mathematical models of cancer kinetics that he developed with Richard Simon at the National Cancer Institute, and applying them really, to dose density strategies for chemotherapy and breast cancer, which we'll discuss. Dr. Norton was raised in suburban New York. He received his undergraduate degree at Rochester University, his medical degree at the Columbia University College of Physicians and Scientists. And then he did his residency at Einstein Associated Hospitals in the Bronx. He then went on to complete a medical oncology fellowship at the National Cancer Institute from 1974 to 1976 and stayed there an extra year. And then he returned to New York and joined the faculty at Mount Sinai in 1977, where he stayed for about a decade. He then moved to Memorial Sloan Kettering, where I think most of us think he was born and raised and lived his whole life. He's held many positions there. And particularly, he was responsible for really building the breast medical oncology service and starting the Evelyn Lauder Breast Center. He now sits in the Norman S Seraphim-- did I pronounce that correctly, Dr. Norton? LARRY NORTON: Yes, you did. DANIEL F. HAYES: Chair in Clinical Oncology, he's authored over 450 peer reviewed papers. He's won too many awards for me to list, as have most of my guests on this program. But in particular, he's won the triple crown, in my opinion. And that's the Karnofsky, the McGuire, and the Bonnadonna awards. At least those of us in breast cancer would strive to win all three of those. And importantly to this series, he served as president of ASCO from 2001 to 2002, has served many roles at ASCO and has had a major footprint in where ASCO is today. Dr. Norton, welcome to our program. LARRY NORTON: Great pleasure to be here. Thank you, Dan. DANIEL F. HAYES: So we'll start with some of the origin stories. I know you weren't bit by a radioactive spider and got spidey powers. But I've known you for a long time. And I know, really, your first love was music and that you started out to be a professional musician. Can you give us some background? What were your instruments? I know you went to Rochester specifically to be in music. And feel more than free to do some name dropping, because I think some of the people in music are people we'd all recognize. LARRY NORTON: Well, I don't know whether that would be totally right. I've known a lot of people in music. My first love was music. I grew up in Long Island, was able to commute in with one bus and one subway to Greenwich Village in the '60s, which was, really, the hotbed of much of what was going on in music to this day. I didn't even realize it was a golden age. I remember all the giants, Bob Dylan, when he was a very young kid in town, in small coffee houses. But it was also in close proximity where a lot of the jazz scene was happening, and just to take the A Train would be very easy to get up into Harlem, where there's a lot of jazz things going on. Like a lot of kids growing up on Long Island, I had some musical education. I started off with the clarinet, went quickly into saxophone in terms of music. But I played a whole variety of instruments. Like everybody else, I play guitar. I played percussion. I played bongos behind beat poets and was very excited to be really part of that scene. I think one of the major turning points for me, actually, was the Vietnam War. Because like a lot of people of my generation, it did not seem to be reasonable war. And even McNamara wrote a book later saying, yep, sorry, it was a mistake. We were looking for things that could interest us and also help us serve our country in ways other than sacrificing our lives in Vietnam. That's how medicine got into my life. It seemed to be the right compromise. Fortunately, starting off in Rochester which had the Eastman School of Music, which was a great influence on me, and a fantastic school, and has evolved continuously to be an even better school now. It has a very active jazz program now, which didn't exist at that time. We had to do jazz on the sly, which was very easy to do, because there are a lot of jazz clubs in Rochester at that time. And it was really very easy to play jazz all night and then to play classical music all day. And that was totally, totally a great experience. We were young. We didn't have to sleep at all. But I hankered to get back into New York. When the opportunity arose to go to medical school, I was fortunately chosen to go to Columbia, where I actually was able to play music and at the same time go to the medical school. But after a while, as all of us in medicine know, it becomes all consuming. And so the medicine part of it just slipped. When it came to a lot of my friends from the old days up until the present day, very little performing, I've done a couple of benefits. I'll do the one namedrop with Elton John, because he's been so terrific at raising money for breast cancer research through the Breast Cancer Research Foundation. I had the great honor of being able to play with him twice-- DANIEL F. HAYES: How did you meet Elton John? I mean, it's not like you walk down the street and say, oh, hi, I'm Dan Hayes. LARRY NORTON: Mutual friends, mutual friends in the arts, basically, one of our closest friends, close friend of his, close friend of mine, someone named Ingrid Sischy was a fantastic writer and editor, very involved with Andy Warhol in the beginning, and then continued a career in art criticism and art writing. And she was a friend of everybody and a close friend of Elton's and a close friend of mine. And so I think she made the original introduction. And he's really been terrific. But the music is put aside, although I do play every day. I still keep that as a very important part of my zen escape from other stresses of life. Although, music itself has its own stresses. The good thing about jazz is improvisation. So it's an immediate feeling, no such thing as a wrong note. You hit a wrong note, and you play around it. And it becomes a right note. And so music is still a very important part of my life. DANIEL F. HAYES: That's terrific. Actually, I interviewed Hyman Muss a few weeks ago. And he and some others have introduced me to tying flies for fly fishing. And it's sort of the same thing. I can take 15 minutes and tie a fly. I'm not sure it looks like anything official-like. But it's not medicine for a while, and that's good. LARRY NORTON: Yeah, but medicine-- DANIEL F. HAYES: The other thing-- LARRY NORTON: I want to get back to this for a second, because I mean, DANIEL F. HAYES: Yeah. LARRY NORTON: It's not a separate thing. I mean, music and-- especially my early music education just taught me a lot that's really helped me in my career in medicine. I think it's very important for people to know. The talent for music is a talent to practice. Essentially, anybody who can speak can-- has enough control of tones that they can actually do something with music. I'm not sure how much is really inborn ability. I'm not sure there is such a thing as a talent in that regard. But some people can practice for long hours successfully. And some people can't. And I think that that's something that may be inborn. I don't know. I'll leave that to the developmental psychologists. But that is a very important trait, obviously, in medicine. You have to spend a long time studying. You have to learn a lot. You have to concentrate a lot. You have to be able to concentrate on individual patients, when you're taking care of them. And that's been very important, but it's also empathy. Music teaches you to feel what other people are feeling. You're not going to be a good musician unless you know how you're affecting your audience in a profound way. And you can sense when you're losing your audience, and you can change the direction you're going in. And when you hit something right, you can play it. And that ability to feel what other people are feeling, I think, is really essential to be a good clinician. And music teaches you that. I think arts in general teach you that. DANIEL F. HAYES: Actually, I hadn't thought about it. Do you think that your music and your mathematic leanings are tied together too? LARRY NORTON: There is a tendency for mathematicians to be musicians, not true quite vice versa. Although they are-- good musicians really are mathematicians. But they don't know it. A lot of people think math is the written equation, and it's not. It's a certain approach toward nature. Thinking in spatial ways, for me, thinking of shapes, and the way shapes form, the way shapes move over time and space, then you learn the tools for being able to write it down which is the actual mathematical notation. DANIEL F. HAYES: Yeah. LARRY NORTON: And the same thing with music, I mean, music isn't the notes on the page. I mean, that's a very poor reflection of what sounds you're making. It's the sounds. It's the sounds, and they go up and then down. That's spatial, and they go forward in time. And so they're temporal, and they have meaning. It's not just random sounds. They have meaning. They connect to each other, and they tell a story, as we say in the jazz world. And the notes are a poor reflection of that. Some of the best musicians I know can't read music. And as a matter of fact, it used to be said that if you want to be good jazz musician, you shouldn't learn to read. Because if you learn to read, you'll cheat. And you should be able to play by ear. And that's what's going to make you a better musician. So I think math and music are very closely aligned. You have a problem to solve, when you think about it, and in novel ways that are not verbal. And the non-verbal way of thinking in music and in math are very similar, I think. DANIEL F. HAYES: So let me segue onto how you changed paths. I know that it was-- I've heard you talk about it was a discussion with Dr. Ron Bloom, who I think has remained a good friend of yours, and then in association with Dr. Regelson at Roswell Park. Can you tell us about that? LARRY NORTON: Well, Ron got me-- I mean, Ron, great, great oncologist, retired now, and his wife Diane also very, very important in the cancer world through her leadership of organizations. They both went to University of Rochester same time I did. I was actually perplexed at the end of one semester. So both Ron and Diane were at the University of Rochester, the same I was. And I was perplexed at the end of one semester, because I had several opportunities to do things in the summer coming forward. One of which was very music oriented, and it was a very exciting possibility. But I was at that time considering a change in direction very strongly. Math was one of the things that was drawing me. The question, should I become a professional statistician? That was the course that was turning me on mostly at that time. I thought physics was an incredible art form and was intrigued to that. But I also had music that was drawing me. And also the question, of what could keep me helping people, and helping my nation, and keep me from necessarily bearing arms in Vietnam was a big concern. And I met Ron on the stairs of the Rush Rhees Library at the University of Rochester, a famous library, that by the way, has a famous ghost associated with it. That's a whole different story. He said that he had this unbelievably wonderful experience the previous summer by working at Roswell Park Memorial Institute in Buffalo, New York State Cancer Research Institute, particularly under a guy named William Regelson who was just totally inspirational to him. And that was one of his major motivations to spend his career in cancer medicine, which I didn't even know it. I had another connection to Bill Regelson is that my father and his father actually knew each other. Because they were in businesses that touched. His father ran a Catskills resort. And my father was a professional writer and travel editor at The New York Post. And so that there was that connection. So that when I relayed the story to my parents, they said, oh, we know Regelson. So well, one thing led to another. And on a cold and rainy night, I took a bus into Buffalo, New York. And I met Bill Regelson in the laboratory at Roswell Park Memorial Institute. It was late at night, and it was freezing rain, kind of miserable night. And he asked me a lot of very tough questions and was not very pleasant toward me. But the end of the interview, he says, I like the way you think. And I'd like to offer you an opportunity to work with me this summer. And I jumped at that opportunity. And it was really, truly the turning point in my life in many ways. Because I, eventually, many years later ended up marrying Bill Regelson's daughter. My current wife-- DANIEL F. HAYES: I was not aware of that. LARRY NORTON: Yeah. Rachel, the love of my life, it was an extraordinary experience, because I got very close to family. And she was in New York at Columbia, at Barnard, the same time that I was in medical school. And so that's how it all came about. But anyway, Bill was really an inspirational character for many people of my generation who were in contact with him. Because he was just filled with enthusiasm, and energy, and optimism. You remember, the early days of oncology were very special. And by the way, if you want to catch a glimpse of that, it tends to be this book, The Death of Cancer. I'm giving it a big plug, fantastic book that captures the whole history of his life and cancer. But the early days is very important for people to recognize what it was like in those early days. It was just an enormous challenge just to get people to pay attention. The possibility that drugs could actually be useful in the treatment of cancer, and it was often ridiculed. I can tell you a little story later about my early experiences when I came to New York in that regard. DANIEL F. HAYES: So did you know you were going to be an oncologist when you went to med school? Or did that-- LARRY NORTON: I'll tell you two of the turning points in that regard that I think are particularly interesting. One is, at the very beginning of that summer, Bill Regelson brought me-- in those days, the labs were right next to the clinic, the inpatient service. And he brought me right from the lab a few steps in to see a patient who was admitted to the hospital with a pelvic tumor. I don't know what type, didn't register in my mind at that time, but a pelvic tumor that had grown very large. And it actually had eroded out into the skin and was large, and infected, and bleeding, and just awful. And the patient was in terrible pain. And he said, we're going to treat this patient with a new drug that I think is going to help her. And it's called methotrexate. And he treated with methotrexate, and I saw the I saw the medicine go into her arms. And over the next few weeks, during that summer, I saw this tumor shrink down. I saw the skin heal over. I saw the pain go away. And it was, I'm seeing this monster eating this woman from the inside out. And I'm seeing just this yellow chemical going in there, and the monster being defeated. It was like magic. It was something just beyond conception that, actually, you could take something that awful and that terrible, and actually give it medicine, and actually make it go away. And I said, this is a world I can't turn my back on. This is a world I have to be in. This is just a magical, wonderful world, where you can actually heal things that couldn't be healed by other ways, I mean, totally beyond surgery, totally beyond radiation. And here's medicine going in. So that hooked me. But at the very end of the summer, and toward the very end of my time there, another thing happened which would be a good segue. But also very important is the real person running medicine A at Roswell Park at that time was this person named Jim Holland. And Jim Holland was not there all summer, because he was riding a horse. And he had his daughter, one of his daughters on the horse. And the horse was acting very, very jittery. And he was a little afraid of what the horse would do. So he went close to a fence, where he could actually unload the daughter, so she can grab on to the fence. And the horse didn't bolt and crushed his hip against the fence. And so he was out with a fractured hip or pelvis the entire summer. But he was well enough toward the end of the summer to come in and speak to the summer students. And he came in, and he sat in a chair in the middle of the room. And all the summer students who gathered around him-- if I thought Bill Regelson had energy, to see this tornado of a personality in the room, with his loud booming voice and his probing questions, his clear intelligence and enthusiasm for his field and dedication to it was just inspirational. And so it was a crescendo of a summer for me. And that was it. The experience of Bill Regelson, the experience of Jim Holland, I knew that I was stuck. And even though other things were attracting my attention, nothing was going to capture my life as much as the medical oncology. DANIEL F. HAYES: You went on then to work with him for 10 years at Mount Sinai. LARRY NORTON: Right. DANIEL F. HAYES: In addition to what you've said, his obnoxious ties also always stood out for the rest of us. But those 10 years must have been unbelievable. Because the guy never quit thinking, at least in my experience with him. LARRY NORTON: I mean, there's so much to say about Jim Holland. I had the honor to speak his funeral, the sadness to speak at his funeral, but it was the honor to speak at his funeral related some of the stories. But there's so much to talk about him that it's actually worth a whole book, even an opera, with the bigger than life personality he was. But he captured something that I think was very important. And some of the early pioneers that we were talking about before really captured which is, I mean, these were real pioneers. I'll just give you a little side story. I mean, I came into grand rounds once, when I was working with him late, as I usually am to pretty much everything. But nevertheless, I came in a few minutes late, and everybody was gathered around. And I remember it was a thoracic specialist, a pulmonologist, who was actually conducting grand rounds. And as I walked in the door, he says, how come you're late, Larry? Were you out there saving lives? And everybody roared into uproarious laughter. Because medical oncology was the last step before the cemetery. Hopeless situations would all come to us. And then we'd give them drugs and not help people whatsoever. And of course, I felt this deep humiliation. I was a young doctor at the time, and all these great, senior people, great luminaries were arrayed around. But that was the attitude of a lot of people in medicine at that time is that hopeless situations, send it to them, they'll take care of it. They'll hold hands, whatever. And to see where we are today, and how many cases we cured, and how many patients we've cured, and how well we managed things, certainly, we don't cure enough. And you and I and our whole community is working hard on that. But we do cure a whole lot of people, and we do help their lives. And we do keep them functioning for a longer period of time with the medicines. So the people that went into the field at that time and actually established the field of oncology, medical oncology, at that time were really had to have a real pioneering spirit. And so Tom Frei obviously pops to mind in that regard, and many others. I could give a long list-- DANIEL F. HAYES: Well, I should say, I had the great privilege of training with Tom Frei and the pleasure of interviewing Dr. Freireich who, sadly, passed away a few weeks ago. I did not get to interview Dr. Holland. But because of his friendship with Dr. Frei, Dr. Holland adopted me as well, even though I was never working with him directly. And the three of those guys, I think our listeners need to understand, they were really cowboys. And they did things that we would now just, I think, repel, just have you can't do that sort of thing. But they did it, because they had to. As you said, there was nothing else to do. It took a special personality. LARRY NORTON: Totally-- I mean, everything you're saying is-- I agree with. But also, that's why we are where we are today is because they took chances, because they had a vision, and they attacked that vision very, very aggressively. And I'll do one more namedrop in music that is one of my and still friend is Quincy Jones. And Quincy Jones had this wonderful phrase in terms of jazz improvisation that was really very important to me. Sometimes, Larry, you have to jump without a parachute. And how do you get into an improvisation? You just start. And then it has a life of its own. And the better you get, the more experience you get, the better you start it, and the better you're going to develop it. But you just got to start. Hit the first note, doesn't matter what it is. And that kind of spirit of jumping in into it was really, very important. And I think that's something I really miss from modern oncology. If we're going to talk about where we are now compared to where we are then, a lot of things have changed that are very positive. Obviously, the amount of science that we have to draw from now is just astronomically greater than what we had in the early days, when we're talking about very primitive things. The whole Norton-Simon thing was all about attacking cell division, the best way of attacking cell division. We're so far beyond that in so many ways. That's one of the bigger changes. Our access to information, I mean, I had a question. I have to go to the library and got to cart catalogs, and pull books off the shelf, and open them up, and spend hours and spend days finding out one piece of information that now I can find out in about 15 seconds, if my fingers are slow on the keyboard, 15 seconds. And so that's it. But one of the major things is that it was all about concepts then. It was all about principles. The principle that antimitotics could actually make tumors shrink and could be beneficial. That's a principle. Combination chemotherapy is a principle. Dose dense sequential therapy, if you take it into further development of my area as a principle. And the overarching concepts on patient centrality of it also is that the early clinical trials were very small trials. Because each and every patient was a valuable piece of information. They were almost collections of anecdotes. And obviously, we've evolved way past that in very positive ways. But what you learned from the individual patient was extremely important to that generation of pioneers rather than large numbers. And I think we moved away from that. DANIEL F. HAYES: Actually, I'm going to interrupt you, because I think almost everybody I've interviewed has stories like you started out with. I saw a patient who I couldn't believe responded to X or Y. And I have the same stories. And I'm hoping our young folks still believe that's as important as filling out the meaningful use things on their documentation. I told my own son, I want him to be a doctor and not a documenter. You need to document, but you need to be a doctor. Can I segue into-- LARRY NORTON: We ought to spend the whole podcast on that topic someday. DANIEL F. HAYES: No, yeah, let's do that. LARRY NORTON: Because the thing is-- well, because I think that the thing is, when you're taking care of a patient, and you're thinking, obviously, we're always thinking what's best for the patient, all of us. But you're also thinking of gathering information in a verbal way about the patient. So you can talk about that patient to your colleagues, or write it as case reports, a series of case reports is a different mindset than when you're thinking about how am I going to fill out my electronic health record? And I think the mindset differences, and I frequently say to the younger people that I teach or that I'm in contact with, that they grew up in a digital world. And I grew up in an analog world. And the way you think in an analog world is very different than the way you think in a digital world. Maybe it's for the better. I mean, only history will tell, but I just miss that kind of analog thinking. Much of what we have today is because of it. DANIEL F. HAYES: Let me take you into your role in modeling and especially with the so-called Norton-Simon hypothesis. How did you hook up with Richard Simon? And what did he teach you? Because I find him to be a fascinating person. LARRY NORTON: Oh, a fascinating person, and obviously, one of the really important people in my professional career. The math was in there. Because along with, I mean, I studied math. I had studied math in college, and I was-- DANIEL F. HAYES: I should-- describe it. Just for a minute, describe what it is for our listeners. LARRY NORTON: Oh, the Norton-Simon hypothesis and the-- DANIEL F. HAYES: Yes. LARRY NORTON: All right. Oh, yeah, well-- DANIEL F. HAYES: Briefly, briefly. LARRY NORTON: It's very simple is that way before my time, Skipper Schabel and colleagues at Southern Research Institute had described the way experimental tumors in their laboratory grew which was exponential. And they made the observation called the Log Kill hypothesis, which is the Log Kill rule which is a given dose of given drug kills a percentage of the cells that are present rather than an absolute number of cells, which is actually counterintuitive. It shouldn't be that way if you think about it in terms of biochemistry, but it is that way. And we were all taught the Skipper Schabel model and Log Kill hypothesis. We were all taught that. And I was in the clinic taking care of a patient with Hodgkin's disease, nodular sclerosis Hodgkin's disease. And this patient had [INAUDIBLE] involvement with Hodgkin's disease. Remember, I was working with Vincent Davita, a great influence on my life, Bruce Chabner, Bob Young, many people who-- George Canellos, who you know very well, great luminaries doing lymphoma therapy as a clinical associate at the National Cancer Institute. Hampton's patient is they had to Hodgkin's disease, got MOPP chemotherapy, roared into complete remission. Basically, two cycles of MOPP, was in complete remission. I've been involved in oncology since the early days of MOPP to show you how long I've been involved in oncology. And I got four more cycles, because we give six cycles no matter what. We're two cycles beyond complete remission in that setting. And it was about a year. And the patient came back with mediastinal lymphadenopathy. The biopsy showed that was exactly the same lymphoma. Put him back on MOPP chemotherapy, and he responded again and went back into remission. I don't recall whether it was complete remission or partial remission. And I said, this is really fascinating, because the math was already in my head at the time. Because I thought I want to graph it out and show how well it fit the Log Kill hypothesis. And it didn't fit at all. I mean, it just didn't make any kind of sense. From a mathematical point of view, you couldn't make the equations fit. And about that same time, I became aware that others were describing that tumors were not really growing exponentially-- solid tumors were not growing exponentially as Skipper had shown in his laboratory models, a certain leukemia named leukemia 01210. But rather, by a very strange curve called a Gompertz curve, which was developed in 1825 by Benjamin Gompertz to fit actuarial data, actually, not anything in terms of biology. And that's an S shaped curve. So it looks exponential at the beginning. And then it bends over and eventually seems to try to reach a plateau size. And so I went back, and I applied the Skipper Schabel model mathematically to the Gompertz curve. And I realized that, for this individual patient, it would make a whole lot of sense if the tumor, when it was growing quickly, regressed more than when it was growing slowly at a very large size. In other words that the hypothesis is that the rate at which it would shrink is proportional to its rate of growth. And since, in a Gompertz curve, the rate of growth is always changing, the rate of shrinkage changes as a function of time as a tumor shrinking down. And that was of germ the idea. And then the question is how to test it. Under contract Arthur Bogden in Massachusetts did some animal modeling for us. And we published my first paper actually that showed tumors were growing in a Gompertzian fashion. And in fact, a subsequent paper showed that they regressed also in the Gompertzian fashion which is what the Norman-Simon hypothesis is. Almost immediately thereafter, a couple of implications, in terms of cancer therapeutics, and I want to get back to that. Remind me to get back to that later on. Because this is around 1977 or so that all this was really becoming clear. So it was actually one patient that made me think of it. I mean, frankly, it was one patient's experience that made me think of it. And that's what you were saying before, Dan, is the importance of learning from each individual patient. DANIEL F. HAYES: And actually, it's gone on to be tested in many, many trials. But probably the most definitive was run by Marc Citron and CLGB under your guidance. And I just want to say a few words, because Marc passed away just a few weeks ago. He was really instrumental in ASCO and very, very generous to the foundation. We'll miss him greatly. But that trial of 97-- LARRY NORTON: 41. DANIEL F. HAYES: 9741, demonstrated that dose density was superior to giving things in big doses for longer periods of time. Let me ask you about-- LARRY NORTON: I just want to second there what you're saying about Marc. I mean, just an incredible human being, an incredible person, incredible clinical scientist, and he was actually the first community clinician to chair a major national trial from a co-operative group which was just an intentional decision. I believe, you were involved in that decision, actually, Dan, Hyman Muss, certainly. DANIEL F. HAYES: Marc and I started in a group at the same time. And we grew very close. I miss him. Let me ask you to look into your crystal ball for a minute and that is with precision medicine and targeted therapy. Does the Norton-Simon hypothesis still apply to that? Do you think chemotherapy still-- LARRY NORTON: Oh, yes. Oh, yeah, yeah. Well, first of all, I mean, I'm not-- now we're getting into sophisticated science topics here. But the thing is that I'm not, to this day, I'm not sure I have chemotherapy works. I don't think that all of chemotherapy effect is just killing dividing cells. First of all, it's mathematically impossible. Does chemotherapy, does cytotoxic therapy affect the relation cell to its microenvironment? Does it affect its relationship to the immune system? These are all things that are under active investigation and active study at the present time. There's more to what we do every day in terms of giving chemotherapy than just killing dividing cells. Chemotherapy can be very precise. I mean, methotrexate and dihydrofolate reductase, we talked about it before. It's very, very precise therapy, hormone therapy, tamoxifen and the estrogen receptor. So we've been talking about precision medicine for a long time. It's just that our level of sophistication in terms of likely targets has changed. But still, it works. It's a law that fast things, things that grow faster regress more quickly than things growing more slowly how you return them. And I think that there are important lessons there that we still have to learn about cancer biology. And that got me into some very exciting areas with [INAUDIBLE] and colleagues and to cell seeding theory with cancer, for example. And that story is evolving. And more data is becoming available there and much more sophisticated mathematics that will apply to those days that I hope I will have time to work on in the next few years to be able to actually establish those principles. But I still think that we're doing something wrong if you're talking about a crystal ball which is that-- and it relates to what I just said before. We're so self-hypnotized into thinking that cancer is a disease of cell division. The vast bulk of our targeted therapeutics are oriented toward molecules that are related to mitosis. You hear talk, that'll be a very specific talk about molecular pathways starting with genomics and [INAUDIBLE] signaling. At the end of the slide, it says, invasion, metastasis, and growth. It's a nice little package. And that's the answer. Well, I mean, that's a big cloudy area. I mean, those are different things. Those are separate things. Those all have their separate biology. But they're all related. It is totally true. And how are they related? And why are they related is one of the very important topics that we have to wrestle with, because that's what we really have to perturb. And I think that the, again, crystal ball guessing, or at least where I'm putting my energies now is we have all these incredible tools for developing medicinals that can attack molecules. Are we attacking the right molecules by focusing in cell division? Should we be looking more toward perturbing tumor microenvironment relationships? Should we look at more sophisticated ways of using the immune system as one element in the tumor microenvironment, one of many in the tumor microenvironment, to accomplish the goals that we have to accomplish? And are we actually looking at the right things in terms of molecular analysis in cancer by looking at pathways that are concerned with cell division primarily and secondarily with other things? Or should we be looking at molecular networks and molecular pathways in a more sophisticated fashion? Just like the early days of oncology, we have to be willing to take intellectual chances. And that's something I'm seeing much less of now than I did if you go back half a century. DANIEL F. HAYES: We can go on with this one for a long time too. And we probably will the next time we get to sit and have a drink together when the pandemic goes away. I think it relates to dormancy. And I don't think we understand dormancy or how it is broken and how to treat it. I have two things, and we're running out of time. One of those is you probably, in my opinion, have been the king of understanding the importance of philanthropy in our field, especially in relationship to what I see directly, which was your relationship with Evelyn Lauder and her husband, Leonard, of course, in the Breast Cancer Research Foundation. But I'd just like you to emphasize to the folks coming in the field how important that philanthropy is. I think some of them believe it's dirty to get involved with that and ask people to give money. And you and other people I think have taught a lot of us that these folks want to help us. And it's important to address that in a dignified way. LARRY NORTON: We're all in this together. I mean, I think that's the important thing to recognize as a physician or as a scientist. I said in a paper once that just as all of us are either actual or potential healers, all of us are actual or potential patients. Cancer is a very important problem that needs to be solved. And people have to solve in every way they can, with our intellectual ability, our hard work in the clinic, our hard work in the laboratory. And people who are working hard in other fields who accumulate some element of wealth, or even people that just in normal life contribute small amounts, a lot of people doing small amounts adds up to a lot of money also. I mean, they're all part of the same process. I mean, the importance of philanthropy is that-- and it goes back to what Evelyn said which I quote all the time. She was very instrumental in the building of our first breast center at Memorial Sloan Kettering and then our second breast center, which is freestanding building at Memorial Sloan Kettering. She and Leonard involved in every way and not just in terms of philanthropy, but actually thinking through the problems and helping solve them and design in every way. When we built the first building that we had, we actually raised a little bit more money than we needed for the actual physical structure. So the question is, what to do with it? And obviously, a research fund at Memorial was established. But then in terms of where else to go with it, she invited me over to her place in New York overlooking Central Park. And we sat in the kitchen, and we drank tea. And I said, what I perceive, and with my colleagues, I'm not the only one, obviously, who's perceiving this, is an explosion of science, basic science in understanding cancer, and an incredible collection of clinical investigators that can do clinical trials, and do large clinical trials as well as pilot clinical trials in our institutions. But I didn't see the connections being very tight. Because we were in different worlds, speaking somewhat different languages. And we had to tighten those connections somehow and do something translating scientific advances in the laboratory into clinical benefit. It also allowed the scientists to understand what the clinical problems were and how to have the approach, and how we're going to do this. And she said, I've worked around creative people all my life in my professional life. And I know, you've got to identify the right people first of all. So that's a little bit of a talent. But that the main thing is that when you identify them, you've got to give them freedom to use their imagination and the security to know that if they do something good and it doesn't work out, that they're not going to lose their job. Freedom and security is the secret of making progress in the field. And I said, that's what we need. We need a foundation that can give the right people the freedom to use their imagination and the security to know that as long as they do good work, they're not going to lose their funding in a more traditional grant mechanism. And that's really where it started. So the whole thing is all based on that, is to get the right people and to give them freedom and security. And another part of it I just want to mention is networking to give people-- DANIEL F. HAYES: So let me focus this. LARRY NORTON: OK. DANIEL F. HAYES: Breast Cancer Research Foundation, how many people are you supporting? And how much money did you give this year? Just to give-- LARRY NORTON: Oh, about, oh, I mean, it's about 200 or so or more than that. Investigators, it's international at the present time. This year has been a tough year, and the next few years probably, because of COVID, because of the pandemic. It's been a tough year. But in general, we've probably given away about a billion dollars. But it's not given away. It's actually an investment, investment in the future. DANIEL F. HAYES: Yes. I agree. LARRY NORTON: And it's all about bringing people together. New investigators come in, and they're used to gladiatorial combat when it comes to grant acquisition is that they have to fight against the people to beat them out. And what we reward is people working together and sharing ideas. And phenomenal things have occurred in that direction, phenomenal, huge programs in metastasis and molecular biology, Translational Breast Cancer Research Consortium which has been a fantastic thing that we've helped support. So it's really been a joy. DANIEL F. HAYES: It's been great. Final 1 minute, the other thing you've done as well or better than most is mentoring. And I personally want to thank you for helping me in my career. But probably, your greatest success is mentoring Cliff Hudis who's now the CEO of ASCO and is responsible for ASCO continuing to be probably the world's greatest oncology professional society. Actually not probably, in my opinion, for sure. So for that, I thank you. We've run out of time, unfortunately. I think you and I could go on for another hour or so with this stuff which is what's fun about my getting to do this. But I want to thank you for all you've done for the field, for all you've done for so many of us in the field, and most importantly, for the patients who have benefited from what you've done. It's pretty remarkable. This has been so much fun for me to get to interview so many of the pioneers. But you certainly rank up there at the top. So thank you very much for your time and look forward to talking to you later. LARRY NORTON: Thank you so much for the kind words and for inviting me to do this with you, Dan. Thank you. [MUSIC PLAYING] DANIEL F. HAYES: Until next time, thank you for listening to this JCO's Cancer Stories, the Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories, the Art of Oncology podcast is just one of ASCO's many podcasts. You can find all the shows at podcast.asco.org. [MUSIC PLAYING]

In Knuckles by Kathryn Hitchcock, a radiation oncologist and a patient learn how people are not always who they seem. TRANSCRIPT ANNOUNCER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] LIDIA SCHAPIRA: Welcome, to JCO's "Cancer Stories-- The Art of Oncology," brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org. [MUSIC PLAYING] KATE HITCHCOCK: The swastikas on his knuckles kept stealing my attention. I tried not to stare, but every time he gestured to emphasize his words, my gaze snapped back there. That awful symbol multiplied across all 10 digits refused to be ignored. The blue lines were blurred, misshapen, probably jail tats. I grew up in a prison town and then joined the Navy. You would think the inking of flesh could no longer hold any fascination for me. My appearance seemed to be equally distracting to my patient and his wife. Hair just beyond clipper short, no make up, button up shirt, and pressed slacks. I could practically see the thought bubble over their heads. Definitely a lesbian. Different word, though. Their brows creased every time I spoke. I had learned not to expect much from people who looked at me that way but wrestled the feeling down. We had serious business. I explained what we needed to do together-- 5 and 1/2 weeks of radiation treatments if we went through without a break. Not too tough day-to-day, but a real marathon taken together-- fatigue, loss of appetite, and loose stools. He'd have to eat as best as he could. His wiry frame didn't carry much he could afford to lose. I glimpsed at his teeth and wondered if he was still using meth and not admitting it. We were going to have a couple of long months. He sat stiffly while I listened to his heart and lungs as if I were a ghost that would become real if he acknowledged it. I took a chance and patted his shoulder reassuringly anyway. He was alone when he came for the first of his weekly on-treatment visits. His body language announced that he was not excited to talk with me, but I deliberately stayed away from the computer. I would be all-in on this, even if he wasn't. Your weight is steady so far. You must be doing a good job with eating, I said. He nodded and looked at his fingernails. Any pain? Nope. Bowels doing OK so far? Yep. He sighed and looked at his watch. I knew my excellent, meticulous nurse had covered all of this already. I just had to find some way to get him to talk. How is your wife taking this, I asked, without moving or changing my tone of voice. He was so startled, he actually jumped a little and met my eyes for the first time. Well, I think this is real hard for her. She has to work while I do this. We got to have her insurance. Yes, that's how it is for most folks unless they're retired. Thank goodness you guys have insurance. A lot of people, spouses, or even the patients have to work the whole time to try to pay for this in cash, I said. Money's the last thing you should have to worry about at a time like this, but it's always there, isn't it? Yeah, it is, he said, and paused. I think she might be a little depressed. I can imagine, I said, for people who have brain chemistry that turns that way, anyhow, and sometimes, I think that's all of us, this is exactly the kind of situation that can make it hard to deal with that. Yeah, I guess so, he said, pensive. I let him think on that for a minute and then, what about you? Do you think you're feeling depressed? He shrugged with one shoulder. Wouldn't look at me. Whatever you think about that, I trust your judgment, I said. But you told me you'd use some drugs before. I know for a lot of people that's a way to try to dig their way out of depression when they can't get to a doctor for whatever reason. I held my breath, hoping I hadn't just made things worse between us. Slowly, to my great relief, he started to nod. Yeah, I think I've been pretty far down for a long time. It's hard to get a job, he said, holding out his hands and gesturing to the Confederate flag on his neck. Once you've been convicted, it's hard. Yeah, I've heard that, I said. Tough when people judge you by how you look before they get to know you. He met my gaze again, sharply. He knew I wasn't just talking about him. So you know, I pressed on, there are treatments that can help get your brain where it's supposed to be. We just aren't made for this modern life we live. We are wired for chasing buffalo across the plains and taking them down with spears. Instead, here we sit on fluffy upholstery with the air conditioning blasting over us. Our bodies are comfortable, but our brains just can't deal with it sometimes. He nodded. I guess so. I guess I never thought of it that way. So what do you think? Want to see if we can get your brain to a better place, I asked, trying not to let my voice sound too hopeful. I doubted he was ready for any sort of agenda from me. I guess, maybe so, he said slowly. Is there something we can do now? There was. Like so many before him, he learned that when he had someone to tell about the many weights on his mind and added some better brain chemistry, the world looked like a very different place. At the start of his third on-treatment visit, he actually stood up and shook my hand. No smile, but I'd take what I could get. We talked about the usual things. His gut was not loving the rads. I reiterated the need to stay hydrated and not work outside too long in the Florida heat. He said a friend of his had started coming over every evening after dark so they could get a little work done while it was less than 90 degrees outside. They were shade tree mechanics of some kind. When we were finished, he got up and headed toward the door but paused with his hand on the knob. I saw your technician, the lady who gives me my treatment, I saw her looking at my tattoos yesterday. I was wondering if you could tell her for me that that's not who I am anymore. I was full of hate back then, but I'm not too proud to say I was wrong. I was going to get rid of them-- do that laser thing. But now all that money is going to my cancer bills, he said, searching my face for some sign of understanding. I just blinked for a moment. This was more words than he'd given me in our entire acquaintance, all at once. There was a lot to unpack there, and I wanted to get it right. I finally decided on a reply. She grew up in the South. I think she gets it. You've been nothing but polite to everyone here. I'll make sure she knows, though. That therapist had a best friend whose granddad was a vocal segregationist but whose parents doted on both women as though they were twins. She knew people could choose to be better than their upbringings. He nodded. I've changed a lot. Sure, I said. None of us is who he used to be. We just have to try to keep moving in a good direction. Yeah, it's hard to know what that is sometimes, but I'm trying. Thanks for understanding. Of course, I said. Just remember this conversation later when I do or say something stupid, OK? Sure, Doc, he said. I guess I can spot you one. He smiled then for the first time since I'd met him, and it was truly beautiful. His wife was with him on the last day of treatment. She talked to me this time, instead of looking at the wall while she spoke. She even smiled a little. He cradled his diploma carefully in his lap. We give people a certificate when they finish their last radiotherapy treatment-- tangible recognition of what they've endured. Thank you for taking care of me. Sometimes doctors try to get rid of me because of how I look, he said, fiddling with the snap back of his mesh trucker-style hat. Well, I guess I can sympathize. Sometimes people don't have much use for me because of the way I look, too, I told him honestly. Yeah, when my wife and I first met you, we wondered what we were getting into. He laughed, and I laughed with him, remembering the furrowed brows. She looked a little embarrassed but smiled shyly. We thought about changing doctors. I'm really sorry about that. We just haven't known anybody like you before. I'm really, really glad I stayed. Well, I'm glad I've made it worth a try. We're all learning as we go, aren't we? Yeah, he said. I'll tell you, this cancer's been good for one thing. I understand a lot more of what's important in life. There's so much I can leave alone now. I feel like one of those great old guys who love their gardens and their grandkids, and really, they love people, too, everybody. They just laugh at the rest of us running around and worrying about who deserves a nice car or who should get to be the head of the Parent Teacher Association. They're just happy. Well, I hope that rubs off on me, I said. Maybe I can get a little ahead of the usual schedule in figuring that out because of you. I appreciate you're talking to me about it. I appreciate you, he said, one arm out in the offer of a hug but holding back a little, prepared for rejection of his kindness. I took him up on it. LIDIA SCHAPIRA: Welcome to "Cancer Stories." I'm Lidia Schapira, your host for this program and the consulting editor for "Art of Oncology." With me today is Dr. Kate Hitchcock, a radiation oncologist and an assistant professor at the University of Florida College of Medicine. Dr. Hitchcock is the author of "Knuckles," that was published in JCO's, Volume 39, Issue 3 on January 20th of '21. Welcome, Kate. KATE HITCHCOCK: Thank you so much for having me. LIDIA SCHAPIRA: It's a pleasure to have you. And before we start talking about "Knuckles." I love to ask our contributing writers a little bit about what they're reading and what drove them to write? So in this case, let's start with the first question. Are you a reader, and what are you reading now, and what's on your table? KATE HITCHCOCK: I am so much a reader. It is a little out of control, in truth, as it is with a lot of serious readers. I always have two or three books going, at least. Right now, those include my book in Spanish. I'm learning Spanish, since there are a lot of Spanish speakers in Florida, and I want to try to meet them halfway. So I'm reading a novel in Spanish right now that is fluffy, light read, but enjoyable while I'm building some vocabulary. I am reading a book of collected stories from my old ship from when I was in the Navy that's called "King Paul's Reactor and Engineering Memories." It's from the Enterprise, specifically. A lot of sea stories, written down by my shipmates, and that's a really fun read. But yeah, those are my two main books right now. LIDIA SCHAPIRA: So when I was looking up your bio, I saw that you have a PhD in biomedical engineering. So in addition to a career in the Navy, it seems, you've done a lot of things. Tell us a little bit about that and how your past experiences outside of medicine inform your relationship with your patients. KATE HITCHCOCK: Well, I would say the most important effect that they have on my relationship with my patients is that the Navy teaches you very quickly to do very complicated and very emotionally difficult things with people who are nothing like you. And I think that's part of what I was trying to capture in the story that we're talking about today. What a gift that is to have been through that experience of not only working but living very closely with people who grew up completely differently from me, who have completely different cultures than I knew up until that time. And what that allows me to do now, as a doctor, is try to meet people where they are. And that is it. Boy, that is the art of medicine right there, because I can have the best treatments in the world. If I can't convince my patients that they're the best thing, if I can't convince them to make it through hard treatment, which radiation often is, then all the science that I have isn't good for anything. LIDIA SCHAPIRA: That's so interesting, and it made me pause and think about how all of that informed your encounter with this patient, who is the protagonist of your story. So tell us a little bit about what made you see the story in these encounters and when you thought about telling the story and actually sharing the story with others? Because many of us write, perhaps, to process difficult experiences, to achieve clarity. But then to bring it out and share it with others through publication requires many different steps. So walk us through that, from this encounter, this patient to the story. KATE HITCHCOCK: I would say this encounter with this patient started as my time with my patients usually does, which is in me trying to figure out who they are. And I have to be a very quick study there because cancer doesn't wait. You've got to get people in treatment. And a lot of times, coming into the radiation oncology clinic, they have lots of preconceived notions about radiation. And it's a very scary thing for a lot of people because they haven't learned about it in school very much. So I very quickly need to figure out who they are, where they're coming from, so I can figure out how to talk to them. And the process of doing that is the joy of my work. I love meeting new patients and hearing about how they see the world and how it's different from the way I do. And so many times, in fact, just about every time, I wish I could capture that experience of getting to know them and share it with my loved ones, share it with my friends, because the joy of it is just, ah, it is just indescribable. So I think that's where it started with this particular patient, was realizing, boy, this is going to be one of the more challenging times, that I really need to do a good job at this. I can save this man's life. This is a very curable cancer, and he's going to die if I don't treat him. So somehow, I have to figure out a way to get us there. And it was a tall order, as I hope I captured well in this story. Because it was so hard and because I constantly sort of think back over those experiences later, the writing of this story was good for me, too. It let me kind of process what went well, where there are things I could have done better. And I hope that that's something I can bring to my future patients. LIDIA SCHAPIRA: So you start with these amazing visuals-- the swastikas on the knuckles, then the Confederate flag on his neck. But it's not just about him. It's about you plunge into this two-sided checking each other out. And you see the patient and his wife looking at you, and you use the expression, I think, their brows creased every time I spoke. And I'm quoting you here, "I had learned not to expect much from people who looked at me that way but wrestled the feeling down." I was just blown away by that phrase. Tell us a little bit about what was going on there. KATE HITCHCOCK: That moment happens every time. I always-- my heart is always in my throat a little bit as I go to put my hand on that knob to walk into the exam room. And that started back in medical school, where there were practice patients, trained actors who are on the other side of the door. It was a zero stakes situation, but still that feeling of walking in and not knowing what you're going to encounter on the other side of that door, ooh, that is a powerful moment. And I know it is for my patients, too. You know, they're sitting there. They hear voices in the hall. They are going through one of the most difficult times of their life, and whoever comes through that door is either going to save them or fail to save them. What a moment that is. It's just so full of emotion. And I think the big thing from the doctor side of it is just to try to figure out how to get past that initial reaction, that initial set of presumptions we have about each other. And of course, all of us have that in life. We all have preconceived notions about other people. First impressions are so, so important, and this is just a very high-pressure version of that. LIDIA SCHAPIRA: And then you go on to say, and you can tell, I love your writing, so I'm going to keep quoting you to you. "Tough when people judge you by how you look before they get to know you." I was just very struck by how direct you are and how quick you are to figure out that what's on the line is building rapport and trust. And you come at this from so many different ways. And then you take us through the sequence of the visits, when he comes in not just for the initial consult but also for the exit consult but for the checks, the weekly checks. And you try to address mental health and you address the acceptance and show support and praise. Tell us a little bit about all of that with this patient. What were the moments that were really key for you, and were there moments when it didn't go well? KATE HITCHCOCK: Sure, there are always moments when things don't go quite like you wanted them to, and you have to figure out how to recuperate from those. I would say the hardest ones for him, as is true for a lot of patients, is those moments where he was most worried about what I was thinking about him. And so I had to choose my words so carefully to not reinforce maybe ideas he had about my preconceived notions or about the way that the world views him that would not be constructive to our relationship together, would not help us get where we needed to be. For example, mental health is a huge issue in the way that people accept it all over this country and a lot of other countries, too. It's a very delicate topic to bring up, but it plays into every interaction I have with my patients. Of course, they're stressed out. Of course, a lot of them are experiencing symptoms of depression that make it hard for them to get their cancer treatment. Sometimes it's a matter of trying different approaches to that topic until I find one that works. And in this case, as I wrote about in the story, that was through talking about his wife's feelings, first. He was so worried about how she felt about everything, and a lot of cancer patients, or really any patients who have a serious illness, that's really the number one thing on their minds is they feel like they're being a burden to their families. And if I can address that and figure out a way to, if I can't improve their financial situation or anything material with it, if I can at least give them some tools to think about in a way that makes them feel better, that is really constructive to what we have to accomplish. And luckily, in this case, I think I was able to do that. LIDIA SCHAPIRA: So when I hear you talk, and you come across as somebody who's really mastered many techniques. You clearly have mastered the physics of radiation and the art and science of communication. But one of the things that I found so enormously compelling about your story is that you make yourself vulnerable, too. Your hesitation or your vulnerability comes across, and you put it right out there. Can you talk a little bit about that? KATE HITCHCOCK: I think that's so important. And it's a difficult thing to do, because we, as doctors, we're just people. And we have to set aside our egos sometimes and make ourselves vulnerable to our patients. And I think I figured out when and how to do that, at least part of the time. And it's not an easy task. You know, doctors, when we're talking to each other, both to our coworkers and in social media and so on, we talk a lot about do we put ourselves out there on social media? Do we let our patients have ways to contact us that might be outside of work? And I think the problem there is twofold. One, that you're opening yourself up to harassment and problems. This gentleman certainly could have come back to me in a way that would have hurt my feelings or caused me problems in other ways. But also, we're still coming away from the old approach to doctoring in which the doctor was this unapproachable being, who had to think of themselves as being a little omnipotent, a little removed from the rest of society, and they wanted their patients to think of them that way. And through time here, we're growing to where doctors and patients are much closer. It's not this paternalistic relationship that it used to be. And I really think part of that is the doctor has to have some skin in the game. We have to be able to talk about how we feel about things and the problems that we're having, if our patients are going to trust us with their lives with critical decisions. And I have found that doing that in a careful way, not making the conversation about me but talking enough about myself that they see me as somebody who is a person who is really invested in their future, it really pays off. LIDIA SCHAPIRA: I agree with you. And at the beginning, you hint at the fact that you were, in a way, at the margin. And you bring that up because you say they're looking at me in this way. I'm dressed this way. I'm a lesbian to them, but they were probably thinking about this using a different term. That is pretty raw. How has that experience-- I mean, you put it out there in your first paragraph. So it's right there in front of the reader. So how have those experiences in a way deepened, perhaps, your compassion for others, who are themselves different or are viewed or are likely to be judged quickly by others. Tell us a little bit more about that, because I think that it adds another dimension, another depth, even, to the essay. KATE HITCHCOCK: Absolutely, I think people who have grown up in a marginalized way for whatever reason bring a lot to any sort of situation where personal interactions are important and especially where lots of different people have to come together. And I think medical schools are starting to figure that out. This process of getting people into medical school-- they are really starting to value true diversity, not just we're getting the guy from the lacrosse team instead of from the football team, but really trying to get people from a broad array of backgrounds. And one of the reasons is exactly the one that you mentioned, which is that when you've grown up in a way where you were discriminated against, it makes it a lot easier to anticipate the sort of mental barriers to good care that your patients might have. So, so important in this country where there are a lot of marginalized populations, who don't have good relationships with the health care system overall, and that's very much to their detriment. They are the ones who are paying the price for that. And I think the burden is on us, as physicians, to try to figure out how to overcome that. And luckily, I do think I have a convenient tool there, having grown up in a place where, I think it was pretty obvious that I was different, even from a pretty young age. And I got bullied a lot and ran into problems there. Of course, my experiences isn't their experience, but at least I have a place to start in thinking about where they're coming from. LIDIA SCHAPIRA: So to wrap it up, I must say, I was very moved, too, with the ending that you have for the story. The first line is so confronting, the swastikas, and I immediately ask myself, would I ever have the compassion and the kindness and the discipline to really work through my reactions to get to the point where you did, which is that not only did you help him, but he offered you his hand halfway through treatment. And then he ends by offering you a hug, which you accept. So I'm just getting goosebumps thinking about this right now, and I've read and reread your essay a bunch of times. So let me give you the last word, and tell us and our listeners what that final interview was like. KATE HITCHCOCK: That final conversation together was pure magic, you know? There was no certainty going into it that it would go the way that it did. We were both a little unsure of each other, and especially with his wife there, who hadn't sat with us very much through the course of treatment and had to rely on his interpretation of the situation. But that magic is-- that's it. That is everything right there. I think part of what I was trying to capture in this story is that this is what we need in the country right now. This is the only way that things get better. We can't lecture each other into accepting the way other people think about things. We have to find this moment over and over again. That's it. LIDIA SCHAPIRA: Well thank you, I and our readers and reviewers understood your message very clearly. And we thank you so much for sending us your work. So thank you, Kate, for being with me today. And I hope you continue to write, and let's keep reading and talking. Thank you very much for your time today. KATE HITCHCOCK: Thank you so much. I really appreciate it. ANNOUNCER: Until next time, thank you for listening to this JCO's "Cancer Stories-- the art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts or whatever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's "Cancer Stories-- The Art of Oncology" podcast is just one of ASCO's many podcasts. You can find all of the shows at podcasts.asco.org. [MUSIC PLAYING]

In "Trying To Remember How We Saw Patients on That April Morning" by Mikkael Sekeres, an oncologist reflects on virtual visits during the COVID-19 pandemic. TRANSCRIPT SPEAKER 1: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] SPEAKER 2: Welcome to JCO's Cancer Stories, The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org. SPEAKER 3: During the past few weeks, I have become a reluctant participant in virtual health care, not because of any Luddite tendencies when it comes to technology. I just miss the physical intimacy of my patient visits. The app on my phone buzzed and flashed a green banner notification that a patient had just entered my online waiting room when I was in the midst of an actual in-person visit. My in-person waiting room has soaring ceilings, well-spaced furniture, and muted color tones, and artwork by [INAUDIBLE] and Spencer Finch, whose Trying to Remember the Color of the Sky on that September Morning graces the National September 11 Memorial Museum. The tragedy of a cancer diagnosis, in which a rogue cell metes out punishment on an unsuspecting body, or of this pandemic, in which a virulent guerrilla virus exploits a naive immune system, and of the more than 2,500 people who died during the terrorist attacks on the World Trade Center, have their similarities. Everyone sitting in my in-person waiting room is now masked, captive to both the malignant golem of cancer and to the coronavirus pandemic that has already claimed more lives in New York than the 9/11 attacks. If only the mask could protect them from both. I imagine my virtual waiting room to be way groovier, though, with swirling, vibrant colors, a less hypervigilant, party-like atmosphere, and no masks. People can actually sit next to each other in my virtual waiting room, lean in as they engage in conversation, sotto voce, without masks, and appreciate seeing the subtle beginnings of a smile as the lips curl at a joke anticipated or bon mot received. You remember, like how we all used to interact only a few weeks ago. I said goodbye to my in-person patient as she walked to our infusion area to receive chemotherapy and left for an unoccupied exam room to greet my virtual patient. I pressed the Next Patient button in the app, and his face soon came into view, filling my phone screen. He's in his 60s and lives with his wife of about 40 years in northeast Ohio, where he's a minister at a small church. Another patient of mine, also a minister, had once described what I did for a living as being similarly pastoral to his own line of work, as I gave counsel, relieved suffering, and generally ministered to the sick. It was one of the nicest compliments I had ever received. My patient had myelodysplastic syndrome, which in its most aggressive forms can slay a life in a handful of months. Luckily for him, he had a lower risk version of the disease, one that was so indolent that he didn't even need treatment for it. Yet another patient had once referred to this flavor of MDS as Mild Displeasure Syndrome. He didn't enjoy fighting the traffic to come see me in Cleveland every few months, nor did he appreciate having to pay for gas or parking. Otherwise, though, the disease didn't afflict him too much. He had gone to a laboratory close to home a few days earlier to have his blood drawn, and his counts were unchanged from a few months earlier. He wore a dark fleece shirt and sat in what looked like a comfortable, ladder-back wood chair. A watercolor painting hung behind him on the wall of his home. I asked him how he was holding up in these strange times and realized I was still wearing my mask from the previous in-person patient visit. No risk of infecting my virtual patient, so I slowly removed it as he answered my question. [SIGH] OK, I guess, he grimaced, probably feeling the weight of all he had undertaken recently to modify his lifestyle. I stay in, mostly, and conduct services virtually now on Sundays. This was at a time when some states were still allowing religious gatherings, highlighting how science, politics, and theology can often be at loggerheads with each other. I think you're doing the right thing for the health of your parishioners and yourself, I told him, trying to be supportive. He grimaced again, the difficulty of the choices he was making evident. My focus was on the physical health of my community, but his was on the spiritual health of his flock, people whose need for his leadership had become acute. It's hard, you know. I FaceTime members of my congregation, which has been fine. He didn't sound convinced of the ability of the technology to transcend his usual connection with the members of his church. But I held a graveside service last week, and people just can't help wanting to be next to each other and me at a time like that to comfort and console. If this had been an in-person visit a few weeks earlier, we would have been chatting at a distance of a couple of feet, and I would have grasped his arm to support him, to let him know that I understood this pain. That's what we do for our patients. Instead, I nodded, smiled warmly, and again tried to support him with words. But I missed the physical contact. I asked my usual questions about any symptoms of his MDS, which remained non-existent, and about the precautions he was taking to guard against COVID-19. I told him his laboratory values looked great. Then my eyes drifted again to the painting on the wall. I asked him about it. For the first time, his face relaxed into a natural smile. Oh, my father painted that. Here, let me show you. He lifted his phone up and focused it on the painting, which now filled my screen. It's a fishing shack in Turbat's Creek, Maine. He paused, giving me time to absorb the image of the ramshackle building with red wood lap siding, by what may have been Cleeves Cove decades ago. One advantage of these virtual visits is how I get to make virtual house calls and see how my patients really live. It's beautiful, I told him, calming. A simpler life, he answered, as we reflected on the difficult decisions we both had to make in the midst of the pandemic. It was really good to see you, I told him, meeting him in the eye as best I could. It had helped me spiritually to know he was OK. You too, he said sincerely. I hoped I had done the same for him medically. LIDIA SCHAPIRA: This is Lidia Schapira, your host for Art of Oncology, Cancer Stories. With me today is Dr. Mikkael Sekeres, who is a professor of medicine and the director of the leukemia service at Cleveland Clinic. Welcome, Mikkael. MIKKAEL SEKERES: Thank you, Lidia. It's a pleasure to be here. LIDIA SCHAPIRA: It's a pleasure to have an opportunity to chat with you. And today's talk is about your most recent work published in Journal of Clinical Oncology about practicing oncology in the COVID era. Tell us a little bit about your reflections and what led you to write this piece. MIKKAEL SEKERES: Well, I embarked on this piece based on a patient interaction I had where I saw somebody in person, and as we're learning how to provide virtual care to people, we have interspersed with our in-person meetings virtual meetings. I specialize in leukemia, as you mentioned, so most of my interactions are in person because people have to get blood drawn. And as much as virtual technology has progressed, we still can't draw blood over Zoom. I'd seen a patient in person and then switched to this virtual world and realized actually how dystopian our lives have become. Not only are we trying to treat a terrible, terrible diagnosis of cancer, this malignant golem that ruins people's lives and causes everyone to hit the reset button, but we're also doing it in the midst of a pandemic. And we're struggling to do this while we're also newly wearing masks and sometimes face shields and trying to navigate technology, multiple serious diseases, and provide personal care. So this piece started with an interaction over video. And part of it involves this fantasy about what our actual waiting room is like and what our virtual waiting room could be like. Our actual waiting room people cautiously sitting, separated by at least 6 feet, covered with masks, not making eye contact, nervous about being in an enclosed space with other people, as opposed to a virtual waiting room, where, my word, we're actually doing things like sitting next to each other and interacting and whispering things to each other and actually laughing. And it's amazing how much laughter has not been part of our patient interactions because we've been so nervous and our patients have been so nervous. And then in the piece, of course, I get into what it's like to have a virtual visit with a patient. LIDIA SCHAPIRA: That's so interesting. So much to unpack there. Let's talk a little bit about the stress that you feel conducting these virtual visits. Can you tell me a little bit more about that and how that has evolved over the last three or four months? Because let's remember, you wrote this when it was still fresh. And now, unfortunately, we've all become more experienced in conducting these virtual meetings. MIKKAEL SEKERES: One of the biggest stress points for me-- and I don't think I'm unique in this aspect of caring for patients-- is the inability to touch somebody. I think a lot of us go into oncology-- and let's face it. We are staring down the scariest diagnosis a person can get. And I always tell the story about how when I a long time ago wrote a book about cancer, I, being a good Jewish grandson, of course, the first thing I did was give it to my Jewish grandmother, so she could fell over it with her friends. I hand it to her. She saw that it had "cancer" on the cover and immediately hit it in her bookshelf. Because it was from a generation when they never mentioned cancer above a whisper, for fear of invoking it. So we're facing this. And I think the reason we take this on, in addition to the fact that I think we're good people, is because we like that intimacy. And there's an intimacy in caring for a person with cancer, where they are letting us in to probably the most momentous part of their lives to be a part of it, reluctantly. They don't want us to be a part of something that involves cancer, but they're letting us in. And we're seeing them make decisions and address these events that people really only face once or twice in a lifetime and be a part of those decisions and those events. And I think we're drawn into this empathically and want to touch them, want to hold their hand, want to hug at the end of a visit. And amidst COVID, we can't do that anymore. So there's this artificial separation that none of us is used to. And I think that's why I've seen some of the smiling and some of the laughter disappear from these visits. LIDIA SCHAPIRA: In a way, the laughter and the smiling can be present when you're doing it remotely through video and not when you're physically with somebody because you have to keep your distance and your masks. And yet it's bizarre because you can actually see that with a camera focused on somebody's face, you can see their expressions. But there's something that's just missing that we can't do. As you said, we can't draw blood through Zoom, and we can't touch through Zoom. And many of us have gotten to rely on our ability to touch patients to convey some of our good positive feelings towards them. And so we're left without that. And I think that is stressful as well. Tell me a little bit about how you process some of these experiences and the role that writing has in your life as a means to help you process some of these experiences. I mean, clearly you write also to share with others. But writing also, for many of us, has a way of helping us sort of understand what happened and has some sort of a therapeutic value, wouldn't you say? MIKKAEL SEKERES: I think writing is the way that a lot of us process this deluge of humanity that we're faced with every day we see patients. Right? It's an incredible experience to be part of somebody's life when that person is facing down the scariest thing we can imagine. And it really is. We use the word "privilege." We say it's a privilege to be part of their lives. But in this case, it really is. We're invited into a person's life in a way that they really only invite their closest family members. So when we face this all day long, I think we need a way to process it. And sometimes we process it by decompressing with a colleague or going home and venting with a colleague. Hopefully we don't process it in ways that are dangerous to ourselves through substance abuse, but that really does happen. I process it through writing. And I know that I have to write about something when I leave a patient's room and my stomach turns. And my stomach turns because there's a point of tension. And I think all writing starts at a point of tension. And it's turning because I can't figure out something that happened in the room. It's something that bugs me. And maybe it's the way I reacted to something that a patient says. Maybe it's the way they reacted to me. So I know that when that happens, there's a story there that I need to process. Or at the very least, there's something I need to process and talk through with a friend or with my wife. And stories start at that point of tension, and ideally they work backwards and forwards. Because the point of tension isn't starting point zero in a story. It's somewhere in the middle. And it's our job to figure out what preceded it and then what's going to follow it. LIDIA SCHAPIRA: That's amazing. So it requires a measure of self-awareness that you've probably cultivated over time. When did all of this become so clear to you, that when you feel that there's something about that visit that you need to process that triggers the physical sensation, that that sends you to your desk and to your keyboard? MIKKAEL SEKERES: I don't think there's one seminal point when you have insight into yourself. I think over a lifetime, you hope you get better insight into yourself. But I'm constantly reminded that there are blind spots that I have, as I'm sure everyone has. When I was a resident, I had this wonderful attending. And there was one point I came out of a patient's room, and I said to her, you know, there was this interaction that occurred, and I just don't feel comfortable with that. And she said, ah, your Spidey sense went off, didn't it? And I said, what do you mean? And she said, well, it's just like Spider-Man. When Spider-Man senses danger, his Spidey sense goes off, and he needs to investigate what's going on. She goes, always pay attention to your Spidey sense because it means there's something you have to unpack there. So I think it really started very early in my career when I realized that she called it a Spidey sense. I call it that turn in your stomach. There's something you have to unpack, you have to explore. And maybe in doing so, you recognize something that's there in your patient that you never knew was there before. But more often, you're recognizing there's something in yourself that you hadn't seen before. LIDIA SCHAPIRA: My follow-up question to that is, when do you decide that you want to share it with others and publish it, and when do you decide that this is just for you? This is just helpful for you to vent or process. MIKKAEL SEKERES: Well, as you know, I have had the extreme pleasure of being one of your editors for Art of Oncology, so we all see a lot of essays, a lot of people who write about experience. Because there are a lot of people who are processing this deluge of humanity that they see. There are certain essays where someone is processing, and they successfully process it but haven't communicated it effectively to an audience. And I think the reason is that when we're writing-- and I'm sure you do this too-- the most important person in the essay is your patient. It's not you. So I recognize-- I hope I recognize when I write that if I have an instance where it's about my patient, I'm really celebrating people, not saying, oh, this was a really hard patient to deal with. A hard patient to deal with, that means that I'm having trouble with it. That doesn't mean my patient is a hard person. And taking ourselves out of those essays and out of those experiences and focusing on just the wonders of humanity is when there's an essay that should be shared with other people. If it's about my problems and how I screwed up during the patient interaction, then I think it's worthwhile sharing with other people also if I'm exposing my own vulnerability. The time it's not OK to share with other people is if you're blaming the patient. Patients are blameless. The original definition of cretin and cretinism, they were Christlike. They were born without sin. Our patients are not born of sin. They have a terrible diagnosis. It's our job to try to fix it or to try to help them along a journey where they've made decisions that align with their goals. They're never to blame. So if an essay comes out and a patient is blamed, that's when you put in a drawer, don't let other people see. LIDIA SCHAPIRA: I see. Putting it in a drawer just dates us, right? MIKKAEL SEKERES: [LAUGHS] LIDIA SCHAPIRA: I have said that to some aspiring young writers. I said, you should put this in a drawer for six months and then revise it. And then I realized that it sort of fell flat. It did not land in the way it was intended. Tell me a little bit more about what writing means in your life. And I have a very specific question, which is that you published a lot of research. So for original research, we cultivate a certain writing style, and we are sort of in a hurry to get it published as quickly as possible, whereas with these reflections, the writing is different. The style is different. And we need that little extra processing time or maturity, and so sometimes it's better, actually, to wait. How do you think about these things? MIKKAEL SEKERES: So I don't make as much of a division between scientific writing and creative writing because there's creativity in scientific writing. And I look at it-- it's almost like a game. How efficiently can I communicate information and waste as few words as possible in a manuscript? And how can I communicate something that I think is just amazing, this scientific finding or this nuance of a study, to somebody else so they'll think it's amazing also? I think those aspects are actually very similar between scientific writing and creative writing. The difference, as I think you're leading up to, is that often, we write something creatively, and we've processed. We feel so much better after it. And I've been guilty of this also. You feel as if it's just been handed down from the mount. This is the word of God on paper or on your screen, right? And it is perfect. And any ability, any attempt to modify it would be like modifying the Ten Commandments. But in reality, first drafts are just that. They're first drafts. I once heard from somebody-- I love this concept that writing-- in most of life, we have these George Costanza moments. So remember in Seinfeld, George Costanza would be in an interaction. There was one episode, and then afterwards, he would go, oh, I wish I had said this instead. Oh my God, as he's complaining to Jerry and anyone who's listening to him. He wishes he had the chance to modify that instead. Writing is the only time we can undo those George Costanza moments. Where we put things down in our first draft and we think, oh, this is the word of God. Put it away. Put it in your electronic drawer. Then go back to it a week later and you read through it and you go, oh my God, this is embarrassing. I wish I had said this instead. Well, you can say that. You can change it. So my advice to writers, particularly creative writers, is don't submit it immediately. Put it in your electronic drawer for a week, two weeks. Go back to it. Look it over. You'll have that George Costanza moment during that time when you can correct things. Then go back to it again and make it something that's really special to submit. LIDIA SCHAPIRA: And my last question, to wrap it up, is have you thought about writing for a lay audience or for a broader audience? I know you've published a lot of assays in journals and that you write for The New York Times. What is the next step for you? MIKKAEL SEKERES: So I write in that way because I am the product of two English majors. I'm the only doctor in my family. And when I went to medical school, I learned all these complicated Latin terms and put on my armor of being a medical student with these new terms but who really didn't know what he was doing and would use these terms around my parents. And they would regularly rebuke me on the phone for using complicated language and tell me I had to simplify things and explain things clearly. So I gravitated towards writing for a lay audience because I am the product of a lay audience and had to speak to them. I have written a book called When Blood Breaks Down, Life Lessons from Leukemia, with the MIT Press, where I write in long form about three patients who are composites of patients I've seen over my career who have different types of leukemia. But really to get to that nugget of how we communicate with patients, how these conversations actually go, and how people make decisions, and how being part of our patients' lives makes us such better human beings. LIDIA SCHAPIRA: Well, thank you so much for that. I look forward to reading the book. Is it out yet? MIKKAEL SEKERES: It is. It's out now. LIDIA SCHAPIRA: Excellent. I'll need an autographed copy, sir. So thank you so much for chatting with us. This ends our podcast today for Cancer Stories, The Art of Oncology, in a wonderful conversation with Professor Mikkael Sekeres. Thank you so much, and I'll see you next time. SPEAKER 2: Until next time, thank you for listening to this JCO's Cancer Stories, The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories, The Art of Oncology podcast is just one of ASCO's many podcasts. You can find all of the shows at podcast.asco.org. [MUSIC PLAYING]

Dr. Hayes interviews Dr. Muss on geriatric oncology. Dr. Daniel F. Hayes is the Stuart B. Padnos Professor of Breast Cancer Research at the University of Michigan Rogel Cancer Center. Dr. Hayes' research interests are in the field of experimental therapeutics and cancer biomarkers, especially in breast cancer. He has served as chair of the SWOG Breast Cancer Translational Medicine Committee, and he was an inaugural member and chaired the American Society of Clinical Oncology (ASCO) Tumor Marker Guidelines Committee. Dr. Hayes served on the ASCO Board of Directors, and served a 3 year term as President of ASCO from 2016-2018. TRANSCRIPT PRESENTER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. DAN: Welcome to JCO's Cancer Stories, The Art of Oncology brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insights into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org. Today, my guest on this podcast is Dr. Hyman Muss. Dr. Muss has been instrumental in several facets of the history of oncology, the generation and conduct of cooperative groups, the establishment of medical oncology as our board of the subspecialty, and perhaps he's most well known as one of the founders of the field of geriatric oncology. Throughout his career, he's devoted much of his efforts to research in breast cancer mentoring many young investigators, and, frankly, I'm very proud to consider myself one of those. Dr. Muss's personal journey is fascinating. He was raised in Brooklyn, which even though he spent the last 50 years in other locations, including Boston, North Carolina, and Vermont, our listeners will appreciate from his dialect within the first 10 words from his mouth that he is, indeed, from Brooklyn. He received his undergraduate degree at Lafayette College in Eastern Pennsylvania, where he was elected to Phi Beta Kappa. He got his medical degree at the State University of New York downstate in Brooklyn, where he was elected to the AOA. He did his internship and his residency at the then Peter Bent Brigham Hospital, now the Brigham and Women's Hospital in Boston. That shows how old you are, Dr. Muss. HYMAN MUSS: [LAUGHS] DAN: Then he took a tour to Vietnam for a military tour of duty. He won a bronze star during that experience. He returned stateside, and he obtained his medical oncology fellowship at the then Sidney Farber Cancer Institute, which is now, of course, designated the Dana-Farber Cancer Institute. Following his fellowship in 1974, Hy joined the faculty at Bowman Gray School of Medicine at Wake Forrest, and there he served many roles over the next 22 years before he then moved to the University of Vermont to head the division of hematology oncology. After 10 cold years in Vermont, he got tired of the snow, and he returned to North Carolina and this time at the University of North Carolina, where he is now the Mary Jones-Hudson distinguished professor of geriatric oncology and the director of the geriatric oncology program in the University of North Carolina Lineberger Cancer Center. Dr. Muss has authored over 500 peer reviewed papers, and like most of the guests on this program, he's just simply won too many awards for me to list them all. However, in addition to his bronze star from the US military, I know he is particularly proud of being an eagle scout. And if you ever meet Hy and he's got his tie on, you have to ask him about his tie tack because it is an eagle scout tie tack, one of the few people I know who has one of those. Dr. Muss has served ASCO faithfully in many roles. He served on the board of directors from 2004 to 2007, and perhaps importantly, he was the recipient of the Allen S. Lichter Visionary Leader Award in 2020, which was well deserved. I knew of very few people with the vision that Hy Muss has shown for our field. Dr. Muss, welcome to our program. HYMAN MUSS: Thank you so much. My mother would have loved that introduction. DAN: [LAUGHS] Let's start with your origin story. I know you weren't bit by a radioactive spider in Brooklyn and became Spider-man, but seriously, I've heard you speak about your father, who was a dentist, and your uncle, a family practitioner, who, I think, shared an office or something. And this sounds a little bit different than the typical medical establishment that we work in these days. How did that influence you? HYMAN MUSS: Oh my god. How different it is. I grew up in Brooklyn. And I went to PS-167, and we lived in a little brownstone. And my father was the neighborhood dentist, and my uncle was the neighborhood GP, a term not used anymore. And I grew up with them, and I didn't always know I wanted to be a doctor. But I used to do house calls, especially with my uncle. And patients loved him. An interesting digression is he went to Howard University. He got a minority scholarship. He was picked out of Brooklyn. He had a lot of African-American patients too, and he would take me in his Buick. And I'd go, and I'd get candy and ice cream and love what he did. And I loved the patient interaction that he had. And I think that was instrumental eventually in college of me after working in a chemistry lab for a semester doing research on cyclic ketones to say I don't think I can do this for a living and consider medical school, which I think was probably one of my best choices. So I had a great upbringing and saw medicine. If my parents saw a credit card or an Epic EMR, they wouldn't know what it was. They'd think it was science fiction. DAN: And I'm sure you were HIPAA compliant when you were making the rounds with your uncle, right? HYMAN MUSS: Oh, yeah. So when he got very sick and he couldn't really do his practice anymore, my father said go to your uncle's office and take his records down to the basement. And I went in, and my uncle's records were 3 by 5 index cards with the name of the patient, Mary Jones, diabetes, and her phone number. That was it. That was it. And I could move them down in a cardboard box. And today when we see one patient and start one Epic note, we got 85,000 documents in there, so it was great. DAN: How did you get to Lafayette College? HYMAN MUSS: My father had a patient, and I inherited from both my parents loquaciousness. And my dad would talk with all his patients, and bring them up occasionally, have a scotch with them. And he had a patient-- I was probably a junior or a senior in high school. I was really-- didn't know what I wanted to do. I wasn't the greatest student academically in high school. Although, I went to Brooklyn Tech, a terrific high school. Rich Schilsky went to Stuyvesant, and the patient told my dad that he knew of a small college in Pennsylvania, a boys college, that was really good academically about 100 miles from home. Told me about it. I went and saw it, and liked it, and went there, and it really changed my life going to Lafayette. I got one on-- I went from 6,000 boys in my high school, no women, to a small college with maybe 1,200 boys, but I got to know my professors. It was a lot of one to one. It was terrific, and it still is. DAN: It's amazing how many people I've interviewed where what they do is serendipity. This sort of thing. Didn't know what I wanted to do, and I was-- you may have heard Dr. Freireich when I interviewed him. Told me that when he grew up in Chicago, his mother was a single parent, and so he started stealing hubcaps to pay for his tuition. [LAUGHS] The founder of our field was a juvenile delinquent. HYMAN MUSS: Oh, god. Yeah, no, I wasn't that bad. But Lafayette really changed my life, and I had people who actually knew me, knew my name, knew what I was interested in. I had some-- I was a chemistry major, not a really premed. And I had some wonderful professors, and I think they were disappointed when I didn't go for PhD graduate school in chemistry. DAN: Again, it's just amazing, and I remember this every time I run into a med student, where I think I don't have time to do this. And just one little comment or pat on the back and suddenly they're off in a different way, so I think all of us keep that mind. I've interviewed several of the pioneers, who many of them were so-called yellow berets at the NIH in the 1960s to avoid going to Vietnam and, frankly, changed the picture of medicine in America I think, especially oncology. But so far, only you and one other interviewee, Larry Baker, who I know you know and good friends, actually joined the military and was sent overseas. He did it sort of unwillingly. It looks, to me, like you did it more willingly. It's not that he was unwilling, but it wasn't in his career plans. That must have really been a very frightening but enlightening experience. Are you willing to give us any back stories on this and talk about it? HYMAN MUSS: Of course. So I was in medical school. Vietnam was going, and the draft was hot. And we were all worried that if we got drafted out of medical school or out of residency, we'd have to repeat a whole year. So there was something called the Barry plan. And what it was is you joined the military, you could join any service, and they would let you finish medical school and actually credit me for time in the military during medical school. And then they promised in residency not to draft me in the middle of the year. So I joined the Barry plan, and so I knew I had to go into the military. And so when my time came because I had good training, I was at the Brigham then, the military said, well, if you want to do three years instead of two years, we'll send you to this place or that to do research. And I didn't want to spend another year, so I know the minute I told them that I was heading to Vietnam. I did go to the NIH to look at a cardiology training. And I got there, and I was the only guy sitting in that interview area who hadn't written 10 papers. So I knew I was going to Vietnam after that day too. And I didn't about the NCI. I didn't know about cancer. Some of my close friends and your friends went to the NCI. Had I known, it would have been a terrific thing, and I would have applied. I would have worked with the greats there at the time. But I didn't know, so I went to Vietnam. And I was with an artillery battalion. I wasn't anything elegant. I never saw any units with MASH with women or anything. I was married three months. It was extremely hard on my wife, Loretta, who you know well, but I learned a lot about myself then. I was 27 years old. I didn't have 25 smart people behind me to ask questions to, residents, and terrific faculty, and colleagues, and I got to know myself. I was terrified when I went, terrified, but I got to know the system. And you learn how well-run the military is. Unlike some of our clinics, they really know how to do it. I got a very valuable experience there, and I set up a drug amnesty program, which is why I won the bronze star. It wasn't anything like I was in front of a machine gun. We had a major drug problem in Vietnam. Young people, nothing to do, time on their hands, frequently poor kids who got drafted and went in. It was the poor kids. World history, so I set up a program to try to help a lot of them not really get deep into bad drugs. And I think we had some success. Hard to measure. DAN: So when you say you were an artillery unit, were you like the doctor for the artillery unit? HYMAN MUSS: I was it. DAN: Were you patching up injuries and stuff, or taking care of sore throats, or what? HYMAN MUSS: I did. I did a lot of sore throats. I did a lot of venereal disease. I did back pain. I set one or two fractures. The first fracture I set, I had a big book in another part of our little aid station called the Palma. It was like a-- we didn't have YouTube. I needed YouTube videos. I put this cast on this guy. It probably weighed 300 pounds, and he said, doc, have you done this before? And I said, oh, yeah, I've done this a lot. So I did that, and I took care of a heart attack or two on the base in the base hospital. Although, I was in a unit that had little field units out with artillery, and I used to go a few times a week in a helicopter and check on the medics and troops. So it was an extremely valuable experience. DAN: That's incredible. Well, let's go on. You already sort of alluded to this, but I've asked almost everybody. What made you go into oncology, especially in the 1960s when there wasn't oncology? You came back to the Brigham. What got you interested in doing cancer? HYMAN MUSS: When I was an intern and resident at the Brigham, our chief of hematology was a guy named William Moloney, and I know you know him. DAN: I sure do. HYMAN MUSS: And he was an incredible guy. He was a professor at Harvard, but if you think my Brooklyn accent is heavy, you should have heard his Boston-Irish accent. It was off the wall. And he was the most terrific guy. He kind of served as my dad for part of the time because my dad had passed. He would round every day, and we'd see all the hem patients. And we had all the AMLs, so I'm talking about, oh, 68 to 70. I never saw a remission. Never. And they all passed away, but he loved the patient care. And I got interested, and so when I was in Vietnam and when I got out of the Vietnam and was back, I thought, what do I want to do? And I said, I really like that hematology. DAN: I'll just say that Dr. Moloney was almost exclusively hematology. HYMAN MUSS: He was almost all exclusive. He used to grow little AML cells in little chambers in mice and treat them with drugs, and so I decided to do hematology. And I came back, and I think in my first weeks there he said, Hy, you're not going to believe this, but you can actually put these people into complete remission and take their leukemic bone marrow and make it look normal. And I'm saying, oh, yeah, right, because I had used all these regimens like VAMP, methotrexate, all the things that never worked. And we had two new drugs, ara-C and daunomycin. And so I used to go up and treat these patients' IV pushes, ara-C and daunomycin, big doses, and I started seeing remissions. And I said, this is amazing. And then during that year, we had our first child, and I started to run out of money. DAN: So this is when you're still a resident? HYMAN MUSS: This is when I'm now a fellow. That year, we were very short of cash. I had a new baby, and I went to Dr. Moloney and talked with him. And he said, I'll try to help you, and he talked with a guy named Dr. Francis Moore, who was chief of surgery, one of the icons of surgery. And Dr. Moore talked with some of his donors in the Brooklyn area, and I became the first Sidney Farber Cancer Research fellow. I knew nothing about cancer, solid tumors. So as the requirement was, I had to go over to the Jimmy fund, the Sydney Farber Cancer Center and see cancer patients. And all my hardcore hem friends said, oh, you're not going to like it, but it's worth doing for the stipend I got. The first day I was there I knew medical oncology was for me. I loved-- it was open. We were treating everyone with CAF-- CMFVP, the old regimen, every single cancer. There was so much to be learned. There was so much opportunity for clinical trials. And then in the middle of that year, Tom Frei came, and he was so inspiring. And I knew that I was going to do an onc career. There were no hem-oncs then. There were hardly any oncology fellowships, so I got to love that. I did two years, not three. DAN: So let me interrupt you for just a moment just for our speakers-- our listeners. So Tom Frei was one of the three who were the first to put combination therapy together. HYMAN MUSS: Right. DAN: Jay Freireich, Jim Holland-- actually, it was Jim Holland's idea frankly. I figured that one out, and Tom Frei. So, again, in terms of pioneers, you were right there with the first pioneer. HYMAN MUSS: And I did little combinations of things I'm not going to tell you about. They're embarrassing. They didn't work, but I learned so much. And actually, Ezra Greenspan was in that early group in breast cancer treating patients with hormonal agents and chemotherapy. But I learned from them, and I just love the clinical environment. And those days, there was nothing. I've witnessed other miracles like Larry Einhorn developing platinum and curing testis patients. I'm old enough, every male I saw with testis cancer and mets died. Everyone. Drugs like that were virtually miraculous, and we're doing so many great things today. So I was at a really great crossroads. DAN: Who else was at your level at the time, especially before Dr. Frei? You must have been pretty much alone. HYMAN MUSS: There was a fellow named Jacob [INAUDIBLE] you may remember, who was there and was really interested in chemotherapy timed by your biologic clock, and a few other people, people like Craig Henderson and others who came in after. I preceded them, so I was virtually one of the few oncology trainees at that time. DAN: And who mixed up your chemotherapy? HYMAN MUSS: I did. DAN: And who started the IVs? HYMAN MUSS: I did. DAN: And who-- HYMAN MUSS: You don't want to know. I was very careful with daunomycin, and so Dr. Moloney had a little office in the Brigham. And it had a little bathroom, and a very popular regimen-- and we had a lot of lymphoma patients-- was COP, cyclophosphamide, vincristine, and prednisone, COP. So I would go into that little bathroom. It's very hard to dissolve this stuff. I put it all in a little sink. I'd have to tell the patients I'm going to be in here a minute. Don't come in. And I would put it all in syringes. I'd put them in a little chair, like kids sit in in school. Put your arm on the side. I'd start the IV and give it to them. When I got to the Farber in the second year, now they were training because they had so many kids. They had nurses that could do some of that, but I think I recall giving it there. But in the Brigham, I gave the chemo. DAN: Did you do any pediatric work with Dr. Nathan? HYMAN MUSS: I did a few months in peds with Dave Nathan, another amazing, amazing guy, and that's where I met people like Larry boxer. DAN: Larry was a colleague of mine here at Michigan. HYMAN MUSS: I know. DAN: Passed away about two years ago. Just a wonderful guy. He also, by the way, was my attending physician when I was a med student at Indiana on pediatrics-- HYMAN MUSS: Oh my gosh. DAN: --just by coincidence. HYMAN MUSS: His wife, Grace, was one of my colleagues. DAN: Let's move on a little bit. From there, I know you went to Wake Forrest. And I have to say, how does a kid from Brooklyn, who has been at Harvard in the middle of, really, no oncology probably outside of the coast, end up in North Carolina? HYMAN MUSS: At the Brigham, I knew I wanted to do a career in-- I wanted to try academics, but I didn't want to go in the lab. And I was actually offered a job by Gene Brown Wald and others at that time to work to stay in the Harvard system and do work on methotrexate in the lab. High dose methotrexate was hot then, and I couldn't see myself in a lab. I worked with Frank Bunn, one of the world's great hematologist at the Brigham, who is-- really became a great friend and knew me. And he said, Hy, I know you don't-- laboratory work isn't for you, so he knew someone at Wake Forrest doing work on sickle cell anemia. They were infusing urea to try to prevent sickling. And he called this fellow, and they said they were looking for oncologists, clinicians. And I went down there and another open place. I met my future boss at that time, a guy named Charlie Spurr, who is also one of the pioneers in oncology. Gave nitrogen mustard after the war. Just a terrific guy and probably my most-- among my most impressive mentors, and they offered me the job. And I told Loretta about it. I was thinking of Rochester and some other places, but I decided on this job. And one of the reasons was the other places I went it had snowed, and I was delayed and couldn't get out. True story. You talk about serendipity. And I came out here. There was some azaleas blooming, and I said, I'm going. And it was a difficult adjustment for a kid from Brooklyn to go down here. My mother, who was alive at that time, never heard of North Carolina. She was one of these women born in a candy store in Greenwich Village over a candy store by a midwife, and she said, they're going to kill you down there. And I said, I think it'll be fine, and Loretta got out of the car when we drove down here and cried. But it turned out that Wake Forrest and my mentorship and ability to work in their cancer center was incredible in my career, so I was able at Wake Forrest to really set up lots of research studies in breast cancer, prostate cancer, brain tumors. It was an open field there. They didn't have, really, many people like me, and it just was absolutely terrific. DAN: Let me segue that. There's a lot more I want to talk to you about, but I got to know you because of our experience in CLGB and the cooperative groups. And it was clear to me right away you were a major player, but I also-- and you still are as far as I can see at CLGB Alliance. But you're one of the few people I know who then went off and started his own group, the Piedmont Group. What was the background? What made you think you could compete with the big boys, and how did you get those folks to play? And how did you also straddle two different groups at once? HYMAN MUSS: Well, we had a very-- Dr. Spurr was an amazing man, and he realized that most oncology was going to be practiced in the community. Even at that time when I started my career, I would drive out to these small towns occasionally once a week, once a month, and actually give some of the chemo still or train nurses in practices. There were no medical oncologists around there. I took the second set of boards, so I think I'm talking about 1975 or something. And so he knew that, and we cultivated some very strong community relationships. And we didn't have CCOPs and NCORP there. Although, Dr. Spurr and his colleagues were instrumental in getting CCOPs and things going in this country, so community people didn't have a lot they could do. It wasn't a formal mechanism. And so we formed a little small group called the Piedmont Oncology Association. It was kind of fluffy. We didn't have 5,000 bylaws or anything. It was just a conglomerate group, and ironically, I published a New England Journal study out of that group reviewing all the things, and how long to give chemo, things that people like yourself have really expanded on and made much better. But we work with them, and then there was an announcement to form regional cooperative groups from the NCI. And I was involved in CLGB but not heavily at that time. We didn't have all the traveling and things that we had, and now we've replaced it with Zoom meetings and things. And so I knew a lot of these people. I'd seen a lot of their patients. So we applied, and we got funding for the POA. And we did OK for a few years, and it actually is still in existence as an educational group. But we couldn't compete with the large cooperative groups. We did well with accrual, but the brainpower to develop and keep up all the diseases-- disease sites were emerging. I was writing prostate cancer stuff. I couldn't keep up with the expertise nor could my colleagues. So it was a good experiment, and a lot of them ended-- my colleagues ended up in CCOP and now NCORP and have made major contributions. And I suspect we got people used to trials and protocols, but it was a short lived experiment. DAN: Well, short lived but changed practice. And by the way, some of your colleagues still talk about it and what a great experience it was, so you're the-- all right the next thing I want to talk to you about is your real love, which is geriatric oncology. And you got involved in geriatric oncology before the word existed as far as I can see. Two things, one is you weren't geriatric at the time. Although you are now, as am I. And, two, is-- just talk about the people you got involved. I know Dr. Hazzard had a big influence on you, but also Ludovico Balducci and Harvey Cohen. And tell us about how that all got started. HYMAN MUSS: Yeah, so when I was in my career at Wake Forrest, Bill Hazzard, who's one of the grand old men of geriatrics, wrote one of the first textbooks, and is still hanging around as professor emeritus, came to all the faculty and said, I'd like you to work with one of our residents in a project related to your specialty and geriatrics. So he came to me specifically and said you would like to do this. He's my chair. He's got to promote me someday, so I said, oh, of course. So what we did is Dr. Spurr was ahead of his time, and actually, we had codified all people in local protocols, our POA, into a database system with the punch cards from IBM, those little cards. I can remember that great movie about those African-American women where there's one woman who's the only one who knows how to use those cards. DAN: In NASA, yeah. HYMAN MUSS: I could go and actually ask our statisticians to run things, so what we did was we compared. We had metastatic breast cancer. We had no upper limits of age on protocols, which was very common then. We were patronizing to older people, and we compared women above 70 with 50 to 70 and less for metastatic breast cancer. And when I looked at the data, I had about 60, 70 patients, and I work with a wonderful woman who's now a medical oncologist named Kathy Christman. She was the resident, and we put this together in a paper. And we submitted it to JAMA, and I thought, oh, they're going to-- this will be gone. And they accepted it actually without any revision. Then I had to get my friends to read it because if you read the-- if you hear the way I talk and see the way I write, we need a lot of editing here. So in any event, it got there, and I really enjoyed the project. And I started learning about other people. Then what happens-- and you know this, Dan, your biomarker and all your expertise-- your friends start calling you. Hey, Dan, should we be doing this or that? And so they'd start to call me about older women with breast cancer and say, you think she could tolerate chemo? And so I got more and more interested. And then in the CALGB at that time, there were some other people interested, Peggy Kemeny, et cetera. DAN: Harvey Cohen, I think. HYMAN MUSS: Harvey Cohen. And we formed the-- and Rich Schilsky. DAN: And Stuart Lichtman was also a big player, as I recall. HYMAN MUSS: Stu Lichtman, yeah. I'm going to mention-- so we thought we'd form something on cancer in the elderly, and Rich Schilsky backed this up. And we made a working group, and one thing led to another. And then we became a committee. We were very successful. We wrote clinical trial protocols not just in breast cancer. We had terrific people like Stu Lichtman. Harvey and I chaired that committee for 22 years. We didn't even know it was that long, and we saw such evolution in our field. At that time, there was expertise evolving nationally with people like Ludovico Balducci. And I should add that early in my career at ASCO, BJ Kennedy, who's really considered one of the fathers of oncology, used to get up at meetings and when he heard a presentation and there were no older people, he said, where are all the older people there? And if you know BJ, he was not a man who was afraid to get up and speak his mind. And so he was really-- pushed this too, and Ludovico, and our cooperative group. And we slowly built up a wonderful committee. It really evolved, and then we pulled in people like the late Arti Hurria, one of the world's most incredible people, who really taught us how to get geriatric assessment into clinical trials and do it in the community. And it just evolved, and it's never-- DAN: You just stole my question, which is that you just told us about the first generation, and the second generation has taken this and run with it. This is why you're being interviewed. You were a pioneer. Arti was a settler. HYMAN MUSS: Oh, yeah. DAN: In terms off-- and we miss her so much. For our listeners, I think many of you know, she was tragically-- lost her life. She tragically lost her life in a car accident a few years ago, and she was on the board of directors. I remember standing with her during cocktail hour before one of the board of directors meetings, and I said, you know, Arti, you're going to be president of ASCO someday. And, well-- and she kind of looked at me like, are you kidding? And I said, no, I'm not kidding at all. You're on your way. It's such a tragedy. Actually, the final thing I want to do is I was going to ask about BJ Kennedy and his role in geriatrics, which you covered, but that allows me to segue into BJ's role in our field becoming a field. And you sort of stepped into his shoes, in my opinion, with the American Board of Internal Medicine, but BJ, I think, was responsible for our becoming a boarded subspecialty. Can you talk more about that? HYMAN MUSS: Oncology, we were relatively new, and to become an ABIM subspecialty, you have to show a need, that there's a need and enough patients and that you're doing something uniquely different and beneficial. And for a long time, the hematologists were a little-- think what do those oncologists do? They have one drug. They have 5FU. DAN: 5FU for colon cancer. HYMAN MUSS: Yeah. And maybe nitrogen mustard or something. But so they felt there's certainly a need. There's no question cancer was a need, but they really can't do much for their patients. And it was people like BJ, Jim Holland, and other visionary guys that really worked with ABIM and pushed to make it a specialty. And I think we began in 1973. I think hematology was 30, 50 years before because there was so much more knowledge in that field. And so it took people like BJ and Jim Holland, strong, outspoken people, to convince the board and not back off. Well, come back when you guys really have something to do for patients. No, we're doing things for patients now. This was well before pall care and all the other things we do non-treatment related that are so wonderful for patients. And they pushed it, so this was crucial in BJ building this, and being on the front line, and doing this, and building the whole field. And then what can I say? I think we're all in the greatest field in medicine, most exciting, best biology, can do tremendous things for many sick patients. But they were the people that really got us going or it would have taken 10, 20 years more. DAN: Yeah, it's a remarkable story. And actually to cap it off, I think you probably saw two days ago, the ACS, Siegel et al, put out their annual cancer statistics. And the last year, which was to 2018 to '19, was the greatest reduction in age specific mortality in the history of the statistical thing. And overall, since the '80s, there's been about a one third reduction in the odds of dying of cancer in this country. And it all started back with you and the generation ahead of you. I mean, there are very few specialties that can look at that kind of success, and look backwards, and talk to the people who were there. The cardiologists can't talk to Harvey and-- HYMAN MUSS: Yeah, I owe so much to my friends supporting us through the years, like you, like Larry Norton, one of my also great mentors and friends, Rick Schilsky, for just supporting the field, and the studies, and things or it never would have happened as well, and so many wonderful people involved. And so many nice things that ASCO has done, like education, and developing YIAs, and things. As you say, it's got to be the new generation. It's going to be the [INAUDIBLE], and William Dales, and all these absolutely terrific people that are going to have to push this field, Heidi Klepin. And I just was in the right place at the right time in all of this and had tremendous friendships and mentoring. DAN: Well, and I can't remember who said it, but those who don't remember history are destined to make the mistakes of others. So one reason I'm doing this is so all those people know what it took to get us there and the history behind it. So I want to finish this by thanking you for all you've done for me as a mentor, and all you've done for our field in terms of pioneering geriatrics, and the Board of Internal Medicine, which you've been on now for, what, 15 years I think. HYMAN MUSS: Yeah. Well, I'm off now, but I-- DAN: Oh, you're off now. OK. And mostly for our patients. So many of our patients are alive and doing well because of what you've done, so thank you very much. Appreciate your time today, and looking forward to being on the river with you someday soon. HYMAN MUSS: Oh, yeah. DAN: For our listeners, we both like to fly fish, so-- HYMAN MUSS: Thank you so much, Dan. I appreciate you allowing me to do this. I'm very grateful to ASCO. Thank you. DAN: Until next time, thank you for listening to this JCO's Cancer Story, The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories, The Art of Oncology podcast is just one of ASCO's many podcasts. You can find all the shows at podcast.asco.org.

Dr Hayes interviews Dr Ganz on pioneering quality of life studies. Dr. Daniel F. Hayes is the Stuart B. Padnos Professor of Breast Cancer Research at the University of Michigan Rogel Cancer Center. Dr. Hayes' research interests are in the field of experimental therapeutics and cancer biomarkers, especially in breast cancer. He has served as chair of the SWOG Breast Cancer Translational Medicine Committee, and he was an inaugural member and chaired the American Society of Clinical Oncology (ASCO) Tumor Marker Guidelines Committee. Dr. Hayes served on the ASCO Board of Directors, and served a 3 year term as President of ASCO from 2016-2018. TRANSCRIPT: PRESENTER 1: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. PRESENTER 2: Welcome to JCO's Cancer Stories: The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the role of cancer care. You can find all of the shows, including this one, at podcast.asco.org. DANIEL HAYES: Today, my guest on the podcast is Dr. Patricia A., Patti Ganz. Dr. Ganz has been a pioneer in establishing an entire field in our discipline, the discipline of survivorship. And really, this has been based on studies of quality of life and toxicities of therapy in patients with established active cancers that Dr. Ganz was involved with for really, the last four decades. Dr. Ganz was born and raised in Los Angeles. She received her undergraduate degree at Radcliffe, graduating in 1969. And correct if I'm wrong, Patti, I understand you were in the last class before the merger with Harvard. But I see you got your degree from Radcliffe and Harvard. So she received her medical degree and completed her residency and incidentally was chief resident and then medical oncology fellowship, all at UCLA. She then joined the faculty at UCLA and spent much of the early part of her career at the UCLA associated VA hospital. In 1992, she moved back to the mothership where she is now professor of medicine in the David Geffen School of Medicine, a professor of health policy and management in the Fielding School of Public Health, a distinguished professor of medicine and health policy and management, and the associate director for population science research in the Johnson Scott Comprehensive Cancer Center, again, all at UCLA. Dr. Ganz has authored over 400 peer reviewed papers, way too many chapters and reviews for me to recount here. And since 2017, she served as editor-in-chief of the Journal of the National Cancer Institute, one of the leading journals in oncology. She has an enormous list of honors that, again, is too long for me to go through today, except for a few I'd like to highlight. She's received two of ASCO's highest honors, the American Cancer Society award in 2008, and the Joseph B. Simone award for excellence in quality and safety in the care of patients with cancer in 2016. She was also the recipient of the Ellen L. Stovall award for the advancement of cancer survivorship care. She was a founding member of the National Coalition of Cancer Survivorship, and she was inducted into the Institute of Medicine, now designated the National Academy of Medicine, in 2007. And she's really played a major role in the efforts of the Academy to improve quality of care in medicine and particularly in oncology. Dr. Ganz, welcome to our program. PATRICIA GANZ: Thanks, Dan. It's great to be with you. DANIEL HAYES: So just to start out, there are so many things I'd like to talk to you about. One of those, in my opinion, you've been the epitome of role models for women in academics. And a lot of this series has mostly been men, because it was mostly men who started a lot of what we do way back 40, 50, 60 years ago. I know you grew up in LA. What shaped your decision to go into medicine in the first place, and then to stay in academics? PATRICIA GANZ: I went through college at Harvard and Radcliffe in a very turbulent time, in the late 1960s. Social issues were very important to us then, political issues just as they are now. And I was a biology major. And I was thinking about what I would be doing in the future. And for me, I really felt that I had to do something connected with people. And that was part of my decision. But of course, I had a major influence from my father, who was a physician. He actually went to the University of Michigan. And he always encouraged me to think about medicine, although he said ophthalmology, radiology, those are good careers for women. So you know, I had this lurking in the background. I didn't want to necessarily do exactly what my parents said to me. My mother was someone who also had been working in a family business for many years. So I had them behind me saying it was possible to have a career and to move forward in medicine. And of course, summers, doing various kinds of research that was involved with a potential career in medicine. So it wasn't a big surprise. Now why did I come back to LA? I guess that's a good question. Nowadays, when people actually are applying to medical school, I think they apply to 20, 30, 40. In those days, I think I only applied to six, if you can believe it. And three of them were UCs, and three or four of them I guess where on the east coast, or Northwestern with another one. It was a tough time. It was just on the feminist movement, also social change in terms of more African-Americans being admitted to medical school. And it was a tough time for those who were underrepresented, such as women. And in fact, at Harvard Medical School, I think family took 10 women. UCSF maybe took seven or eight women, where I'd gotten accepted there. And when I finally went back to school at UCLA, there were only three women in my class. So again, quite a striking difference than the way things are now. But I did come back to LA because UCLA was pass/fail. Having heard about the competition and medical school people being pretty cutthroat, I said, mm, probably good to go to a place where that wasn't the big issue. In addition, I actually met my future husband in a lab, working in a lab before my senior year in college. And I guess that might have been a motivation as well. DANIEL HAYES: And have you seen major change in attitudes regarding sex/gender in academics now? Do you feel that we've really made advances, or is it all just covering of a system that still exists? PATRICIA GANZ: I could speak for an hour on that, so I'm not going to do that. But I have to say that being a minority in the class was not unusual. Because at Harvard and Radcliffe, there were 300 women in my class at Radcliffe, and 1,200 men. And obviously, in the science classes I took, the women were in the minorities as well. But for women at that time, getting into medical school, they were actually a lot smarter and a lot better than the men because we were highly selected. However, my class, the three women-- one was me coming from an elite Ivy League school. One was a blonde valley girl who was coming from a California State University and another was a Korean immigrant. So we were all quite diverse-- yeah, even then. But by the time I graduated, we had a few women who transferred in. And actually, my husband who was a physicist at that time, went to medical school at UCLA five years later, and his class had about 25% women. So things were rapidly changing then. DANIEL HAYES: So I understand you really started doing hospice care when you were at the VA initially. And how has that colored what you ended up doing in terms of your career? I mean, in the 1980s, there wasn't a lot of hospice care. It must have made you think about and led to what you're doing now, what you've done. PATRICIA GANZ: That's an excellent question, Dan. And it was actually the late-- 1978, where I joined the faculty. And the chief of medicine said, you know, we have this kind of intermediate care unit. We'd like you to start a hospice for our oncology service, et cetera, et cetera. And there was actually a national hospice randomized trial that was going on at one of the other VAs here in Los Angeles. And having come out of my oncology training and thinking about it, I really thought well, you know, lot of those things that we're offering people at the end of life, like pain control and psychosocial support and things like that, we should really be doing that earlier for people. Because why should it just be reserved for those last few weeks? And so as I develop my unit at the VA, I actually called it a palliative care unit, a palliative care ward. Because at the VA I worked at, we had patients who actually often were in the hospital for five or six weeks getting their radiation, traveling by bus to the radiation facility. So they would be in for five days a week and then go home on the weekends. And these-- again, this was 1978, what were we seeing? We were seeing lung cancer. We had men with widespread prostate cancer who needed palliative radiation to the bones. We had a lot of colon cancers. So I was taking care of those patients. And while they weren't in imminent need of end-of-life care, they had trajectories which clearly were not good if they had advanced cancer. And it seemed reasonable-- I had a wonderful team, a physiatris, a psychologist, a social worker, even the pharmacist made rounds with us. It was just wonderful. And I essentially took all of the things that the palliative care end-of-life focus that hospice used and brought it up to the earlier part for some of these patients who, in fact, could be cured. I can think of someone who had localized small cell carcinoma who I took care of for many, many years. He was in getting chest radiation and whole brain. And you know, he lived a long time but he got all the tender, loving care that our nurses and our team were able to provide early in his course. DANIEL HAYES: You know, it segues really into my next question, which is in my own training, in the early 1980s at the Dana-Farber, especially led by Dr. Fry, Tom Fry, who's one of the fathers of medical oncology. We were really trained to learn how to treat and hopefully cure cancer. And there was very little regard to the toxicities. Dr. Fry used to tell us, cure the cancer first, we'll figure out the toxicities later. And at least the shackles begin to fall from my eyes as I began to see what you and others started to say. Well, you know, these people are going to survive. We need to worry about that. And personally, I think you almost-- not quite, but almost single-handedly taken our field beyond just treating the cancer, but worrying about the quality of life of survivorship. When you were starting that, either at the Bay area or when you went back to the main campus, what were the hurdles? Were there people who told you, you were wasting your time? Most have been told this is a fool's errand. You'll never get promoted by doing this kind of research. And you have done OK, I think. PATRICIA GANZ: Yeah. You know, I actually wanted to even go back to my training, you know? Because in the late '70s, there was actually-- in my heme/onc division, it was mostly liquid hematologists who were the leaders. And there were one or two solid tumor oncologists. And because I was interested in medical oncology primarily, I was the mentee of this person in his clinic. And essentially, what happened-- this was in the early days of adjuvant TMF chemotherapy. And you know, I was giving women chemotherapy for 12 months. And they didn't want to take it. They wanted to stop because of the toxicities of treatment. And he typically had me see those patients who needed that kind of support and symptom management and things like that, which were rather primitive, obviously, at that time. Because he was very technocrat in terms of knowing the literature and making those kind of decisions about therapy, but not managing all of this. So because of this collaborative relationship in his clinic for a couple of years, that's essentially where I began to see these issues because patients felt comfortable talking to me about it. Early on actually, at the VA, I was very fortunate, first of all, just to say I was a biology major in college. I never took a psychology class, ever. I took maybe a sociology class, which was on China at the time, but really wasn't trained in behavioral science. And I was very fortunate because there was a psychiatrist who was very interested in understanding the impact of cancer and its treatment on patients. And again, mind you, the five year survival was less than 50% at that time. And certainly, for the patients we saw with lung, colon, prostate that was metastatic, very much shorter. And he got a grant from the VA to do an intervention trial in the veterans and their spouses. But in order to be able to understand what patients were experiencing, Ian, the psychologist he hired as a project director, said, well, we've really got to interview patients and talk to them and find out what they're dealing with. And the psychological or psychosocial literature at that time was rife with issues related to coping. And coping is a concept that is not easy to explain to people. And certainly, it isn't necessarily universal in terms of many cultures. So it was difficult, then, to kind of operationalize this. And again, because I work with this great team, they began to interview our patients in clinic, and really, in detail, understood the day-to-day things that people were dealing with in terms of their cancer and the side effects from the treatment and their social relationships. And then we, all of a sudden, began to think of ourselves as a multidisciplinary team. And in fact, the person, Joe Collin, who was the associate director for population science at the Cancer Center at that time at UCLA, kind of said, gee, you make the ideal multidisciplinary team, you know-- a psychiatrist, a psychologist, and some medical oncologists. And it was from that time forward, that we began working together and I got my first grant. And really, they taught me so much about measurement, reliability, and validity. And in fact, we published our first paper together in JCO the second volume, which was on the Karnofsky performance status we visited, where they compared their ratings of the Karnofsky with my ratings of the Karnofsky for the clinic patients. And because they did a systematic interview about what patients were experiencing, noted that the function of patients was much worse than what I as even a sympathetic clinician would rate them. So that was really so important for me and working with them. And again, I think that's been the hallmark of my career to have had so many psychologists and psychiatrists, behavioral scientists, who embraced working with me, partly because I gave them access to patients if they wanted to study them, but I was also interested in really understanding, in a very rigorous way, how we could measure some of these things. DANIEL HAYES: Yeah, that raises another issue. In my career as a clinical investigator and translational investigator, pretty much inherited the tools to do what I want to do, how to do a clinical trial. It's always struck me that you, and I guess, Charles McKinsey and others had to make up your own tools, basically, to get it out of the realm of touchy-feely, if you will, and into the realm of true quantitative science so you could describe what you've done and how you've done it. How did you go about building those tools? PATRICIA GANZ: So again, a lot of these strategies or approaches to measurement were available in the social science literature. And they were just beginning to be translated into medicine. And again, this goes back to when I was training at UCLA. The Rand Health Insurance Experiment was going on in the '70s. My attendings in clinic were all involved in that. And John Ware, who was a great psychologist/methodologist, developed huge measures to look at patient outcomes in that big insurance experiment trial, which then got adapted into many other instruments that are widely used, such as the SF-36, and more recently, the Promise measures, which are publicly available. So I kind of was-- again, I had these kind of parallel streams of exposure. Health services research was very prominent at UCLA. These were my clinic attendings. And there was a very robust community of health services and health outcomes researchers. So I saw myself as kind of being an oncologist who could use those methods and apply them to the cancer problem. And there certainly weren't too many people out there. In addition, I had good fortune to begin to work in the cooperative groups, Ware and SWOG, with someone like Carol Moinpour, who led the efforts there in terms of patient-reported outcomes for many years, and then actually had a sabbatical in Switzerland, working with some of the IBCSG people and really having a time to just self-educate myself about this methodology. So I'm really self-educated, but have had wonderful collaborators who have kind of held my feet to the fire and said, you know, that's not rigorous enough, on occasion, certainly. DANIEL HAYES: So you were doing team science before the word came up, before the term. PATRICIA GANZ: Yeah, exactly. Certainly, when you have certain gaps in your knowledge, you need those collaborators. DANIEL HAYES: You know, this brings up-- I alluded to her just a moment ago. But when I think of cancer survivorship and quality of life, I think of you. But I think a lot of the late Jimmie Holland, who sadly passed away before I was able to interview her for this series. Can you just-- I think maybe some of our listeners don't know of her, haven't heard of her. We've got a lot of people young people listening to this. Can you just give a little background about Dr. Holland and the things she did? PATRICIA GANZ: Sure. Dr. Holland was a psychiatrist who really invented the field of psycho-oncology. And really, because she was working almost always in a cancer hospital, cancer setting-- I believe first at Roswell Park with her husband, James Holland-- she began to notice the neglect, if you will, of the impact of the cancer on the whole person and on the psychological aspects of cancer. And because of her being within a cancer hospital setting and then later moving to New York and obviously leading this effort at Memorial Sloan Kettering-- and really being very involved with CALGB and now the Alliance-- was able to introduce very early into the cooperative groups, the need for not just looking at the disease and its treatment, but to look at the after effects or show what were going on in the patient and how they were dealing with the illness. And she actually developed one of the first collaborative groups in psycho-oncology, which had people like Gary Morrow, who's at Rochester and who's had one of the big ENCORE research bases and has really continued to carry on a lot of psycho-oncology research across the country. Following what was really an early innovative approach, she developed a whole training program at Memorial. She trained many outstanding psychologists, psychiatrists working in this field and textbooks. I had the good fortune to work with Julia Rowland for a number of years. Julia was a direct descendant, if you will, Dr. Holland, having been at Memorial working with her and leading some of their early survivorship work. But she just trained probably more than a generation of people to take this seriously. As I kind of mentioned in an email to you, just as I would go to the ASCO meeting to listen to what Dr. Fisher or Dr. Bonadonna had to say, because I was interested in breast cancer and it was very exciting to hear the new reports of adjuvant therapy, I would also go to hear her and to Barry Castle, who was another leader in the field at the University of Pennsylvania, who basically were bringing rigor and clinical expertise to characterizing the patient experience, and publishing papers often in high profile journals like the New England Journal. So they were really role models for people who wanted to go into this field, although they weren't oncologists. And I think that's where I had kind of a double opportunity. Number one, I was perceived as a card-carrying oncologist. I was treating patients. I was in a cooperative groups. I was involved in trials, but I was also saying what about this secondary objective to our trial to look at the experience of the patients? So having entree to the patients, being perceived as one of the oncology community was, again, a really good thing to do. Although I must say that there were dozens and dozens of conferences where I was the last speaker on the program because quality of life was down there at the bottom-- not so much anymore. DANIEL HAYES: Your stories are great. I have one brief anecdote again, for the younger listeners. Jim and Jimmie Holland where as different as night and day. And Jim Holland, who was one of the three guys with Dr. Fry and Dr. Freireich-- who decided to put two drugs together and suddenly, we were able to cure some cancers-- was blustery. You might even call him a blowhard. I loved him, but I will never forget as a very junior person in CALGB, and I was appointed to be chair of a committee. And I was running my first committee meeting-- and needless to say, I was nervous anyway. And all of a sudden in the back of the room, Jim Holland, without a microphone, screams out something about, Hayes, if this is the way you think it's sounding, when I'm reading to you now, duh, duh-- so I went ahead and got through the reading. And later, Jimmie walked up to me and said, you know, he really loves you. His bark is much worse than his bite. PATRICIA GANZ: No, and you know, I think the early days of oncology were so much like that. Because again, we would have these wonderful people come to the microphone and ask a question. In the case of Dr. James Holland, he didn't need a microphone. But the point is, that we actually saw these people in real life, posing questions, challenging sometimes what was presented in a meeting, but also being very collaborative. And I think it was wonderful. And I think it's good that we have-- you know, our meetings today, obviously, are quite different because of the pandemic. But in our large meetings, we have scheduled discussions which is good, but it doesn't have the same spontaneity that we obviously were fortunate to experience in an earlier time. DANIEL HAYES: Yeah, I agree. You know, I think probably, of the many, many contributions and things you're known for, I believe your role in the Institute of Medicine then, now the National Academy of Medicine, regarding survivorship may be your greatest impact on what we do. How do you think that's translating now, to use the word translational science, which it really is? And when I was present, I was struck. There are probably 15 million cancer survivors in the United States right now. Have we really changed how they do based on your report, or is that falling on deaf ears? What do you think's going on with that? PATRICIA GANZ: Well, you know, there's several things that have happened. So the report that was in 2006 was led-- actually, Ellen Stovall was actually one of the co-leads of that committee. And you know, that was very seminal in that it was-- it's called the lost in transition report. And it really called out-- at that time, there were 10 million survivors, and that this whole large body of the population didn't really know, didn't have much direction about what to do after treatment and were kind of lost, because the oncology care system didn't really give them any guidance. And if somebody went to their primary care doctor, they would say, uh-oh. I don't know what that's about. You go talk to your oncologist. And then the oncologist would say, oh, that's a weird symptom, but it's not-- you know, you don't have any evidence of disease. That would be the typical thing. But it was usually an ongoing long-term effect of the treatment or possibly a late effect that was emerging, you know, such as a cardiac problem or a neurological problem that might be a secondary to previous treatment. And so the patients really weren't getting good care. And they kind of said we need there to be a group of people-- whether it's an oncologist or someone else-- who will take an interest and really tell us what do we need to be on the lookout for. And that was kind of a way to say, we need an end-of-treatment discharge summary. And it became actually very apparent. I was on the ASCO board actually during that time with the NICCQ report. I don't know if you remember that, but it was a report that ASCO did looking at the quality of care for breast and colorectal cancer patients. And what they found was you could find the op report from the surgeon. You could find the radiation therapist's summary note. But the chemotherapy flow sheets-- and this is, again, before electronic records-- were the only way you could even find out if somebody a series of treatments. And that went on, sometimes, over several years. So there was kind of no summary after the medical oncologists finished their treatment. So they try and figure out, even if you were the treating physician many years later and you needed to retreat someone, it was hard to know what was happening. So in some ways, the treatment summary and care plan had two roles. One was to say, well, what did they actually get? And the patient should know what they got in case many years later, you find out there's the late effects. But also, what do we need to look out for? And so really, again, building on what the childhood cancer survivor people had been doing for many, many years in terms of long term and late effects, this became an issue. Now Ellen Stovall, who was really focused on quality of care for cancer patients, and again, unfortunately, passed away a few years ago from complications of her Hodgkin's disease, really wanted there to be treatment planning and not just the treatment summary and care plan at the end of treatment. So I was actually fortunate in 2013 to lead another-- to lead, at this time, a report on quality of care and quality of care for cancer patients. Because Joe Simone had done one in the late '90s, and this was kind of a catch-up report. But it was also focused on the large and growing number of cancer patients, and many of them older. And with the baby boomers going into an age where cancer is very common, you know, how was our health care system going to approach this? And so we were, in that report, in many ways, echoing what had come about in the earlier survivor report, but saying you need to do this right from the very beginning. And it is very important for survivors. If we're going to be worried about fertility preservation, we need to do it right upfront. If we're going to be worried about potential complications in terms of cardiac toxicity occurring later, we need to be thinking about it in terms of planning the treatment for patients so that maybe they don't need to get chest radiation if they're a lymphoma patient. But chemotherapy and the very targeted therapies and the sensitive PET scans might help us avoid using unnecessary radiation to those individuals. So it has to be upfront thinking about what's going to have happen afterwards. And as part of the 2013 IOM report, we basically had many different recommendations which were kind of, I would say-- I kind of want to say pie in the sky, but futuristic. And one of them was that the insurers-- primarily Medicare, but other insurers-- should insist on patients having a treatment plan at the time of diagnosis, that their needs should be met, that they should have an understanding of the financial impact of the treatment decisions they're making, and that this should be part of a quality of care assessment strategy. And again, the thought was OK, maybe three, four, or five years from now, that will come about. But lo and behold, a year later, CMS picked this up and we had the development of the oncology care model, which in essence, took from our report the 10 or 13 point items that need to be part of initial coordinated care, which also included our survivorship care plan and treatment summary at the end of treatments. So I think to me, actually, that's one of the most significant accomplishments because now I see there's going to be a second version of the oncology care model, that many practices across the country have adopted these things. And as they've been part of the oncology care model, they're delivering this care to everyone, whether patients are insured by CMS or a private insurer. So I think this is an example of how long it takes to implement anything. Again, part of what I see our role, or my role as a health services researcher, is implementation science. If we know what works and what's important, it may take 15 years before it happens, but you need something like CMS to have a bundled payment plan. Or in the case of the treatment summaries and care plans, we have the American College of Surgeons who have championed that. And without these external regulatory policymaking organizations and payers, we don't get a lot of change. A long-winded answer, but to me, that's where the rubber hits the road. DANIEL HAYES: Well, I agree completely. I think that'll be your legacy, among many things. I mean, isn't it also part of the QOPI designation for QOPI accreditation in ASCO, isn't the survivorship plan? PATRICIA GANZ: Yes, the treatment summaries and care plans. I don't know-- I haven't seen any data. Recently, when I was more involved with the ASCO quality care committee, I saw some of those results. I don't know how compliant or adherent people are. But actually, part of the complaints that people have had has been, oh, it's hard to do this treatment summary. But if you actually start out with your initial treatment plan-- and we're actually doing this now on our Epic system at UCLA. There's something called the oncology history. And if you actually begin documenting from the beginning of treatment, you can actually move toward a treatment summary that's easily generated from the electronic record. But it's hard when you have to go back and do it retrospective. DANIEL HAYES: I was going to say, for all the young people who, at the end of a very long day, find themselves also having to do this long-term care plan for their patients, you could blame Patti Ganz for the work she started 30 years ago. PATRICIA GANZ: Yeah, OK. DANIEL HAYES: Actually, in the few remaining moments we've got, I want to bring up your new role as editor-in-chief of JNCI, the Journal of National Cancer Institute. I believe that you and Dr. Disis are the first women who have been editors-in-chief for major oncology journals. In fact, I don't believe it, I know it. You've been in the role now about three years. JNCI has always sort of had a niche that the other journals don't cover very well, in my opinion, and that they do. In taking it over, what are you keeping and what's your vision for the way you'll mold it in new ways and take it in new ways? PATRICIA GANZ: So I've been very fortunate, I was-- you know, I actually had a lot of experience at JCO as an associate editor for many years. And then I was also on the editorial board, and then deputy editor or associate editor and deputy editor of JNCI for quite a while as well. And Carmen Allegra took it over when Barry Kramer stepped down seven, eight years ago. And I knew Carmen from NSABP and RG. We had worked together closely. And I was kind of amazed when he took it over with all the obligations that he had as head of a heme/onc division and other roles, both leading gastrointestinal cancers at the NCI and NSABP Foundation. So he was doing a lot, and I thought, oh my gosh, you know? This is a difficult job to do as well. He basically moved the Journal a bit more towards a clinical perspective. And again, the history really is that JNCI was one of the first cancer journals. And maybe there was cancer research, but it was one of the first journals. And it essentially covered everything from soup to nuts, a lot of basic science. If you go back and see some of the highest cited papers, many different fundamental assays and so forth were published in JNCI. But if you look at the space in oncology, now there are 240-250 cancer journals so that we have many more outlets where some of the more basic science and translational science-- certainly, AACR has many wonderful journals-- so that we actually moved away, I think with Carmen's tenure, from the more basic work. And we really are taking almost no basic work. Things have to be clinical, in a sense that there has to be a translational component, cell line studies. And in vitro and animal models are not something that we're covering anymore. And again, that's a transition that I think occurred in prior years. I'm certainly continuing that. But I think because of my interest in breast cancer, obviously, and outcomes research in psychosocial work, we get more of those papers than perhaps when Carmen was the JNCI editor. But it's stiff competition, you know. We've had a strong epidemiological bent. We still get a lot of epidemiological and genetics papers. And I guess when I think about what I'm doing, it's really cancer prevention and control. That's what I've been doing for over 25 years, both in my academic research leadership position at UCLA, in my own research, and it's very broad. It's really applying all of the disciplines, if you will, of public health to the cancer problem, which means epidemiology, biostatistics, behavioral science, health outcomes research, you know, all of these things-- environmental science. All of these things are very important in both the etiology of cancer, the prevention of cancer, as well as the management of cancer. And so it's this cancer prevention and control swath that I think is our niche, if you will. So it's not as narrow as some journals. We're not just doing clinical trials, although we have them. But we're trying to have the broad scope of cancer prevention and control. That's pretty much how I see it. DANIEL HAYES: OK, thank you so much. Our time has come to an end. I can't tell you how much I appreciate your taking time to talk with us today. But more importantly, taking time to change the field of oncology in the way you have over the last 40 years. I think a lot of the things that our doctors are doing in clinic every day are a direct result of one person, and that's you. And there aren't many people who can say that. So thanks for all you do. Thanks for all your contributions, and I very much appreciate your sharing your history with us today. PATRICIA GANZ: Thanks so much, Dan. It was really a pleasure to speak with you and share what I've learned over time. Thanks so much. PRESENTER 2: Until next time, thank you for listening to this JCO's Cancer Stories: The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts, or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories: The Art of Oncology podcast is just one of ASCO's many podcasts. You can find all the shows at podcast.asco.org.

Dr. Hayes interviews Dr. Lawrence Baker on his early involvement with SWOG. Dr. Daniel F. Hayes is the Stuart B. Padnos Professor of Breast Cancer Research at the University of Michigan Rogel Cancer Center. Dr. Hayes' research interests are in the field of experimental therapeutics and cancer biomarkers, especially in breast cancer. He has served as chair of the SWOG Breast Cancer Translational Medicine Committee, and he was an inaugural member and chaired the American Society of Clinical Oncology (ASCO) Tumor Marker Guidelines Committee. Dr. Hayes served on the ASCO Board of Directors, and served a 3 year term as President of ASCO from 2016-2018. TRANSCRIPT: ANNOUNCER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. DANIEL HAYES: Welcome to JCO's Cancer Stories-- The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org. Today, my guest on the podcast is Dr. Laurence H. "Barry" Baker. Dr. Baker has a long and distinguished career in oncology. It dates back to the early 1970s, when he was intimately involved in new drug development, including doxirubicin or adriamycin, as we know it. He's also led early studies in preoperative chemotherapy in anal cancers. He was instrumental in advances in sarcoma research, and he led the Southwest Oncology Group-- now designated SWOG-- for eight years in the last decade. Dr. Baker was raised in Brooklyn, and since this interview is taking place just a week after the sad loss of Supreme Court Justice Ruth Bader Ginsburg, Dr. Baker informed me that he and his wife Maxine were married in 1964 in the Midwood Jewish Center, Justice Ginsburg's home synagogue. He received his undergraduate degree from the Brooklyn College at the University of New York, and then he graduated from Des Moines University of Osteopathic Medicine in Iowa. He completed a residency in internal medicine at Flint Osteopathic Hospital in Flint, Michigan, and then he has a curious two-year break in his curriculum vitae during which he was on active duty in Vietnam. Upon discharge from the Army, he returned to Michigan, and he served a three year fellowship at Wayne State University, where he stayed on faculty from 1972 to 1994, serving at various times as the chief of the Division of Hematology and Oncology, the chair of the Department of Medicine, and director of the Cancer Center. In 1994, he moved west about 30 miles to Ann Arbor, where he served as the director for the Clinical Research and Translational and Clinical Research Program for the UM Comprehensive Cancer Center, now called the Rogel Cancer Center. And he was also the associate chief of the Division of Hematology and Oncology and currently is the Laurence H. Baker Collegiate Professor in developmental therapeutics. Dr. Baker has authored hundreds of peer-reviewed papers, and like so many of our guests on this program, he has a list of honors that are just, frankly, too long to recite, except two that I want to highlight. He received the ASCO Distinguished Service Award for Scientific Leadership in 2007, and he was named an ASCO Statesman, now designated as a fellow of ASCO in 2010, for his many services to our society. Dr. Baker, welcome to our program. LAURENCE H. BAKER: Thank you. Nice to be here. DANIEL HAYES: Well, it's really great to have you. A lot of questions, but I want to start out, I just can't help but ask you, to be trite, how does a nice boy from Brooklyn end up in the Midwest for the rest of his life? Can you give us some stories about how you got there? LAURENCE H. BAKER: I graduated high school at 15 and went into what some know-- but not everyone knows-- was a very competitive college. Brooklyn College accepted-- was a free school. The grades used in the New York City school system were numerical. They weren't letters. And you had to have a 90 average on high school and certain scores on the state, New York State examinations to get in. And that was it. It didn't matter where your parents went to school. It didn't matter if you had money. And so it was a school largely of relatively low-income families. But that's the one who took me, and I guess they accepted me at 15. To not make this into a long story, but to drag it out a little bit, I was fascinated that I was 15 and I could date 18-year-old girls, and they didn't know it. So that's how I spent the first two years of college. And my grades showed that that was my focus of attention. I did pretty well on the MCAT examination. I would not have gotten into a medical school in this country, and I didn't speak a language that would be sufficient for me to go to Europe, for example, to school. So osteopathy he was where I went. I went to Iowa, but their admitting question to me is, do you have $2,000 a year tuition? To which, of course, I lied. And that's how I ended up being a DO, and that's how I came to the Midwest. And I actually got to like the-- I didn't know anybody from Iowa, as you make reference to my Brooklyn background, but I actually came to really appreciate the Iowa people, and particularly the community people that I came to know. At the time there were-- the really good programs in residency in medicine were in Michigan. That's the direct answer to your question. That's how I came to Michigan. Just about then, just about could have gone to California and gotten an M.D. degree just by taking the licensure examination. And then, that closed. That opportunity closed. So a long story to your question. So I came to Detroit, into Flint, and then returned back to Detroit, and I've been in Michigan ever since. DANIEL HAYES: Now, that raises the second issue I talked about a minute ago. And that is, many of our guests were so-called Yellow Berets at the NIH in the late 1960s and really changed our practice. But you actually ended up in the Evacuation Hospital at Cu Chi in Vietnam. And I've heard horror stories about this. How did that happen? What did you do there? Enlighten me. LAURENCE H. BAKER: Well, there were good and bad things about being an osteopath. The American Osteopathic Association was always in conflict, was always trying to defend itself. And at the time that the Vietnam War was going on, the DOs were not eligible for military service as an officer. You could go in as an enlisted man, but not as an officer. But there was a great need for primary care physicians in Vietnam, and the understanding of the military physicians was that all DOs were primary care physicians. So a deal was struck between the AMA and the Department of Defense that led to the drafting of everyone in my medical school class. Every one of the men-- not women. Every one of the men was drafted. There was a universal draft. I then-- I was given a choice. I could volunteer for the Army or go to jail. Those were the choices. And I had, at the time, two little children with Maxine, and I was not-- you might guess-- not a big fan of the Vietnam War. The alternative was to go to Canada, and I wasn't secure enough to consider that I could actually practice medicine. It was uncertain. So I went in. When I got there, they asked me, did I have any interest in anesthesiology or radiology, because they were really short of those two. And of course, being who I am, I said, if you need a radiologist or an anesthesiologist, why don't you go draft one and let me go home? That didn't work, and so I became-- I was assigned to radiology. DANIEL HAYES: [LAUGHS] LAURENCE H. BAKER: They sent me to Fort Jackson, where-- no, that was actually a good experience then, because I learned a lot about imaging, and I still have interest in imaging, but I don't qualify anymore. This is before CAT scans and MRIs. This is IDPs and upper GIs, right? So anyhow, barium lower bowel examinations. So I was trained for six months, and I stayed on for another few months on staff there and then, lo and behold, was sent to Vietnam. I was sent for a year, but I volunteered to stay an extra month so that I could return without any further obligation to the military and begin my fellowship on July 1, which I had actually secured before I went to Vietnam. So that's the gory details of that. I was elevated to Major about, oh, a few months before I was discharged. And then, because they weren't nasty enough to me when I got home, into my fellowship, I then got a letter congratulating me on being in the active reserve. So I had to go two weeks every summer. That was my summer vacation during fellowship and beginning of faculty. And I had to go once a month for a weekend to play soldier with a bunch of guys who were lucky enough that they didn't have to go to Vietnam. And now we're even, I think. So it was an interesting experience, as I've shared some of it with you. It still is a painful experience in some ways. I was out the busy [INAUDIBLE]. DANIEL HAYES: If you don't mind, a quick story you've told me before about the child with leukemia. LAURENCE H. BAKER: Yes. So they made me a radiologist. I'm not a great-- it doesn't matter where you call me. I am who I am, and I'm really interested in patient care. And there were already five internists, and there was only so much gonorrhea that the troops could acquire. So I volunteered to open a pediatric clinic. And the Army thought that was a good thing for publicity. They did stories about it. Anyway, I opened the clinic for pediatrics. I knew nothing about pediatrics. I mean, the truth is, I had a month of rotation. My wife sent me my textbook. It was Nelson's Textbook of Pediatrics. Nothing I ever saw in Vietnam was ever in Nelson's Textbook. But I did what I could of trying to treat the children as best I could. And along came a young girl, eight years old, who had acute lymphacytic leukemia. I had a wonderful pathologist who was my hoochmate. "Hooch" is translated, there were eight guys who lived in a place. That was called a hooch. And he was a pathologist, and he made the diagnosis of ALL. I had my books from my mentor teaching me about chemotherapy. So even though I hadn't started the fellowship, I had some resources about chemotherapy. And now I had to find chemotherapy. Treated her with-- I started with steroids and penicillin, and then I went to find drugs. I was able to-- I won't tell all the details, but I was able to get drugs at an old French hospital in Saigon. And so I would visit that hospital pretending great interest in the pharmacy, but of course, I stole whatever drug I could steal when the pharmacy wasn't looking. And that included some alkylating agents, methotrexate, 6MP. And so I tell Jay [INAUDIBLE]-- to get to where you want to be, perhaps-- that I invented the bicycle therapy, which was every month, you changed the drug to try to avoid resistance. So that's what I did by necessity. [LAUGHS] And I actually-- there was a second child that I also treated. When I left, they were both in complete remission. And I think that that's what you're asking me. I was lucky that I didn't get shot or thrown in jail for many of these escapades. But I look back and think that at least I did somebody some good. So-- DANIEL HAYES: Kind of makes the current generation who complains about work hours look in a different light, I think. LAURENCE H. BAKER: Yeah, we worked every day. We worked seven days a week with-- there was no such thing as time off. This was the busiest American hospital, certainly in Vietnam, and some think the busiest hospital since the Atlanta train station in the Civil War. It was in Cu Chi, which was on the way to Cambodia, which is, of course, where the North Vietnamese troops would enter into South Vietnam. So it was a major, major place. It was about an hour, an hour and a half west of Saigon. DANIEL HAYES: Let's move on to the rest of your career. You come back, then, and trained at Wayne State, and at the time, [INAUDIBLE]-- and I can never pronounce his name. I'll have you do it. Dr. Venutius Vicevicius-- I always heard him Dr. V.-- who was, I think, a real character and really was one of the first chemotherapy pioneers. Can you tell us more about him? Because we've heard a lot about the folks on the East Coast and the folks in Texas, but not so much what was going on in the middle of the country at the time. LAURENCE H. BAKER: Yeah, Dr. V, or Dr. Vicevicius, who was Lithuanian, he has a story of his life that certainly makes me look like a slump. He was a guest of the Nazis, and then he was a guest of the Russians when Auschwitz was freed. So this was as a child. He grew up in a very educated and somewhat affluent family in Vilnius. And when he got out of these camps, he actually got to medical school in Frankfurt, Goethe Medical School in Frankfurt. He had major interest in biochemistry and, without speaking more than three words of English, chose to come to the United States. And he landed-- I don't really know why; I've heard so many different versions-- but he landed in Detroit and showed up at the Detroit Receiving Hospital-- this would be like LA County or Bellevue in New York, that sort of thing, knife and gun club-- not speaking any English but wanting to do training. And somebody was smart enough to accept him. And so he did his training. He also trained-- after medicine, he trained with Mike Brennan-- that's another name from the past who is a past president of ASCO, by the way, the second or third person, perhaps. Mike was present of the Michigan Cancer Foundation and was the card-carrying medical oncologist in the Detroit area. He trained Dr. V., and he trained another man named Bob Tally, who had a great deal of history to contribute to oncology. And then, V was recruited by Wayne to come there and started a program. He was an extraordinary person. English was the eighth language he learned, and he actually taught me how to write. I flunked college English. I had to take it twice. But he taught me how to write and, I think, made me a better writer. He certainly was an inspiration. His devotion to patients was extraordinary. His knowledge was extraordinary. And so he was a great, great teacher. And one of his major early contributions was the recognition that you could make the drug float-- they had four drugs or five drugs at this time-- but one of them was 5-fluorouracil, that was developed by Fred Ansfield in Minnesota. The drug was given for five days and then every other day until their mouth fell out or their white count got to zero. And maybe that's a little of an exaggeration, but not much. At any rate, he figured out if you gave the drug by continuous infusion-- because it had a rather short half-life-- you could avoid a great deal of the toxicity. And that's how infusion of fluorouracil got its start. He then went on to combine it with other drugs and with radiation, and that was the backbone of this anal canal achievement that you mentioned in the introduction. I had very little to do with it, but I was a cheerleader. It was a rectal surgeon who came to us at the time, and those familiar with that disease-- which we now know is a virus disease that could be prevented, but at that time, nobody had any of that-- the treatment was abdominal perineal resection, and it had to be among the most horrible things we did to people. And the surgeon came to us and said, listen, you guys always squirt those drugs in after they relapse, and I'm really tired of this. Maybe you could give those drugs first, OK? And that's how neoadjuvant chemotherapy got started. It wasn't our idea. It was a surgeon's idea. That story gets repeated again in orthopedics, but that's how it began in anal canal tumors. And so we gave 5FU infusion, and mitomycin, and radiation preoperatively. That almost always shrunk the tumor, by the way-- almost always significantly shrunk the tumor. The patient then once they went through that operation but was cured. And so you took a horrible disease and changed its natural history with that development. If it works once, you know, in oncology, then you try it a second and third time. And I had very shortly thereafter the opportunity to work with a wonderful Japanese pediatric oncologist in Houston, Watsu Tao. He was looking for a partner because he was tired of seeing osteosarcoma patients die. Cure rate at the time was around 20%, 30%, and the surgery that was done for osteosarcoma was amputation, usually of the lower extremities. So 2/3 of osteosarcomas occur around the knee, and the orthopedics really dislike the idea of taking a child's leg off. Every teenager and child wants to be exactly like every other teenager and child, so you can imagine how disruptive it is to have a high amputation of your leg. It took about three months to make a prosthesis, and everyone knew that you didn't really have to do an amputation. You could just cut out the bad bone and replace it with a prosthetic device. But it took three months to make it, because they were handmade at the time. And so the idea came to several people-- Jim Holland was involved in this; Tom Frei was involved in this as well. Different cities were approaching it in this way. And we all ended up giving chemotherapy to these young people-- children, teenagers-- and then having the operation. And osteosarcoma went a cure rate of 20% to 30% to 70% or 80%. And they didn't lose their legs. DANIEL HAYES: I have two personal comments on this. One is you mentioned Dr. Brennan and the Michigan Cancer Foundation. Just for our listeners, Michigan Cancer Foundation is MCF. And if you've done any breast cancer work at all, you've worked with MCF-7 cells or MCF-10 cells [INAUDIBLE], which came from that organization. I think people have forgotten what MCF stands for, except for you and me. LAURENCE H. BAKER: That cell line that you talked about, MCF-7, that was developed by a man with, I think, a high school degree who just had a green thumb at that growing cells-- a wonderful man. And that came from a patient of ours. When I say "ours," I mean Dr. V. I was just the flunky, but it was his patient. And she had ascites from breast cancer. And we would tap ascites, in those days, with some frequency. And the cells for MCF-7 came out of that patient. That's its actual origins, and more papers have been written about MCF-7 than even you and I could count. DANIEL HAYES: Including by me. LAURENCE H. BAKER: I understand. No, it was incredibly useful. I mean, we learned about hormone receptors from this [INAUDIBLE]. DANIEL HAYES: Yep, that's [INAUDIBLE]. LAURENCE H. BAKER: It's was incredible. DANIEL HAYES: My other personal story related to your stories is, as a fellow at the then Sidney Farber Cancer Institute, Dr. Frei was my boss. And he, as you mentioned, was starting to work with Holland and others that had already worked with neoadjuvants. And he would cite your data all the time. Now, I didn't know Larry Baker for us from all the tea in China, but we heard a lot about the Wayne State experience when we were fellows. I don't know if that would have [INAUDIBLE] or not, but people definitely-- LAURENCE H. BAKER: No, I came to SWOG-- which is really why you wanted, I think, to talk to me-- in '70 or '71, I can't remember exactly. And Dr. V, it was an incredible experience. He took me with him. You ran into Tom Frei. They knew each other. And he said, Tom, I want you to meet my colleague, Larry Baker. I just had never been introduced like that. DANIEL HAYES: [LAUGHS] LAURENCE H. BAKER: And Tom was the friendliest person I think I've ever met in oncology. He had a wonderful smile. He clearly-- I was always paranoid that I'm a osteopath. Maybe I went on too long about that story. But when they tell you in school you're just as good as the MDs, you can quickly figure out if you were just as good, they wouldn't keep saying it, right? So that's socially accepted paranoia, and that's how I was brought up. So here is the wonderful, famous Tom Frei being nice to me! I was just amazed. DANIEL HAYES: He used to come to the lunch room in the Dana Farber two or three times a week and would just sit with us, and was constantly thinking of new stuff. This is not an interview with me, but someday, I'd like to tell the stories he told us. He was really just a fabulous man. I want to segway into your work with adriamycin, which is now, of course, also one of the workhorses of oncology. We've all used it. And I believe you were an author on either the first or one of the first phase II trials of adriamycin in Cancer in 1973. Is that an outgrowth of that introduction you just told us? LAURENCE H. BAKER: Yes. That study-- it's in Cancer, I think, not-- I don't think JCO existed. But that study didn't distinguish what the primary was. So it was a phase II study of cancer. And so there was, I don't know, 800 patients. I worked with Bob or Brian on that study. Bob was at Henry Ford, and there was a student of Bob Tally that I had mentioned, and I was the student of V. And the two of us were basically the schleppers for them. And so it had hundreds of patients in it. And in that study, we recognized that it worked in breast cancer, that it worked in lymphoma, and it worked in sarcoma-- and nothing worked in sarcoma. So that was the study. It's often quoted by Jim Dorshow because he said, we do everything that's disease-specific, but look what came out of one study that, by the way, accrued, as I say, 600 or 700 patients in 18 months. And this is before computers, so you can imagine how much work was done to evaluate the flow sheets. It was an incredible opportunity here to work. But it was an amazing paper, and it changed my life, of course. That's how [INAUDIBLE] and other things. DANIEL HAYES: So at the time, you recognized that this was not just another drug off the shelf, that it really was going to be a game-changer? LAURENCE H. BAKER: Absolutely, absolutely. You saw people getting better. And my experiences were mostly in breast cancer patients getting better, and some lymphoma patients that were refractory. First time I saw solid tumor patients dramatically improve. DANIEL HAYES: So I saw that your name is before another giant in the field who was a young Italian investigator who spent time in the United States named Johnny [INAUDIBLE]. LAURENCE H. BAKER: Yeah, that's how I first met him. I don't know that this story's been told. We were trying to make some level of peace with the Russians, and the Russians, of course, claimed that they discovered adriamycin. I don't know, but if you don't know this, I'll continue. DANIEL HAYES: Please go. LAURENCE H. BAKER: OK, but we all-- everyone knew, and certainly [INAUDIBLE] knew, this was an Italian drug, OK? "Adriamycin" is for the Adriatic Sea. As far as I know, you can't see the Adriatic Sea from Russia. But this was a time when our government wanted to be nice. They cared more about building a relationship with the Soviet Union than they did continuing a friendship with the Italians. Jim Holland was then sent to Moscow to negotiate this. That's where the name doxirubicin came from. In other words, we didn't know generic names, trade names. This didn't exist in the early '70s. So we called it adriamycin, which was not only the generic name, it was the trade name, right? Made by adria-- I think far Pharmitalia is the name of the company, right? And as a result of Jim Holland's diplomacy, it became doxirubicin as the generic name. It's a true story. DANIEL HAYES: Yeah. I know that "adria--" came from the Adriatic Sea, but I've not heard that's where "doxi-" came from. That's a good story. That segways into the next segment of your life that fascinates me, and this is your work in SWOG. When I moved here to the University of Michigan, you were on your way to becoming the chair of SWOG, which you did. And it occurred to me that University of Michigan wasn't even in Southwest Michigan, let alone the Southwest of the United States. Just reminisce a little bit about Dr. Coltman, who ran SWOG, the beginnings of SWOG, even before that, and where you see the [INAUDIBLE] groups now. LAURENCE H. BAKER: So Dr. V brought me to a SWOG meeting in San Antonio, Texas, as you said, in 1970 or '71. At the time, Tom Frei was running the group. J. Freireich was chairman of the Leukemia Committee. Chuck Coltman was chairman of the Lymphoma Committee. V specifically chose to work with this group because of those people. You're right, Michigan is not in the Southwest, obviously, and, there were other groups that wanted-- we had a large population of patients we treated, so there was actually some competition, if you will, for us to join other groups. V was adamant that we would be SWOG and that was it, for reasons that I told you. Tom Frei then was invited to go back to Boston. That's how you came to know him. And there was an election for a replacement. And J. Freireich was somebody that we clearly supported. There was no doubt that J. an absolutely brilliant man-- he still is-- and taught a lot of people, trained a lot of people, and taught us a great deal. But he had one flaw. He could not control his ability to saw inappropriate things. If you knew him, you loved him. If you didn't know him, you were like your reaction to the debate, OK? That's how he ground on people. I grew up with the respect for J., as I told you, as I was introduced to him, and he was always incredibly kind to me. Anyway, so we were actively supporting J. To be the replacement. There were some other people that did not want Freireich. So you had some people who didn't have the same feeling. And that's how Boris Hoogstraten became chairman. Boris Hoogstraten was a hematologist from the University of Kansas. And I remember-- and you'll be very proud of me, Dan-- one of my colleagues from Wayne wanted to do a study of this new drug called tamoxifen-- DANIEL HAYES: [LAUGHS] LAURENCE H. BAKER: --for breast cancer, OK? [LAUGHS] And Hoogstraten said, don't you get it, Baker? We're a chemotherapy group. What's with this hormone stuff? I don't have to tell another story, but that one is true. So SWOG didn't study tamoxifen for a long time. Any rate, Boris was an interesting man. I don't want to cut him short. But there came a time when it was clear that SWOG needed to go in a different direction. And we all thought that the right person for that was Chuck Colton. At the time, I have to tell you, there was two things relevant to this. There were lots of regional cooperative groups that don't exist anymore. I led a revolt-- that's what Colton said-- that included the University of Indiana-- Larry Einhorn was in Detroit plotting against Hoogstraten-- along with the University of Michigan. Al Labulio was in Detroit doing that. So you got the idea. So it was a group of institutions, if you want, that were geographically somehow related to the Great Lakes in some way. There were seven or eight of us. And we represented probably 40% of the [INAUDIBLE] of SWOG. And Coltman came to me and said, listen, stay with the group. Don't do this. Stay with the group. And I said, I can't stand this nonsense. I mean, we're not working anymore. We're just-- Anyway, he said, please stay. And he ended up becoming the chairman. And then he turned to me and he said, listen, Larry, I want you to be the deputy. I don't need a title. I don't want a title. He said, no, no, no, I don't care what you need or what you want. I need you right next to me, because if you led a revolt once, I don't want to see it happen again. DANIEL HAYES: [LAUGHS] LAURENCE H. BAKER: Absolutely true story. And so we abandoned the idea of a regional group. I still think that may have been a dynamite group, by the way. But we all stayed-- Indiana was not [INAUDIBLE] SWOG, so let me be clear. That was ECOG, I think. I think that's right. Anyway, so that's how I came to know Chuck, and I was his deputy for 25 years. I had the best job as deputy, because I had nothing to do. He just wanted me sitting there, and that's what we wanted. Then there was some push from the NCI that maybe to 25 years of being chair is a long time, and maybe there's a reason to move on. From that team the suggestion from Bob Livingston and John Crowley, that I was the natural person to do that. I really didn't want it, to be honest. I still maintain that. But there was a good deal of pressure exerted, both from within the group and from the NCI, for me to do that. So I became the chairman, I think, for a couple of terms. I made some changes in the group. I think as groups go on, institutions either get better or they get worse. I think that's true. And we made a number of different ways of appointing disease chairs and things like that, that the group did get better and started on a better path. But I really didn't want to continue it, and there was a time when I was not only running SWOG, but I was also running this sarcoma group called SARC. And it became overwhelming to me. I was working literally 80 hours a week there. So I gave up SARC first. That really-- University of Michigan was thrilled that I did that-- and stayed with SWOG another year or two. But I knew that I wasn't going to stay at that. And so after two terms, I thought I would set the precedent that, maybe, group chairs should have two terms and move on. Witshoski had two two terms. [LAUGHS] But anyway, being serious, I really think there should be a limited amount of time. There's so many talented people in our field that it's silly to think that one person has to stay in these jobs. And so that's-- I think I answered your question. I'm not sure my [INAUDIBLE]. DANIEL HAYES: I have to tell just a brief-- Nobel laureate Bruce Beutler was my intern when I was a resident at UT-Southwestern. After he won the prize, he came up here as a visiting professor, and we went to dinner. And I said, Bruce, I kind of lost track. I know you did an internship with us, but I never heard if you finished your clinical training. And he said, no, I went-- I loved the lab and went back into it. I never did go back and finish my training [INAUDIBLE]. And then he looked at me and said, but I think I worked down all right, don't you? LAURENCE H. BAKER: [LAUGHS] DANIEL HAYES: And in a similar manner, I would say, for all your humility that you've laid out, I think it worked out all right. SWOG is a powerhouse and has changed practice in so many ways. And part of that, a lot of that, was your doing. So we've actually run out of time. I had hoped, actually, to-- you've done too much in your lifetime, Larry. I was hoping to get into the sarcoma work, but we've run out of time. I think everybody who's listening to this who knows about the work you've done in sarcoma-- and lord knows there's plenty of work to do in sarcoma, so-- LAURENCE H. BAKER: Can I give you just one more anecdote, and you can cut it, and I'll try to be very [INAUDIBLE]? DANIEL HAYES: No, no. Please do, please do. LAURENCE H. BAKER: Remember I told you I became chair of the Sarcoma Committee of SWOG? The man I replaced was a man named Jeff Gottlieb. Jeff was a pediatric oncologist-- little did people know-- who was a student of J and Tom at the NCI. Jeff died in his mid-30s of cancer, by the way, but he was the most brilliant medical oncologist I ever met. He was the originator of combination chemotherapy that became popular in breast cancer, and he was involved in sarcomas in combinations as well. I was handpicked by Jeff to be his replacement, which was probably the nicest thing that ever happened to me. And during that period when Jeff died, I went to Houston to his funeral. And I can give you one-sentence description of J. Freireich going to speak at Jeff's funeral. He stood up, and he said, Jeff-- and he broke down and cried for minutes. And that was his talk. When anyone says something to me critical of J. Freireich, I remember that love he showed to his colleague. So that's worth [INAUDIBLE]. DANIEL HAYES: No, that's-- LAURENCE H. BAKER: Not many people were at that funeral. DANIEL HAYES: --very touching. He also gave Dr. Frei's eulogy in Boston, and he got through it, but just barely. It was very similar. These are the kinds of stories I'm hoping to capture in this series. Larry, I'd really like to thank you for taking time to be on. I'd also like to thank you for all you've done for the field, for me personally, frankly, with my time here in Michigan the last 20 years, and most importantly, for our patients who have benefited from all your contributions, your training of-- we could go on about all the people you've trained. So anyway, thanks a lot. We appreciate it. LAURENCE H. BAKER: Thank you. DANIEL HAYES: And have a nice day. LAURENCE H. BAKER: Thank you very much. I appreciate your kind words. DANIEL HAYES: Until next time, thank you for listening to this JCO's Cancer Stories-- The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts, or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories-- The Art of Oncology podcast is just one ASCO's many podcasts. You can find all the shows at podcast.asco.org

Dr. Hayes interviews Dr. Lichter on his involvement with early breast preservation. Dr. Daniel F. Hayes is the Stuart B. Padnos Professor of Breast Cancer Research at the University of Michigan Rogel Cancer Center. Dr. Hayes' research interests are in the field of experimental therapeutics and cancer biomarkers, especially in breast cancer. He has served as chair of the SWOG Breast Cancer Translational Medicine Committee, and he was an inaugural member and chaired the American Society of Clinical Oncology (ASCO) Tumor Marker Guidelines Committee. Dr. Hayes served on the ASCO Board of Directors, and served a 3 year term as President of ASCO from 2016-2018. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Welcome to JCO's Cancer Stories-- the Art of Oncology, brought to you by the ASCO podcast network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the role of cancer care. You can find all of the shows, including this one, at podcast.asco.org. Today, my guest on the podcast is Dr. Allen Lichter Dr. Lichter has a long and really storied history in the field of oncology over the last five decades. With his colleagues at the NCI, Drs. David Danforth and Mark Lippman, he was the radiation oncologist PI for one of the four studies that demonstrated that breast preserving therapy was as effective as mastectomy for newly diagnosed breast cancer. He more or less single-handedly started the Department of Radiation Oncology at the University of Michigan, now considered one of the top programs in the world. He is one of only three radiation oncologists to have been a dean at a major university in the United States, serving as such at the University of Michigan Medical School for eight years. And he is one of only three radiation oncologists who have been president of ASCO. The others are Sam Hellman, who I've interviewed previously, and our current president, Dr. Lori Pierce, who, by the way, is also from the University of Michigan. And his term was from 1997 to 1999. Dr. Lichter was born and raised in the Detroit area. He received his undergraduate and his medical degrees at the University of Michigan, after which he completed an internship at a community hospital-- St. Joseph's in Denver-- and then a residency in radiation oncology at the University of California, San Francisco. Following that, he joined the faculty at Johns Hopkins University, but after two short years there, he moved a few miles south to the National Cancer Institute in 1978, where he was head of the radiation therapy section of the radiation oncology branch. I believe you couldn't have been more than 32 or 33 years old, Allen, at the time. I counted up the years. He then moved back to Michigan to start the department here, which he chaired for eight years, and then became the dean for eight years. And then he went on to become the Chief Executive Officer of ASCO from 2006 to 2016. In spite of spending the last 20 years of his career as an administrator, Dr. Lichter has authored over 120 peer-reviewed papers. He was the co-editor of Clinical Oncology, one of the major textbooks on oncology, and has really been a leader, especially in radiation oncology, but in cancer in general in this country. I also want to add he was my boss for eight years when I first moved to University of Michigan, and during which time he was also my next door neighbor here in Ann Arbor. And I got to be his boss for one year-- if anybody could be Allen Lichter's boss-- from my term as ASCO president. Dr. Lichter, welcome to our program. It's great to be here, Dan. So a number of questions. I know, first of all, you grew up in Detroit and you went to Cass High School. And while this podcast is supposed to be about the history of oncology, having moved to Ann Arbor, I find the history of Cass High School awfully interesting. Has a number of famous alums, including Diana Ross, Lily Tomlin, Ellen Burstyn, Della Reese, David Alan Grier, Jack White, Alice Coltrane, and-- my guess is, Allen, you don't even know who Big Sean is, but he's a rapper. He's very famous right now for the younger generation. Any memories from your time there? Did you run into celebrities when you were there? It's quite a place to say you're from, I think. It's an interesting school, mostly a technical high school, located in downtown Detroit, but with a small college preparatory program that took students from all over the city with a competitive entrance exam. And I don't know what possessed me to get on the Second Avenue bus and ride downtown back and forth every day, but it was a fascinating experience. It takes you out of your normal peer group. I met young people-- friends-- from all walks of life, from all corners of the city. And it was a pretty rigorous education. I enjoyed it a great deal. And I played on the golf team. And it sounds to me like you knew you'd be a doctor then. Your father was a family practice doc in a small community just outside of Detroit. Was that true? Did you plan to go to medical school? Or did you have some epiphany when you were at high school? No, I never remember a single day not wanting to be a physician. My dad was a general practitioner and really instilled in my brother, and in me, a love of science and a love of medicine. My brother went on to be an ophthalmologist and was chair of the department at the University of Michigan for 34 years, President of the American Academy of Ophthalmology. So my dad and my brother set great examples for me, and into medicine I went. So I have to tell you, my father was a business man and was disappointed that I was in academics because he never understood why I wasn't generating income. My brother went to work for Eli Lilly. He was a doctor, too. And dad always thought he was doing something productive because he worked for Eli Lilly. So I don't know if your dad was disappointed you went to academics instead of family practice, but-- It was interesting. When I started my residency training, I was certainly confident that I would head into private practice and live a life much like my father did. And when I finished training, I decided I just needed a little more buffing up. I figured I'd go into academics for a couple of years, just to make sure I had a good grounding, and then go into private practice. I love the academic life and stayed there my whole career. I've been fond of asking previous interviewees-- why'd you choose oncology, and specifically radiation oncology, in your case? What led you to go into this path? Especially 40 years ago-- there wasn't a whole lot of oncology to go into. Well, you know, I was one of those medical students that loved virtually every rotation, and after that rotation I was going to become a fill in the blank. In my senior year of medical school, we were allowed to take an away elective, and I wanted to explore radiology as a potential field. My brother had a very good friend who was a radiation oncologist at the University of California, San Francisco, and the chance in the early 70s to go to San Francisco-- especially avoiding the Michigan winter-- was very compelling. So I signed up for the electives, and when I got there, I found that it was six weeks of diagnostic radiology and six weeks of radiation oncology. I hadn't expected that, but what the heck. So I did my six weeks of down in the basement looking at teaching sets, which was really quite inspirational. And I went into radiation oncology. And after my first day, I called my father and I said, I found what I'm going to do. I'm going into radiation oncology. It was instantly fascinating. I love the camaraderie in the department. I love the blend between the physical exams of patients, the treatment of cancer, the use of very high technology equipment and physics. It just struck me and I never wavered from that point on. So I've heard you talk about this-- and I'm 10 years behind you and even was true when I trained-- was that there wasn't a whole lot of science in radiation oncology back 40 years ago. And the field has evolved. And there are two things-- one you already hit on, which is it was combined with diagnostic radiology. And the second is it split away from diagnostic radiology to become its own field, and a lot of science. I've spoken with Saul Rosenberg and Sam Hellman and sort of asked them the same question. Give us just a background of the last 40 years of the evolution of radiation oncology because you had a lot to do with that. Well, of course, the field grew up, as you point out, inside the broad field of radiology. I always would tell my trainees that when Rankin discovered the X-ray, he forgot to discover the instruction manual. So there was a trial and error learning with this very useful technology, but very dangerous technology over a long period of time. For quite some period of time, you trained in general radiology. You had some time in diagnostic a little time in therapy, and you went out and could do both. But as I entered the field, it was becoming more and more difficult to learn radiation oncology in just the few weeks that they rotated in from their diagnostic duties. And I was one of the earliest group of trainees who trained in straight radiation oncology-- no diagnostic training, per se. And the field, as you say, split from diagnostic radiology. Had our own boards. I was amongst the earliest group to take the specialty board in radiation oncology. And the other thing that was true, certainly back in the late 60s and early 70s, is that so much of the field was experiential-- that is, people wrote papers like, you know, the last 100 patients with cancer of the lung that I treated. And this was valuable, but the need to do rigorous, well-controlled clinical trials was obvious to everyone inside the field. And so the field did become much more scientific. Never quite much as medical oncology, and part of that is because devices are treated differently at the FDA than drugs. Drugs you have to prove through scientific investigation that the agent is safe and effective. And then you can release it for patient use. For devices, you just have to prove that it basically doesn't kill anybody. And you can get an approval of a device and often get a billing code for the device. So the approval comes, and then you're supposed to do the science. Well, a lot of people, at that point, they're just too busy using the technology, then, to actually step back and do the science. And, of course, if you spent a lot of money for a piece of technology, to do the science to find out that wasn't a very wise investment is not in your self-interest. So our science lagged behind. I think it is certainly catching up, but it's still, in fact, in many cases, has a ways to go. I have enormous respect for our colleagues in the FDA on the devices side, and their hands are tied a bit. But I liken some of what they do to being like underwriter's laboratory. If you plug it in, it doesn't blow up, so they approve it. Yes. It's a little more than that, but you're right. And so much of the device approvals are based on a predicate of a similar device. And it goes from A to B to C and finally, you know, years down the road, the equipment and its use and its underlying structure is so different from the original device that was approved years ago that you rely on, at every step of the way, it really has-- there's been a lot of scrutiny about changing that, and I think over time it will change. You know, historically, it's interesting, by what you just said-- some of the first prospective randomized trials in all of medicine were radiation versus nil to the chest wall with breast cancer. To my knowledge, streptomycin versus nil for tuberculosis was the first, but then a whole series of radiation versus nil. But who would you give credit in the United States-- I would give part credit to you with the work you did with Drs. Lippman and Danforth. Probably one of the first randomized trials in radiation in this country. Well, you're correct that the first chest wall radiation trial started in Manchester, England in 1948. And at that point, doing randomized trials-- giving some patients the therapy and other patients observing or giving them a placebo-- that was not in widespread use in medicine. And over time, those types of trials began to become more common. I think in radiation oncology, our big advance was becoming part of the national co-operative group system, where many of the co-operative groups-- maybe all of them-- had a radiation oncology committee. And our studies were often integrated with surgical care or combined modality care with chemotherapy. And so we began a series of very important studies in breast cancer and lung cancer. The pediatric group did many, many trials that involved plus or minus radiation. I don't know that there's any specific person I'd give credit to, but it was the movement inside the field to join our other oncology colleagues in testing things rather than just doing observational work. You know, in that regard, let's circle back to your work at the NCI. That must've taken a fair amount of organizational and political skills to mount a breast preserving therapy, just at the NCI. The data that breast preserving therapy was safe was just beginning to be reported. The randomized trials in other places were ongoing. Give us some story there, how the three of you got that going and how you ran that. Well, of course, virtually everything at the NCI, from a clinical standpoint, is a clinical trial. Patients aren't treated there, just as going to their community hospital. You come to the NCI-- the travel is paid for, the care is paid for, et cetera, based on your agreement to enter into a study. At the time that I went to the NCI, the NSABP was doing their very large trial of lumpectomy versus mastectomy under Bernie Fisher's direction. My concerns were twofold. Number one-- this was being done at many, many centers around the country, and one could, I think, logically ask the question whether the quality of that care was going to be uniformly high enough to truly test breast preservation therapy. And secondly, I believed-- and many of us believed at the time-- that a boost to the tumor bed was quite important as part of having a low rate of local recurrence, and the NSABP study did not use the boost. They just treated the whole breast and stopped. And I said, you know, let's do a trial where it's done at a single institution, where the quality is going to be absolutely top notch, where we're going to use a boost and all of the technical tricks that we knew how to do this, just in case the NSABP study didn't come through. We'd have a backup. If both of them were negative, we could forget about lumpectomy and radiation, but if the NSABP was negative, we'd have this. As it turned out, the NSABP study, as you know, was positive, established for sure the equivalence of preservation therapy, and our study was sort of a little caboose at the end of the train. But that's OK. It confirmed what Ernie and colleagues confirmed very emphatically. Actually, there's an interesting article in the JCO written by Ian [INAUDIBLE] and his colleagues, about six months ago, that he preluded when he won the award your last year as CEO at ASCO. Was it your award? I can't remember. Yes. But anyway-- yeah. And in which, he designated the term I hadn't heard before of statistical fragility. And he made the point that many single prospective randomized trials are positive and the subsequent ones are not. And I give you and, of course, the Italians and the Brits also ran similar trials. It's nice to have four trials that all show the same thing. There's no statistical fragility in this observation. Yes, well, the NSABP trial was 1,800 patients. Our trial was about 240. We weren't going to change the world, but it was at least comforting to me that we had this trial coming along just in case. The other academic success that I give you credit for and would love to hear more about it is that you're interested in CT planning, which I think, really, was the forerunner, now, of stereotactic radiation and I would call precision radiation, as opposed to just blasting an organ and hoping you hit the cancer. And I think, really, a lot of that you brought when you started the department here. But how did you get interested in that? When I went to the NCI, my first day there, they took me on a tour of the department and we walked by a room with a locked door. I said, what's in there? And they said, oh that's our CT scanner, but we never use it. So I said, well, let me see it. And, you know, this was an EMI 5005. This was one of the early scanners. It was a body scanner, but it had a fairly small aperture. You could not get a lot of Americans into this machine. And I said, well, why don't we start scanning some patients. As long as-- does anybody know how to use this thing? Yes? OK, let's start scanning some patients. And it didn't take long to recognize that this was a machine that was almost tailor made to do radiation therapy planning. It gave you the contour of the patient's surface. It showed you the inside of the patient. It showed you the tumor in most settings. And remember, at that time we were facing radiotherapy treatment planning on plain x-rays taken on the simulator where, for example, when you treated the prostate, you never saw the prostate. You knew where the pubis was. You knew where the rectum was. You knew where the bladder was. And you knew the prostate had to be in there somewhere, but you never saw it. When we started to CT scan the pelvis in prostate cancer patients, there was the prostate in all its anatomic glory. And so we began to plan on this. And then it became pretty clear that if you took these slices and stacked them back up, like if you took a loaf of bread and it was laying out on the table as individual slices and stacked the slices back up, you could rebuild the three dimensional picture of the loaf. We decided that that might be a good thing to do with CT scans. And that's when I went to Michigan, and that's when we brought together some terrific physicists and brilliant programmers and spent a lot of money on a roomful of computers and began to do three dimensional reconstruction. And that led to a transformation in radiation therapy from a two dimensional specialty to a three dimensional specialty. And you could start firing at the tumor from cross sections from different directions. We didn't have to be in the actual plane, et cetera, et cetera, et cetera. And then we put a multi-leaf on the aperture, and so you could shape the field in real time. And it just went from there. So I have to tell you, when I was a first year fellow at Sidney Farber Cancer Institute, and I saw a patient who had received chest wall radiation-- not at our institution, by the way, not even in Massachusetts. She'd come from one of the other states. And basically, they had just stood her up in front of the machine and turned it on, as far as I could see. And the amount of normal tissue damage that she had suffered from this was incredible. And I called your friend, Jay Harris, and said, is this what we do here? He said, no way. Had me come down-- he showed me the beginnings of their CT planning and that sort of thing. I didn't know [INAUDIBLE] at the time, but then I learned later, mostly because of your doing. There were a number of outstanding institutions that were involved in this, and a lot of the inspiration for this came from some of the work that Sam Hellman was writing about, in terms of how we might better use imaging. So it was a team effort across the whole specialty. By the way, you bring up Dr. Hellman. We just lost Eli Glatstein in the last few months. I'll give you an opportunity to say some nice things about him. I know that you worked with him, and he was a giant in the field. The reason I was attracted down to the NCI is that this little short pudgy guy, Eli Glatstein, was recruited from Stanford by Vince Devita to come and run the radiation oncology branch. It was a pretty interesting time. There were five of us with Eli. All five of us became department chairs after our time at the NCI. He was just a phenomenal individual. He gave you a lot of rope. You could either hang yourself, or you could do the work you wanted to do. And we accomplished a lot. The other thing that I remember-- so I went to the NCI 1978. 1980, Eli said to me-- he handed me a piece of paper. I said, what's this? He says, it's an application form to join ASCO. You need to join ASCO. So I said, OK. That's not typically what radiation oncologists do, but I'll join. He sponsored me. And then he said, I'm going to see if I can't get you on a committee. And he did. I was on early Grants Award Committee. We handed out five or six young investigator grants. And I became chair of that committee. And then they said, well, you know, you did a nice job. We're going to put you on another committee, and way led to way. It was entirely because of Eli that I got introduced to ASCO and became such an important part of my life. He was a giant and will be sorely missed by all of us. And that's a perfect segue into my last question, which is changing gears completely, and that is your career at ASCO. Give us some ideas of what ASCO was like in the late 70s and how it has evolved-- principally, I mean, I know that's a whole hour long discussion, but I think you've had such a huge footprint in the society-- and what you saw changed, and the important changes. You know, ASCO was founded in 1964. There were no oncologists in 1964. There were doctors who were treating cancer-- some of them with surgery, some of them with radiation, some of them with these very early, highly toxic drugs. And so the society was formed. And it specifically says, when you read the early writings about this by the founders, that this was not a society of what they called chemotherapeutists. It was a society of physicians who wanted to treat cancer. They brought together all of the clinical specialties. I like to joke that the most interesting thing is that the medical oncologists forgot to found the American Society of Medical Oncology. They're the only specialty in medicine that doesn't have a specifically focused society just for them. They used ASCO, and to this day, it remains that way. And so I got involved. And the leaders of ASCO in the 70s and 80s and into the 90s, espousing how wonderful their multidisciplinary work was. And they used to have annual member meetings at the ASCO annual meeting. And the board would sit up on the dais, and the peanut gallery would ask questions. So I raised my hand, and I walked to the microphone, and I said, you know, it's great how you extol the multidisciplinary nature of the society. But I look at the dais, and I see the 12 members of the board of ASCO, and they're all medical oncologists. You are not practicing what you preach. And I sat down, and they mumbled a few things. And then the next thing I knew, darn it, they created board slots for a surgeon, a radiation oncologist, and a pediatric oncologist. And then they said, all right, big mouth, now that you held our feet to the fire, we're going to run you for the board. And I did get elected to the board, and then, eventually, got elected president. And then when they needed a CEO in 2006, they asked me if I was interested, and I interviewed for the job and then moved to Washington and then Alexandria and did that for 10 years. It was really-- you know, I say that I have been involved with two great organizations during my career-- the University of Michigan Medical School, and the American Society of Clinical Oncology. And to have the privilege of leading both of those organizations was just truly amazing. Well, there are many more things we could talk about, but for our listeners, you should know there's an Allen Lichter Visionary Leadership Award and Lectureship held at every annual meeting now. And for those of you who attend meetings at our headquarters in Alexandria, you'll notice you're sitting in the Allen S. Lichter conference center. Those weren't done by accident, by the way. They were done because of my guest today and all of the contributions he's made, not just oncology, frankly, but in my opinion, to medicine in general. As a dean, I know many of the things you've done, which we don't have time to get into. So on behalf of our listeners, and behalf of myself, and behalf of all the patients who have benefited through your work through the years, thanks so much, Allen. [INAUDIBLE] Dan, it was great being with you. Thanks for talking to me. Until next time, thank you for listening to this JCO's Cancer Stories-- The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts, or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories-- The Art of Oncology podcast is just one of ASCO's many podcasts. You can find all the shows at podcast.asco.org.

A medical team empowers a family to love fully by allowing them to feed their child. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Welcome to JCO's Cancer Stories: The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org. Alonzo was a 10-year-old boy with a recurrent refractory brain tumor whose disease progressed through multiple therapies over many years. When no additional cancer-directed options remained, Alonzo was admitted to the hospital for symptom management as he approached the end of his life. Although Alonzo was unresponsive and posturing, his family continued to hope desperately for a miracle. As they kept vigil around the bedside of his frail body, praying and waiting, they gradually began to notice, and then fixate on, how the sharp angle of his bones protruded more with each passing day. Alonzo's mother believed fervently that his body needed nutrition. She understood that Alonzo was dying, that modern medicine had failed to keep the cancer from ravaging his brain, yet, as a mother, she continued to feel a profound desire and duty to nourish her child. She couldn't bear the idea that he might be feeling hungry, while unable to ask for food. She felt that, if he were to die of starvation as opposed to cancer, she would have failed him as a mother. She also continued to pray for God to create a miracle to heal Alonzo, and she believed that a healthy, nourished body was essential to host this miracle. Each day, our medical team spent hours debating how best to partner with Alonzo's family to align his medical management with their deeply held goals and beliefs. We worried about the provision of enteral nutrition, as Alonzo's gut was impaired in the context of his disease progression, placing him at significant risk for aspiration. We discussed the sizable risks related to the placement of a nasogastric tube to initiate enteral feeds with the low likelihood of long-term benefit. His mother expressed understanding, yet her broken heart steered her to feed him soup in secrecy later that evening. Alonzo choked, turned blue, and developed respiratory distress. It took several days to restabilize him. His mother was traumatized and racked by guilt, and yet she continued to speak of nothing but his need for nourishment. Fearful of oral and gastric feeds, she turned her energy to the prospect of intravenous sustenance. She begged us to consider total parenteral nutrition. As the days passed, we gently explained how the acute risks of volume overload and hepatic dysfunction outweighed the negligible long-term benefits. She expressed understanding, but with tears brimming, she pleaded for us to find some way to give him something. Just a little fat, sugar, and protein. His brittle, translucent skin was breaking down at each bony protrusion, and she believed that even a small amount of nourishment might help to heal his festering wounds. By this time, our medical team was emotionally overwhelmed. Upon admission, Alonzo's prognosis was days to a week or two. By the eighth week, the inpatient team was incredulous and exhausted. We spent multiple hours each day at the bedside with Alonzo's mother, bearing witness to her grief, validating her wish to be a good parent, affirming her spiritual belief in the possibility of a divine miracle, reiterating the limitations of medical interventions, and sharing in her wish that Alonzo not suffer. Our medical team gathered to debrief. Oncologists, nurses, palliative care clinicians, nutritionists, chaplains. We all shared a common desire to partner with Alonzo's despairing family without causing undue harm to our frail, voiceless patient. We talked about Alonzo's mother's love, how she never left his side, her warm hands gently caressing his emaciated limbs. Our nutritionist wondered aloud, might there be a safe approach for the topical application of essential fatty acids? We called our pharmacy, and they had not previously dispensed topical oils to patients. We then turned to the literature, and found several citations that suggested possible benefits associated with the topical application of oil, with no evidence of inherent risk. One study suggested that topical administration of essential fatty acids might lessen the progression of pressure ulcers in individuals with poor nutritional status. A few published manuscripts theorized that the absorption of essential fatty acids through topical application was feasible, predicated on case reports and theories describing the reversal of essential fatty acid deficiencies with cutaneous application of the essential fat linoleic acid in pediatric patients ranging from neonates to adolescents. A randomized controlled trial looked at transcutaneous absorption of massaged oil in 120 newborns in a tertiary care neonatal intensive care unit, demonstrating a significant increase in serum essential fatty acid profiles in the cohort that received topical safflower oil, with no appreciable adverse effects. Yet, even more compelling than the potential to offer a gentle nutritional boost was the possibility of empowering Alonzo's family with a hands-on intervention that could manifest, both literally and figuratively, their love and desire to nourish him. In the context of his family's profound spiritual distress, we also wondered whether coupling two forms of love, nutrition and touch, might offer comfort to the caregivers suffering at his bedside. Prospective evaluation of a systematic intervention to promote physical contact between a caregiver and a seriously ill child in the pediatric intensive care unit has been shown to improve caregiver spiritual well-being. In partnering with his family, perhaps we could minister to their spiritual distress, as well. Our team also became encouraged by reading the growing body of data cataloging the benefits of therapeutic touch for infants and children. We learned that premature infants who receive massage at the bedside gain weight faster and discharge days earlier than those who do not receive therapeutic touch. Within pediatric oncology populations, evidence suggests that the provision of simple massage techniques, either by trained health care staff or by parents who receive training from staff, is feasible and effective for improving anxiety, sleep fatigue, and overall quality of life. Of note, in addition to positively affecting caregiver distress, therapeutic touch may also mitigate patients' suffering, as evidenced by reductions in analgesic administration. Emboldened by these data, and united by our shared mission to support this child and his family, our oncology team sprang into action. A team member drove to a local grocery store and purchased a bottle of safflower oil. A pharmacist officially answered the oil into our formulary for the bedside nurse to dispense. The inpatient team placed an order for one teaspoon of safflower oil gently massaged into the patient's skin by caregiver four times per day. At the bedside, our oncology and palliative care teams explained to Alonzo's family that the topical absorption of oil would not cause Alonzo to gain weight. We discussed transparently that, although a small amount of essential fatty acids would be absorbed, this was extremely unlikely to replete his nutritional stores or prolong his life. Through tears, his mother expressed understanding. A team member trained in pediatric massage demonstrated and taught his mother a series of simple, safe massage techniques to provide comfort at the bedside. We encouraged her to nourish Alonzo with her bare hands, to caress his arms and legs gently with the safflower oil. In synergy with the topical oil, we also started intravenous fluids with 5% dextrose at a few milliliters per hour, plus a tiny daily dose of 5% albumin. We shared frankly with the family that the small amounts of sugar and protein would not yield weight gain. However, the total amount of fluid was low, mitigating the risk of worsening secretions or pulmonary edema. With unified consensus, we gave Alonzo just a little fat, sugar, and protein, less so to nourish Alonzo's cachectic frame, and more to nourish the minds and hearts of those who surrounded his bedside with love. Alonzo's family expressed deep gratitude for these offerings of sustenance. The excruciating daily conversations, which previously had fixated on feeds with circular dialogue, evolved into forward-looking discussions about end of life, grief, and resilience. Alonzo's mother assumed primary responsibility for the application of the oil, creating a formality around the process that culminated in loving caresses and gentle massage. For a hands-on parent, this single intervention carried profound therapeutic power. It allowed his mother to fulfill her duty to feed her child, thereby affirming her desire to remain a good parent, even as she watched her child die. It empowered his family to provide tender, devoted touch as part of their loved one's care, thereby gifting a small sense of control and contribution in the respective faces of perceived powerlessness and uselessness. It eased his mother's spiritual distress, as she felt successful in her advocacy to nurture Alonzo's corporeal host, as she prayed for a divine miracle. It created a deep therapeutic alliance between the medical team and the family that felt heard and honored, thereby smoothing the path for future difficult discussions as imminent end of life approached. And it eased the distress experienced by a clinical team that felt helpless in the face of extreme caregiver suffering, ultimately bringing us together through a unified mission to honor the family's goals while providing high-quality and holistic medical care. 24 days after we offered nourishment, Alonzo died, peacefully, surrounded by his loving family, his frail body gleaming with soft swirls of oil. His mother cried, holding his hand, her face pressed against his. When she lifted her eyes, tears falling, she reached for our hands. "Thank you for listening. Thank you for sustaining us." Hippocrates, revered father of medicine, allegedly said, "let food be thy medicine, and medicine be thy food." Just as we administered medications to ease Alonzo's physical suffering as his disease progressed, so did we offer nourishment. And for his family, just a little fat, sugar, and protein was the medicine that yielded the most profound comfort. As our team debriefed this difficult case, we grasped a salient truth-- to nourish is to love. By allowing his family to feed their child, we empowered them to love fully. Alonzo's story helped our team to realize that addressing nutrition at the end of life is paramount. We have a responsibility to be proactive in discussing nourishment when a patient is dying so as to better support families who feel helpless to nurture their loved ones. We acknowledge that traditional approaches for nutritional support through enteral nasogastric feeds or total parenteral nutrition are not inherently inappropriate for patients who are at the end of life. Our team believes that it is essential to avoid drawing arbitrary lines in the sand that automatically negate the use of low-volume nasogastric feeds or total parenteral nutrition. Rather, we advocate for the consideration of nutritional interventions on a case-by-case basis, weighing the risks and benefits for each unique patient and family. In this case, the clinical team believed that even small volumes of nasogastric feeds and total parenteral nutrition carried significant risk for incurring harm, without hope for benefit. Initiation of topical essential fatty acids, in synergy with low-volume intravenous dextrose and albumin, however, brought Alonzo's family substantial comfort, with no evidence of harm incurred. Since the culmination of this difficult case, our team has offered the option of administration of topical essential fatty acids and massage training to multiple other families who expressed a desire to nourish their children in the context of approaching end of life. For each family, this simple, non-invasive intervention has provided comfort, without appreciable detrimental sequelae. We believe that the interdisciplinary team should explore the nutritional values and goals of every family at the bedside of a dying patient, and all caregivers who express distress or uncertainty should be given an opportunity to learn about topical essential fatty acids and nurturing touch as comforting options. In the context of families perceived to be difficult, clinicians often worry that offering any intervention will result in a slippery slope of demands for additional escalation of care. In our experience, however, we have observed the opposite. These simple and relatively benign interventions lessen tension, facilitate trust and partnership, and create space for dialogue about other goals as death approaches. Cost and accessibility are also important considerations. Compared with enteral or parenteral fats, the price for topical oil is negligible, and options are available at most local grocery stores. Practically, our team typically offers safflower oil, which contains 60% to 70% linoleic acid and has shown potential for topical absorptive qualities. On the basis of prior studied regimens, we recommend the administration of 5 mL topically to extremities through light, gentle massage four times per day, as desired by family. However, sunflower, sesame, soybean, and corn oil each contain linoleic acid, and might be used interchangeably, depending on which oils are most readily available. Among our team and with our families, we acknowledge that topical essential fatty acids and a trickle of dextrose and albumin provide negligible nutritional content if one's metric for efficacy centers on weight gain or repletion of nutritive stores. However, we also recognize that, in these difficult cases, the sum, nourishment, can be so much greater than its individual parts-- a little bit of fat, sugar, and protein. Beyond the concrete value of food, we saw the power of nourishment to support families by gifting them an invaluable sense of control within a situation that is otherwise uncontrollable. Within the quintessentially human belief that food is love, we discovered a unique opportunity to offer a family in crisis a few concrete tools with which to honor and affirm their roles and responsibilities as primary caretakers and good parents. By listening and aligning our medical management with the values and goals most important to the family, we identified a path to build trust, ease regret, and accompany them along the painful anticipatory grief journey. Through this partnership, we found a way to alleviate stress for both the family and clinical staff. Of importance, we also discovered an intervention that bridged multiple medical disciplines, bringing unity and collaboration as sustenance for clinicians practicing each day within a poignant space. When Alonzo's mother carefully reported the safflower oil into her hands, she did so with reverence, determination, and purpose. When she laid her palms on his broken skin, she brought together nutrition, touch, and love in a single, simple, therapeutic intervention. Empowered with the knowledge that she held in her own hands, the ability to provide comfort, she nourished her child and herself, and by doing so, she sustained us all. Welcome to Cancer Stories: The Art of Oncology narrative series. I'm Lidia Schapira your host. And with me today is Dr. Erica Kaye, a pediatric oncologist and hospice and palliative medicine physician and researcher at St. Jude Children's Research Hospital. Welcome, Erica. Thank you so much for having me today. It's great to have you, and love to chat with you about this new piece that you just published in Art of Oncology, which addresses the need to provide nourishment to children who are sort of in the ultimate phases of their illness. Tell us a little bit about the inspiration for this piece. Thank you. So this piece was inspired by a real-life patient for whom our pediatric oncology and hospice and palliative medicine team had the privilege of caring. He was hospitalized at the end of his life, and died very slowly over the course of multiple weeks in our inpatient unit. And during that process, his family struggled profoundly with their inability to feed him. And we began to think quite a bit about what it means to nourish a child, and how nourishment takes many forms, not just corporeal, and not simply food going into the mouth and through the gut, but the many ways that parents love and support and nourish their child and themselves spiritually and emotionally, and the ways in which teams are deeply affected by parents as they struggle in that space. And so we decided to share the lessons that we learned from this complicated and very difficult case at the end of life, and how we found beautiful compromises to help promote the importance and value of nourishing a child even throughout the dying process, what that looked like and what they taught us. In the essay and now, you just talked about the effect this has on the team. In the essay, you mentioned that you all thought this child would die, and then by the eighth week, you say the medical team was both incredulous and exhausted. And it sounds like you needed to find sort of a creative or resourceful way of sort of opening up and aligning again with the family, and that you did this by listening to what the mother was saying, was asking, and by giving her the opportunity to give the child a little fat, and then you provided the sugar and protein. Tell us a little bit about that nourishment, and that idea of sort of the gifts that were exchanged from your team to the family, and then the family back to the team. Thank you. That's such a thoughtful question. And this family, and in particular the child's mama, struggled very deeply with her inability to feed her child as she sat minute by minute at the bedside watching the child slowly die. And I think, in the sort of paradigm of a good parents narrative, how we internalize our role as, quote unquote, "good parents," to a certain degree, the concept of food as love is quite integral to that good parent narrative. And although she fully understood, from a medical standpoint, why giving enteral or parenteral nutrition would likely cause more harm than benefit to her child, the inability to give him fat and sugar and protein created tremendous existential, emotional, and spiritual distress for her. And as we listened and validated and affirmed her wishes and goals and fears, we, as an interdisciplinary team, began to try to think creatively about how we could honor the needs that she had to fulfill her role as a good parent, while also not introducing undue harm or suffering to the patient. And through some research and creativity and exploration of limited existing literature, we decided to empirically trial teaching compassionate touch through gentle massage in conjunction with the application of topical essential fatty acids. And our thought process was that not only could we create a space for his family to offer a small amount of nutrition, the fat that was so important to them, but we could couple that with empowering them to be that good parent, that caregiver at the bedside, participating in the offering of not only sustenance through fat, but sustenance through touch and through love. I think what was most profound as we partnered with the family in this process was seeing their palpable relief, and how much their trust in the team grew through this experience. And the therapeutic alliance that was engendered through these simple offerings was very meaningful and profound, and I think created a remarkable positive feedback cycle. The more they trusted us, the more they listened to our recommendations. And I think it's really important to note that, often, we on the medical side fear a slippery slope hypothesis, that the more we offer, the more the family will ask for. And that has not been our clinical experience. I think when we listen carefully and thoughtfully, with an eye towards partnering genuinely and authentically with families, it does not create unreasonable requests for more. And I think it instead creates trust and love and support bidirectionally. And that was a very meaningful lesson, I think, that our clinical team learned. Yes, and to the reader, Erica, it comes across as the suffering of caregivers, both the professional caregivers, the members of your team, and the family caregivers, the informal caregivers, it was reduced in sync. So what helped the family also helped the team. And there's something very beautiful on an existential level of thinking about that, sort of the power of connecting. You connected with each other, and then with the child. And then, as a reader, what is really impactful is that the child is slowly dying for these eight weeks that feel so exhausting, and then, within 24 hours of relieving this caregiver distress, it's as if everybody can let go and the child dies. Did your team have a chance to think about that? Absolutely. So quick point to clarify, I'd say within hours of beginning the interventions, there was palpable relief at the bedside, and all the conversations evolved in an organic and very meaningful way. The child actually lived another 24 days after initiation of those interventions, which, on some level, was an ongoing difficulty for both the family and the staff because a prolonged dying process is very emotional. But on many levels, those 24 days were such a gift to the family and the staff. There was an opportunity for intentional and thoughtful legacy-building and memory-making, and there was provision of a significant amount of psychosocial supports throughout that process. And I think because we were able to relieve the stress intrinsic to feeling powerless and unable to nurture the child, we were able to focus instead on meaning making, in all of its many, varied forms. And I think that was incredibly useful, not just for family, but for the staff to see and participate in. So wearing your research hat now, if you're looking at this and think about ways of studying it, I have a couple of questions. One is, is your team studying it? And the other is why you chose to tell this story as a story to this readership, in order to perhaps help to start a dialogue or-- you know, what were you thinking? Why present it as a story? Thank you. Those are both incredibly important questions and considerations. The former I think is very interesting. I have been reticent to design a research study to the gold standard that I think is deserving for answering important and unknown research questions, in the sense that I believe strongly in the meaning making inherent to this offering and am quite reluctant. I feel like it is borderline ethically fraught to withhold the opportunity to consider this intervention. I think it's really important to talk about nutrition and nourishment on many levels with the families of all children at the end of life. And so I feel quite conflicted about the idea of offering this intervention to some and withholding it from others. And think it's a very deeply personal decision, what feels meaningful to a family and what doesn't, and would like to empower families to make the choices that most align with their goals and their belief systems. That said, I think it would be very interesting to try to study the value added by this intervention, even if retroactively, through interviews and focus groups with families whose children have died, and ask them, you know, what conversations around nutrition, if any, were had? What was meaningful to you? What do you wish had been discussed? What are your thoughts about this type of intervention? Might it have been helpful to you, or if this or a similar intervention were offered, what was helpful and why? And so that's something that I have been thinking about, and that we will likely be moving towards in the future. To respond to your latter question, I am quite biased as a personal believer in narrative medicine. I think that the narrative, the patient's story holds such tremendous power, not only in allowing for self-catharsis and self-reflection, but also in the transference of meaningful lessons learned and in advocacy, in helping to empower others to learn and teach and move the needle at their respective institutions. And so we were quite intentional about our decision to share the lessons that we learned through the lens of the stories that impacted us. And in this particular case, the one patient who really got us thinking deeply about this issue. I think there's a lot of emotional valence intrinsic to the sharing of a true story, and that emotional valence allows us to connect with and remember lessons learned in ways that, often, objective didactic does not. And so I believe that this format is very meaningful for all of those reasons, and I also think that it reaches a wide and diverse target audience of readers within the field of oncology, all of whom may interpret and synthesize this information in unique and personal ways, and then, I hope, take it with them to share with their colleagues and to help inform the clinical experiences that they go on to have in the future. Well, Erica, that has been so enlightening. I look forward to reading some of that qualitative research that you'll probably do by interviewing families. I love the idea that there's an almost sacred aspect of the experience that perhaps we should always strive to improve, but shouldn't tinker with. And one of those has to do with the expression of that incredible emotional connection between a parent and a dying child. And so we should definitely support it in any way we can. And then how we can strengthen our own community of thoughtful oncologists to be creative, to be resourceful when they are faced with a situation that, at some level, may almost appear to be a conflict, but if you sort of peel back all the layers through narrative, through listening, you actually can find that you can align with the family around a common goal. And that makes everybody better, and certainly relieves caregiver distress, in addition to family suffering. So thank you so much for your beautiful writing, for your advocacy, and for sharing it with the readers of Art of Oncology. Thank you so much. It is an honor to be able to share these stories and, in doing so, honor the patients and families for whom we care. Thank you. Thank you so much. Until next time, thank you for listening to this JCO's Cancer Stories: The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories: The Art of Oncology podcast is just one of ASCO's many podcasts. You can find all of the shows at podcast.asco.org.

Dr. Hayes interviews Dr. Canellos on his involvement with CHOP, MOPP and CMF as well as his role as Chief of Division of Med Onc at SFCI/DFCI for 25 years. Dr. Daniel F. Hayes is the Stuart B. Padnos Professor of Breast Cancer Research at the University of Michigan Rogel Cancer Center. Dr. Hayes' research interests are in the field of experimental therapeutics and cancer biomarkers, especially in breast cancer. He has served as chair of the SWOG Breast Cancer Translational Medicine Committee, and he was an inaugural member and chaired the American Society of Clinical Oncology (ASCO) Tumor Marker Guidelines Committee. Dr. Hayes served on the ASCO Board of Directors, and served a 3 year term as President of ASCO from 2016-2018. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Welcome to JCO's Cancer Stories, The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org. Hello. Today my guest on the podcast is Dr. George Canellos. Dr. Canellos was instrumental in early treatments for breast cancer, lymphomas, -- and chronic leukemias, and he's generally considered one of the so-called Gang of Five with the National Cancer Institute in the 1970s, along with Drs. Vince DeVita, Robert Young, Bruce Chabner, and Philip Schein, who ultimately demonstrated that chemotherapy could be used to cure a fraction of patients with Hodgkin's and non-Hodgkin's lymphomas. Dr. Canellos was raised in Boston, and he attended Boston Latin School. He then received his undergraduate degree at Harvard and his medical degree at Columbia in New York City. But he remained a Red Sox fan, so he returned to Boston for his residency in internal medicine at Massachusetts General Hospital. But he then trained in oncology at the National Cancer Institute where he stayed until 1974 when he once again returned to Boston to join the faculty of the then Sidney Farber Cancer Institute where he served as the Chief of Medical Oncology until 1995. He is currently the William Rosenberg Chair at Medicine at the now Dana Farber Cancer Institute and a Professor of Medicine at Harvard Medical School. Dr. Canellos has authored over 300 peer-reviewed papers and too many reviews and chapters to name. Most importantly, he served as the Second Editor in Chief of the Journal of Clinical Oncology, a role he filled from 1987 until 2001. And during that time, he directed the Journal to become the leading journal in our field. Perhaps even more importantly, he served as ASCO President in 1993 and 1994, and he's been recognized as an ASCO Oncology Luminary, and he's been recognized with the Statesman Award and the Distinguished Service Award for Scientific Achievement from our society. Dr. Canellos, welcome to our program. Good to talk to you. Great to talk to you. You know, I spent a lot of time with you at the Sidney Farber and then Dana Farber Cancer Institute, and I've heard you say, and I've also read, that you originally seriously considered becoming a surgeon because of the work you did with Dr. Oliver Cope, one of the leaders in surgery of our last century and especially related to thyroid and other cancers. So what led you to get away from surgery and become a medical oncologist? Well, I served as a surgical intern at Mass General at that time, which was a lot of exposure to serious illness and surgery. But it dawned on me. Two things dawned on me. One is that if one was interested at all in malignancy that surgery really wasn't the answer, certainly, in any way. And in those days, of course, even radiotherapy was not the answer. And so the other thing I realized, that I had the manual dexterity of a California fur seal. I didn't really feel, being left-handed, I didn't feel that I really had the dexterity required to do some of the complicated surgery that was going on in those days because I held retractors as an intern for some very long operations that really didn't achieve more than taking out a gallbladder. It took three hours. Now, we can do it with a laparoscope in a half an hour, probably. So I switched into medicine at Mass General and stayed in medicine at Mass General. And being inspired to really think about other treatments for malignancy in those days, there were very few really textbooks available that talked about chemo. There was some. I would nip up to the library of the hospital rarely and try to read about them. There were new drugs coming out at that time, but there was very little really known about the action of the drugs and the potential of the drugs that might have existed at that time. Then I went to NCI, as one had to because there was a doctor draft. And two years of residency in medicine, I actually went to the medicine branch of the NCI. And there, under Emil Frei III, another investigator named Freireich, Jay Freireich, who were around at that time and running the program, such as it was, we first were experience-- I was thinking that I would do research there, and I did. But at the same time, the Clinical Associate Program entailed a year of clinical exposure, of clinical care, and I had several colleagues. The first major colleague was Vincent DeVita who really, at that time, decided to approach a treatable more solid malignancy, as acute leukemia of childhood was being approached, with combination chemotherapy. However, there weren't many drugs that were very active at that time. There were some. An alkylating agent, nitrogen mustard, steroids, a vinca alkaloid that had just been relatively new introduced for adult disease. And there was no procarbazine. Of course, it hadn't been invented yet, but methotrexate. And so the first combination regimen that came out of that program was MOMP, M-O-M-P, and that had some activity, but it was only given for a relatively short period of time. Eventually, the tolerance of patients to these drugs was considerable, a considerable issue, because we didn't really have granulocyte support. There were a lot of things that we'd take for granted now that were not available then. So the toxicity of some of these programs, such as the M-O-P-P Program when procarbazine came along, the MOPP program was considerable. But the interesting thing is the patients that we had were generally on the younger side, younger than 45, let's say, and they could tolerate the therapy. And I found that, honestly and subsequently, with testes cancer, that younger people who get a lot of toxicity from these drugs, despite that, if they think there may be a cure around the corner, will tolerate it. And you don't hear a great deal of complaints about it, about the toxicity, interestingly. But the older patients, of course, are far more vulnerable. Their bone marrow reserve not being great, these regimens were quite toxic. But, fortunately, the first targeted disease was Hodgkin's disease, and it's generally a disease confined to younger people, in general. About 20% of them are in the older group. But we first tested the aggressive chemotherapy, known as MOPP, in the younger patients, actually. But what was surprising to us, and surprising to everybody, was the fact that they failed to relapse as they were all expected to do at that time. In the single drug agent era, of course, Hodgkin's disease would relapse eventually. As house officers, we just expected that to happen. Now, the training in the major academic hospitals in those days, oncology was not an important part, or even a desired part, of the program, if you will. And so most who arrived at a place like NIH really didn't have much background at all in the treatment of cancer because they probably didn't see it all that much. I know I didn't. As a surgeon, yes, but not as internal medicine. I was going to ask you that. When you were at Mass General and you said you noticed that surgery wasn't curing people, there couldn't have been anybody around that was mentoring you or said, why don't you-- how did you even hear about-- No, no, there wasn't. There were some docs there who really cut their teeth on giving hormones to breast cancer patients, and that was about it. But very few people were giving-- I couldn't think of anybody who was giving-- one person who was giving chemotherapy, a lady, a fine lady, fine physician actually, but on the private side, but nobody on the academic side that amounted-- So what made you-- What made you say, I'm going to go to the NCI and learn how to do this? I mean, that seems like that was completely out of the blue. Well, you weren't given much choice. Of the two institutes, I applied at the Heart Institute and the Cancer Institute. The Cancer Institute accepted me, and the same with Vince DeVita. He applied to the Heart Institute but got into the Cancer Institute. And we were both there, probably you could say, as our second choice at the time. Because-- Yeah, that's interesting. Yeah. Very little was known about oncology as a field, and there we were. On the other hand, seeing these patients at least respond to these drugs in the way they did, and seemingly not relapsing, made you wonder whether or not, in time-- when I went back to the NIH, I came back to the MGH to be a senior medical resident. I can tell you what was interesting, because there was no oncology Fellow, per se. They would ask me to see a patient if the patient had a malignancy. And I remember going in and seeing a patient with ovarian cancer. She had a huge belly full of ascites, malignant ascites, and I said that the drug for this disease is thiotepa, an alkylating agent. I wrote out the recipe, if you will, how many milligrams, et cetera. And I wrote in the note, and I will give the first dose, which I did. The intern covering the service, a surgical intern covering the GYN service, obviously read part of my note but not all of it, or decided he was going to give another dose as well, but somehow the woman was double-dosed. And there was a certain panic by the nursing staff, et cetera. She tolerated the drug surprisingly well. But more surprising, everything went away. She had this dramatic response to therapy. The ascites went away. The abdominal masses went away. And she was discharged. And I said to myself, at that time, this is a precedent for something, and that era will arrive once-- if it's not the right drug, we'll find the right drug for the disease. But I can tell you, it was very uplifting to me. I had already been to NIH. That's a great story. When you guys were at the NCI, a similar question is, when did the light bulb come on that it looked like you were actually curing Hodgkin's disease? Well, you're talking about a two-year appointment. At the end of the two years there, the remissions were already clear. That is to say, the disease had not come back, and the people were being followed. But two years is just two years. I mean, it's not a long time. And when I went back on the faculty-- see, I went for a year in England to become a hematologist because everybody had to be a hematologist in those days if you were interested in cancer. Anyway, that's what I did. And when I got back, they recruited me to the faculty, and the patients were still in remission, and that was great. And then we put our attention to the non-Hodgkin's lymphomas and modified the MOP regimen by putting cyclophosphamide instead of nitrogen mustard, which was a horrific drug by the way, nitrogen mustard in the doses that we gave. But like it or not, we put Cytoxan into it and we called it CMOP. It was like MOP but it was with C instead of the M. So we called it CMOP. And early in the 1970s, we did a randomized trial with the radiotherapists who were throwing radiation at everything that walked in with a non-Hodgkin's lymphomas, and we did a prospective randomized trial stage by stage, histology by histology. And I remember looking at the data for the large cell lymphomas with the CMOP and I said, Vince, you know, if we judged everything by median, the median survival of our patients was what you'd expect historically. But just below the median, the line straightened up, flattened out, and was going out now several years, at least four or five years, flat in a disease that usually recurred very quickly and killed everybody who was affected by it. And I remember when the Board of Internal Medicine decided to create a specialty called Medical Oncology and have an exam, et cetera, Vince thought it was because of Hodgkin's. And I'm sure it contributed, but I said it must be also the non-Hodgkin's because it's far more common. It's far more common. We helped far more people. And indeed, it probably is. Can I interrupt you for a moment? I interviewed Saul Rosenberg for this series, and he told me just [INAUDIBLE] the radiation psychologist. So Dr. Kaplan had referred to him from Memorial to come to Stanford and do radiation, and Dr. Rosenberg told Dr. Kaplan, I think we need to give these people chemotherapy, and Kaplan agree. But the Chair of Medicine did not and would not let Rosenberg see patients in his own clinic and give chemotherapy. So he wrangled a room from a hematologist, and he told me he would see patients in the room. He had a chair in the hallway. If the patient needed chemotherapy, he'd have the patient go sit in the chair in the hallway. Get an IV pole. He'd start the IV himself and then mix up the chemotherapy himself, hang it up. While the patient was getting chemotherapy in the hallway, he'd see the next patient in the room. Those are the kinds of obstacles he had to do. And the other thing I have to say, I didn't get to interview Dr. Holland before he passed away, but relative to your looking at the Kaplan-Meier curves, I'll never forget his yelling at me one time that, if you need a statistician to see what you've done, you probably haven't done much. I said that, 'cause I remember saying that as well, but anyway. Let me ask you another question. Yeah. You're know for lymphoma and chronic leukemias but also for breast cancer, and generally you're credited for coming up with the so-called CMF regimen. Vince and I were called into the director's office. At that time, the director of NCI was [INAUDIBLE]. And they said, all this lymphoma stuff is wonderful, but we want you to do solids. Now, we didn't have a referral pattern for solids at all. The only breast patients we saw were relatives of employees of the NCI. So Vince wanted to do ovarian, and I said ovarian is a good disease because they have malignant cells floating around, and we can do stuff on those. And Vince really wanted to do ovarian. I chose breast. And, again, we had no mastectomy surgical group or anything. And so what we did was make deals with medical oncologists in the community, two of them who actually trained-- one of them trained at the Brigham Hospital, actually, and they lived in the area. And they liked to come to our conferences and things. They would refer patients. And what we specified, initially, was that we have patients without isolated bone lesions only, that they had to have measurable lumpy, bumpy disease. And so to design a therapeutic treatment for them, we had to use the principles that we learned from the lymphoma experience. And that's where CMF came. CMFP, we used to have prednisone in some circumstance. And so that was the regimen that-- if you notice, the design of it would be like the MOP program. Anyway, so we started treating people like that. Suddenly, they did respond and some responded quite well. They had some toxicity, of course. And the very first paper we wrote was on the toxicity of CMFP. It was hard to get things published in medical oncology areas, and the Lancet was wonderful for us. The Lancet was very helpful, and we published a lot of stuff in the Lancet. But the first one was in the British Medical Journal, the toxicity of CMF program in patients, and we especially cautioned patients who had compromised liver function because they seemed to get worse toxicity at that time in our imagination. But it worked. It did work. We published it in the Annals of Internal Medicine eventually. But the important thing was, our friend Johnny Bonadonna would come over periodically to find out what we were doing. And he came over with an offer. He said he had all these patients who would get mastectomies and then nothing. Let me interrupt you for a moment 'cause I was going to ask you about Dr. Bonadonna. Yeah. Would you, just for the audience, a lot of them may not know who he is. Oh. Well, Johnny Bona-- Do you want me to describe him? Well, at that time, he was a young investigator working in Milan at the major hospital there in oncology, and he trained at Memorial before and then went but back to Italy. So he came and he wanted to know what we were doing. We showed him the protocol that we were doing for breast, and he was interested. And what he offered was the opportunity of doing a randomized trial on patients with a higher risk, if you will, breast cancer, node-positive patients. And he said that in Italy that nothing was done for them and that he could randomize them nothing to chemotherapy, and we offered him a contract. He required money. We gave him a contract. We gave him our protocol, at least the chemotherapy protocol. He went back to Italy and did that trial. And he left the prednisone out. He made sure it was of just CMF. And the patients, apparently, I guess, knew what they were getting, but I don't know whether they had strict requirements or informed consent and things like that. We didn't ask. We didn't ask. All we wanted was randomized data, and he certainly had it. And I remember being at the ASCO meeting in 1976, I think it was, '75 or '76, in Toronto when the first data was presented by Bonadonna. And the media people were there. People were barely hanging from the rafters to hear. The room wasn't big enough, really. None of the rooms were big enough because they never expected the attendance, that there were that many young oncologists around or people interested in oncology. And so he gave that first data, and that was a shot in the arm for adjuvant therapy, certainly for breast cancer, but for other things as well. I think, in general, he and Dr. Fisher, who sadly passed away before I had a chance to interview him, are responsible for thousands and thousands of people. Yeah. Absolutely. Absolutely. Absolutely. But I'm giving you the NCI side, my personal side of it, and you're right. Bernie was a real pioneer because he had so much opposition from the surgical establishment at the time. I can tell you that. From a surgeon's point of view, they really thought he was the Antichrist. I mean, it was terrible. I saw him and Jerry Urban get into a verbal argument at a meeting. I thought it was going to be a fistfight, actually, over-- Really? Yes, yes. Yes, they're severe. But anyway, let me go-- let me go to my next question, which has tended to change gears for a moment. You may or may not remember this, but when you were ASCO President, in your presidential address, I was in the audience and you said something to the effect that the greatest clinical experiment you have conducted are the Fellows you have trained, or something like that. Yes. Yeah. And I was in tears, of course. But you certainly can claim success on that. The division chiefs, department chairs, cancer center directors, most recently a Nobel Laureate, [INAUDIBLE], all of them came out of the program. But when you returned to Boston, you could not have envisioned all of this. What was the atmosphere, and what was Dr. Farber's vision? Well, Dr. Farber had died by the time I got there. Oh, he was already gone? OK. He was already gone. And when I was leaving, when Tom Frei recruited me, Vince thought I was mad because they made me Clinical Director. At least have a go at acting job as clinical director of the NCI. But really, down the line, it was a bureaucratic evolution. And I said, I don't really want to be an oncocrat at this age, anyway. What I said was, Vince, I said, the doctor draft is over. The best and the brightest and the youngest and the cheapest are all going to be in these hospitals, and there are a lot of them in Boston because I happen to know Boston, including house staff at the Brigham, house staff at the BI and Mass General. And I said, that's the future, or at least the future challenge. And I think he accepted it, but he didn't like it. I mean, he thought-- well, we were great buddies and we worked well together, and that goes for Bob Young and Bruce Chabner too. They thought I was very-- Where else-- at that time, there must have only been two or three places to train in oncology in the whole country, I would imagine. Yes, yes, yes. And people were just starting to set up cancer centers, sometimes without funding. And then there were all these, not many, but job requests for me to go and look at the job at Wisconsin or you name it, but I didn't want to do that. I really wanted to do medical oncology and not be a bureaucrat in any way. And many of the places, Dan, would say come and be a head of our cancer program, and it was also translated in parentheses, come and write a CORE grant. A lot of places who didn't deserve a CORE grant were asking me for people to come and write a CORE grant. You knew forever they would never get one because they really didn't have the makeup for it, yet. So what were the hurdles in Boston when you got there? Well, the hurdles in Boston were twofold. One is the fact that oncology had a very slow start in Boston, and that goes at the Brigham and at the MGH. The MGH was even disinterested in oncology at that time, actively disinterested. They didn't think it had any academic merit and therefore didn't put any effort into it. I have to say that Gene Braunwald, who was Chief of Medicine at the Brigham at the time, was interested because he had been at NIH at the Heart Institute, he knew Tom Frei, and he wasn't sure about it yet because he couldn't swallow it, I guess. And the fact was that it was growing a bit, and one of his very close associates developed large cell lymphoma and he got chemotherapy, he got to see MOP. And he was long-term remission. And I remember telling Braunwald, he was shocked that it was so successful. And I kept telling him, I said, this is not a rare event. This is happening. But the big challenge, Dan, at Dana Farber was that there was no oncology known, and we had to build the program from the bottom up. We hospitalized our patients at the Brigham before we opened the beds at the Dana Farber, but we needed the volume of patients. And we had all these beds, I think 59 beds, licensed beds, open. And I kept saying, we don't have the patients. But Tom Frei opened the beds. The next thing you know, I was talking to trustees because Tom said, we'll bring George up and we'll grow. The clinical program will grow. So the trustees thought the program would probably grow the next day. It didn't. It took a lot of effort without the [? scare ?] and myself going around giving talks in every little hospital that existed. And one of the big things I had my mind, because the house staff looked after our patients as well, was to show them what we could do. Now, in those days, other than the large cell lymphomas, of which we did not have many because they were in the hands of hematologists, was testes cancer. And the head of urology at the Brigham Hospital used to have these Saturday morning urology rounds inviting all of the practicing urologists around to come and they'd present their problem cases, et cetera. But he asked me to come along and give a talk about this new drug called cisplatin, which was having a big effect in testes cancer in other places. And I did. And I would come and talk about the early results in other places in testes cancer and that we were interested in actually starting a program. Then, they would-- of course, urologists are anything but chemotherapists, and so they would refer the patients in because, A, they couldn't give any chemotherapy. There was nothing oral that would work. What we would do is, if they sent patients in, we would do an early trial and we would publish the series in a, let's say, not spectacular journal and get reprints. We would send them reprints. And in some instances, I put the name of the referring doctor, if he'd sent us more than one patient, on the paper for, let's say, testing some antineoplastic thing. And we would put their names on the papers and send them reprints. And there's nothing a urologist loves more than to see his name on a scientific paper, a medical paper. And we started getting a ton of testes cases eventually and did trials and wrote papers about them. And I remember, when we recruited Phil Kantoff, a Fellow of mine, and I thought he was going to go back to the NIH and do gene therapy. And he walked in one day and he said, I'd like to apply for the GU job, and I said, it's yours. And he wrote quite a few papers based on the accumulated testicular data and the [INAUDIBLE]. Oh yeah. Yeah. And he was wonderful. He's Chief of Medicine now at Memorial. He's Chief of Medicine at Memorial, yes. I want to bring up one more thing that this segues into, though, and I believe now almost every medical oncologist who has trained in the last 10 years thinks that multispecialty tumor boards have always existed. But I believe that another of your trainees, Dr. Craig Henderson, who was my mentor, frankly, and you really started the first multispecialty clinic perhaps in all of oncology in this country. Do you agree with that? We called it the BEC, the Breast Evaluation Center. Yes, and we got cooperation but from surgeons. There were surgeons around, more nihilistic surgeons, if you will, not wanting to do radical surgery and radiotherapists, like Sam Hillman. And they were all around and doing those things. And we brought them into this BEC, the Breast Evaluation Center, and your mentor, Craig, was a little rough on the Fellows, I can tell you, in those days. Just his demands. Anyway, whatever it was. And so I would go to that clinic as well and see breast patients just to calm things down a bit at times. Anyway, it worked. And I know that the breast people elsewhere were recognizing that Craig had a nice thing going there with the multidisciplinary aspects. You know, it was so awful that breast cancer was treated so badly. I mean, they'd have a radical operation. And God knows, if there was some disease, that they would then get radical radiotherapy to their chest. And they were walking around sort of mutilated. And we had a part-time psychiatrist when I first arrived to see these patients because many of them had body image problems. So the idea of not doing radical mastectomy was revolutionary at that time. And I remember being called by the local Blue Cross to serve on a committee to decide whether or not Blue Cross should pay for breast reconstruction on these poor patients, and we voted. There was a committee of medical oncologists from MGH, me, and a plastic surgeon, and we voted 3 to 3 to they should pay, and they didn't. Then they said, thank you for serving on this advisory committee, but we're not paying. We've decided not to pay. Then, I can tell you, a women's agitation group got a hold of the facts. And one of them called me up and she said, I heard you were on this committee that voted not to pay. And I said, absolutely we voted to pay. They told us, thanks very much but we're not going to pay. So within two weeks then the insurance company changed its opinion because they went bananas at the insurance company. Yeah. The strength of advocacy, that's been something. Anyway, we're running out of time. I'd like to thank you for taking your time with us. Not at all, Dan. Not at all. It's a pleasure. And as I have done for every other interview in this series, I want to thank you not just for taking time with us but for all you've done for the field, for those of us who trained with you or are in the field, and most importantly for all the patients who have benefited. You look back over the-- Yeah, I know. I still follow them. My clinic has follow-ups of cured patients. You become the primary care doc for cured patients. Well, you think of the 60 years of your career and other fine folks that you were with at the NCI and then beyond, and the thousands or millions of people who have benefited, it's pretty remarkable. Yeah, well. Thanks again. I appreciate you being on. Not at all. And enjoy the rest of the day. Thank you very much, Dan. Until next time, thank you for listening to this JCO's Cancer Stories, The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories, The Art of Oncology podcast is just one of ASCO's many podcasts. You can find all the shows at podcast.asco.org.

Dr. Hayes interviews Dr. Mayer on his training at NCI and running DFCI's fellowship. Dr. Daniel F. Hayes is the Stuart B. Padnos Professor of Breast Cancer Research at the University of Michigan Rogel Cancer Center. Dr. Hayes' research interests are in the field of experimental therapeutics and cancer biomarkers, especially in breast cancer. He has served as chair of the SWOG Breast Cancer Translational Medicine Committee, and he was an inaugural member and chaired the American Society of Clinical Oncology (ASCO) Tumor Marker Guidelines Committee. Dr. Hayes served on the ASCO Board of Directors, and served a 3 year term as President of ASCO from 2016-2018. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Welcome to JCO's Cancer Stories-- The Art of Oncology, brought to you by the ASCO podcast network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the role of cancer care. You can find all of these shows, including this one, at podcast.asco.org. Today, my guest on this podcast is Dr. Robert J. Mayer. Dr. Mayer is the Stephen B. Kay Family Professor of Medicine at Harvard Medical School where he is also the Faculty Associate Dean of Admissions, in addition, the faculty Vice President for Academic Affairs for Medical Oncology at the Dana-Farber Cancer Institute. Dr. Mayer was raised in Jamaica, New York. And, Bob, I always thought you were raised in Brooklyn, but I looked it up on the map. And it looks like Jamaica is about two blocks in the middle of Brooklyn. So we'll say you're from Jamaica. Actually, I was a little bit to the east of there in Nassau County. That counted a lot then, Queens versus Nassau, but anyway. So it gets even more esoteric. Bob received his undergraduate degree in 1965 from Williams College, which is way out west in Massachusetts, and then went to Harvard where he got his MD in 1969. He did his residency in internal medicine at Mount Sinai in New York City and then was a clinical associate in the medicine branch of the National Cancer Institute from 1971 to 1974. He served a fellowship in medical oncology at what was then the Sidney Farber Cancer Institute. And then he joined the faculty in 1975. He has spent much of his career at leading clinical research in leukemia and GI malignancies. He was the chair of the CALGB, now called the Alliance TI Cancer Committee for years. But, perhaps more importantly, he was director of the fellowship program at, originally, the Sidney Farber and then the Dana-Farber Cancer Institute for 36 years. And then he was also head of the fellowship program at the Dana-Farber/Partners cancer program from 1995 until 2011. And, frankly, he was my fellowship director from 1982 to 1985. So I owe a great part of my career to Dr. Mayer. He's co-authored over 400 peer-reviewed papers and another 130 chapters and reviews. He serves as associate editor for both the Journal of Clinical Oncology and The New England Journal of Medicine. And, as have many guests on this program, he served as president of ASCO, in his case, in 1997, 1998. And he received the ASCO Distinguished Achievement Award in 2019 for his ongoing leadership in our society. Dr. Mayer, welcome to our program. Pleasure to be with you, Dan. So I have a lot of questions. And, again, I usually do this, you know, two guys in a cab. How did you do that in the first place? What got you interested in oncology coming out of Williams and at Harvard? And, at that time, there wasn't much in oncology. What made you want to take care of cancer patients? Well, I was a third-year medical student at Harvard sort of sleepwalking through the curriculum, undecided what my life was going to be, planning to go back to New York, and I came across an attending physician on a pediatrics rotation, a hematologist by the name of David Nathan. And we hit it off. And I became really interested in blood cells and how looking at smears and bone marrow morphology could tell you a lot about the status and health and nutrition of individual patients. Nathan took a shine to me. And, when I was a fourth-year student and was going to face probably a military service, and there were military actions going on in Southeast Asia, he called me to his home one night and shoved a whole pile of paper in front of me, said fill this out. I want it back tomorrow. And this was an application to be a clinical associate at the National Cancer Institute where he had spent several years I guess a decade before. So I did what I was told. And, when I was a intern, I guess my first day as an intern, I got an overhead page from the-- in the hospital, call from Bethesda informing me that I had been accepted. I had had 10 or 11 interviews. One of them turned out to be a person who would be important in my life as a friend and a mentor, George Canellos, who was first time I met him. And, in 1971, I found myself at the NIH. That's quite a story. And Dr. Nathan, of course, went on to start the Jimmy Fund, probably had already started the Jimmy Fund Clinic at the time, and became the CEO, I think, of Children's Hospital in Boston. He became the CEO of Dana-Farber actually. I do want to just recollect with you my first day or two in Bethesda because some of the people who found themselves there took it more seriously than others. And I was assigned to the medicine branch. And the medicine branch had a chief who was a breast cancer-oriented investigator by the name of Paul Carbone who went on from there to an illustrious career as the founding head of the Cancer Center at the University of Wisconsin and the leader of the Eastern Cooperative Oncology Group. And Paul, at that point, the first day I met him, told us that, if we messed around, moonlighted, didn't show up, we'd be on a Coast Guard Cutter as fast as he could do the paperwork because, technically, we had a position in the Public Health Service. Under Carbone, there were two branches. One was leukemia, and that was headed by Ed Henderson. He was a lanky guy from California, a wonderful man, went on to a career with Cancer and Leukemia Group B and with the Roswell Park in Buffalo for many years. And he was my branch chief. And the other branch was solid tumors. They weren't solid tumors like we think of them today. They were lymphomas. And that was headed by Vince DeVita and had Bob Young, George Canellos, Bruce Chabner, and Phil Schein, all illustrious founders of so much that has become oncology. So that was the setting. And the last thing I'll mention was about this. I came there as a trained internist, but I was assigned to pediatric leukemia. And I learned very quickly that what separated the wheat from the chaff, in terms of families, parents thinking that you were a good doctor, was your ability to maintain the 25 gauge scalp vein as venous access in these children because there were no port-a-caths, no Hickman lines, and, obviously, access was something that was critically important. You know, I think everybody who is listening to this needs to understand that what you just described started out really with just Gordon Zubrod who then brought in Frei, Holland-- or Holland first and then Freireich. And then they brought in the next group, which I believe you would agree is Canellos, DeVita, Bob Young, and others. And then you were sort of in the third wave. And you could just see it began to expand the whole field of oncology really just from a few people going out. Do you agree with that? I do. I do. When I came to the NIH in 1971, there was no defined, certified subspecialty of medical oncology. The first time the medical oncology board examination was given was in 1973. It was given every other year. I was in the group that took it the second time in 1975, but this really wasn't a subspecialty. In 1973 also was the time that the first comprehensive multi-authored textbook on medical oncology was published by Jim Holland and Tom Frei, Cancer Medicine. And I remember devouring that as I prepared for the board examination, but there was no book like that. There was no reference, no UpToDate, no computer to surf the web and find information. And so this was all brand new. It was quite exciting to be there as part of the action. You sort of jumped ahead on what I wanted to ask you, but I'm interested in the establishment of medical oncology as a subspecialty. Can you maybe talk about Dr. BJ Kennedy and his role in that? I think he was pretty instrumental. Was he not? BJ was at the University of Minnesota. He was an extraordinarily decent man. And, somehow, the internal medicine establishment viewed him as a peer and a colleague, which I would have to say was not what they considered many of the pioneers, if you will, in medical oncology. I can remember, in my second or third year at the NIH, traveling around the country to look at fellowship programs. And I was always being met by senior established hematologists who arched their eyebrows and said now where's the pathophysiology. Where is the science here? They really thought that the animal models, the mouse models, the Southern Research Institute that Gordon Zubrod had been such a pioneer in fostering was pseudoscience. I can also remember, when I found myself back in Boston, the establishment of Harvard Medical School didn't initially take oncology very seriously, but there were patients. And there was optimism. And all of us in that generation really believed that we could make a difference, and we could learn a lot and do good for patients and for medicine. And I think we have. So, in my opinion, now, appropriately, our fellows have a very strict curriculum of what they're supposed to learn and how and when and why laid out, again, in a pretty rigorous formal manner. You told me before, at the NCI, it was just sort of learn it. It's up to you. Can you talk about that training? And then, when you went to the Sidney Farber, you then turned that into a training program. The medicine branch was fantastic training, but it was learning from taking care of patients and from your colleagues. The quality of my peers was extraordinary, but there was no formal curriculum. The faculty there each were doing research, the members of the faculty. And, for a month, they would come out of their cave, if you will, their laboratory, and they were very smart and were doing fascinating things, but they didn't have long-term patients. Or there was no real process. And the NCI was sort of like a Veterans Administration hospital in the sense that it opened around 7:30 or 8:00 in the morning, closed at 5:00 or 6:00 in the afternoon. One of us would be on call at night with a couple of nurses, but it was rather primitive in its support mechanisms. We were assigned a group of patients. And then, on rotation, those patient numbers would increase. And we were expected to do everything conceivable for that patient. And, at that time, the oncology care offered in Bethesda at the NIH or the NCI was free. It was paid for by the government. And much similar care was not available in other places. So I would have patients flying in from Omaha and New York or Norfolk or Tampa, Florida. And they would be housed in a motel that was on the edge of the NIH reservation, but, if one wants to talk about continuity of care, you knew everything about every one of those patients because you were the only person who knew them. So what were the circumstances then that you ended up in Boston? Well, that's an interesting story because it gets back to David Nathan. I was working after my clinical year in a basic laboratory as I could find. It was run by Robert Gallo, Bob Gallo, who was one of the co-discoverers years later of the HIV virus. But, one day, I got a phone call from Dr. Nathan's secretary saying that he was going to be in Washington a week from Tuesday or whatever. And he wanted to meet with me in the garden of the Mayflower Hotel. OK, fine. So I trotted over to the Mayflower Hotel, and there was Dr. Nathan. And he said, you know, Dr. Farber is getting old, but there's a new building. And there's going to be a cancer center. And he's just recruited Tom Frei to come from MD Anderson. And it's time for you to come back to Boston. Didn't say would you like to come back, would you think about coming. No, he, just applied to the NIH, shoved the papers. Here, it's time for you to come back to Boston. So, a few Saturdays after, I flew up to Boston. And, in that interim, Dr. Farber passed away. He had a heart attack, an MI. And there was Tom Frei who I met for the first time, made rounds with him. We hit it off. And he told me that he would like me to spend one year as a fellow and then join the faculty and become an assistant professor. Well, I didn't need a plane to fly back to Washington. I thought this was tremendous because I was looking at hematology scholarships around the country. And there was no career path. And this seemed to be a career path in a field that I was really interested in. And he talked to me really about coming back to do leukemia because that's what I had been doing at the NIH. And, a year later, I found myself, July 1, 1974, being part of the second fellowship class at what's now Dana-Farber. There were six of us. There were six the year before. We were piecing it together step by step. There, again, was nothing chiseled in marble. There was no tradition. This was try to make it work and learn from what works. And, what doesn't work, we'll change. You must have had a lot of insecurity coming into a program that really had just started. There had to be chaos involved in that. Well, there was a little chaos, but, to be honest, I was really engaged in it because it was exciting. I thought that oncology, as I still do, is this marvelous specialty or subspecialty that unites science and humanism. And, because other people weren't interested or maybe weren't capable of providing what we thought was the right level of care, to be able to sort of write the playbook was a terrific opportunity. We sort of-- and it extended into the year that you were a fellow as well-- followed the medicine branch mantra in the sense that we assigned fellows patients. And they took care of those patients and were expected to do everything that was necessary for them. There weren't rotations at that time that you would spend a month on the breast cancer service and then a month doing lymphoma. You would see new patients or follow-up patients. We didn't really have enough patients or enough faculty at that point to be smart enough to think about that being a better way or an alternative way to structure a trainee's time. I remember, at the end of my first year, when I finished that year as what I think Tom Frei called a special fellow, I was the attending on the next day, which was July 1. And I remember that a fellow, a first-year fellow who was just starting, Bob Comis who became also the chairman of the Eastern Cooperative Oncology Group years later, a marvelous lung cancer investigator, was the trainee. And, on that day, we went ahead and did a bone marrow on a patient with small cell lung cancer and being a fellowship director just started because there was no one doing it. And Frei said please move ahead. I have to say, when I started in 1982, I just assumed this was the way everybody in the country was training fellows in oncology. It really didn't occur to me that that was only a few years old and the way you had set it up. A few years ago, the Dana-Farber had a banquet to celebrate the 48-year career of a guy named Robert J. Mayer. And I was asked to speak. And I got up. There were over 300 people in the audience, all of whom had been trained there. And, as I looked around, I sort of put my prepared words aside and said look at the people sitting next to you. They are either former or to be presidents of ASCO, ACR. They're cancer center directors, department chairs, division chiefs, and a bunch of really terrifically trained oncologists all due to one guy, and you're the one. So you started with Bob Comis-- I've never heard you tell that story-- to really training some of the greatest oncologists in the world in my opinion, myself excluded in that regard, but, nonetheless, you must be quite proud of that. Well, yes, but I want to flip it around the other way because, for me, this became a career highlight, the opportunity to shape the patterns, to make the people who trained here leaders, and to have them-- right now, the director of the NCI is a Dana-Farber alumnus. To have people who are of that quality-- and you certainly represent that, as an ASCO president and one of the hallmark leaders of the breast cancer community-- this is what a place like Dana-Farber and Harvard Medical School, hopefully, not too much arrogance, is supposed to be doing. And to have that opportunity, to be able to fill a vacancy that nobody even appreciated was a vacancy, and then to develop it over enough time that one could really see what worked and see what didn't work is an opportunity that most people don't have. And I'm so grateful for it. Now, Bob, I want to just, in the last few minutes here, you've obviously been a major player in ASCO. Can you kind of reflect over the last 25 years since you were ASCO president, the changes you've seen, and what you think of your legacy? I know you don't like to brag too much, but I think there's a reason you got the Distinguished Service Award. And can you just reminisce a bit about what's happened and then where you think we're going as a field? Well, ASCO has been my professional organization. The first meeting I went to was in a hotel ballroom in Houston, the Rice Hotel, which doesn't exist anymore. And it was a joint meeting of ACR and ASCO in 1974. There were 250 people. And everybody was congratulating each other at the large number of attendees. I had the opportunity, in large part because of Tom Frei and George Canellos and other people, to become involved in picking abstracts for leukemia presentations, being part of the training committee, and then chairing the training committee. I actually had the opportunity to be one of the four people who started the awards program, which now has the Young Investigator Award and Career Development Award and things of that sort. These are just opportunities because they weren't there before. And, if you're willing, and you put in the time, I guess people come back to you and give you the chance to do these things. I became then involved in the JCO, the Journal of Clinical Oncology. I became involved in the debate about physician-assisted suicide and palliative care that led to some very educational debates and probably spawned the field, to some degree, of palliative care. I had the opportunity to be at the forefront of starting the Leadership Development Program that was really Allen Lichter's idea, but I was able to devote the time to make that happen. And, most recently, I've been on the Conquer Cancer Foundation now for almost two decades. And watching that grow has been a joy. ASCO, when I came, was a very small trade organization, if you will, didn't quite know the questions to ask, had a hired office, a management office, that was based in Chicago, came to Alexandria in about 1994 or somewhere in that range with its own office and its own staff, and now is the world organization for oncology. And I think that that growth, that expansion, that international, multidisciplinary pattern, if you will, is a reflection of the growth of oncology in medicine. I have to say, if you take a look at the popularity poll of what the best and the brightest young physicians choose in their careers, when I was in training and, Dan, when you were in training, most went into cardiology. Maybe some went into GI. Now there are more people going into oncology than any other medical subspecialty. Maybe that'll change after COVID, but that's the way it's been. And our hospitals now are filled with cancer patients, and those hospitals are very dependent on the care that we provide cancer patients. I guess the other thing I would say is, looking from a guy with some hair left, although gray, but looking at it from afar, all of those high-dose chemotherapy programs, the notion of dose, of cell poisons, alkylating agents, the solid tumor autologous marrow programs that were so fashionable in the 1980s, have been, in large part, replaced by such elegant, targeted therapy, now immunotherapy, circulating DNA. Who would have thunk any of that when I was taking care of those children with leukemia 45 years ago? So I think this is such an exciting field. I'm so-- continue to be so pleased and proud of the quality of the trainees. Last night, we had a virtual graduation session for the people completing their fellowship here. And I hate to say it. They're as good as ever. And, if we thought and, Dan, if you thought your colleagues that you all and we all were the best, they're all phenomenal. And it's really a reflection on how the pioneers in this field had a vision, how the need for science to understand cancer was so important, and how medicine has changed and how oncology now is a respected and acknowledged discipline of scholarly work. Well, you had two things that I'm fond of commenting on. One of those is I frequently say publicly I wish I was 30 years younger for a lot of reasons, but because of the scientific excitement that's going into oncology and, also, so that I could run the way I used to, but I can't. That's one. The second is I don't think I would choose me to be a fellow. I'm really intimidated when I do interviews with our residents and say, you know, I wasn't nearly in that kind of category of the people we're interviewing now, which is great. I think our field is in good hands, going to move forward, and things are going. Bob, we've talked about a lot of your contributions to training and education, but you've also had a major influence on the way patients with leukemia are treated. Can you talk more about where the 7 and 3 regimen came from? The 7 and 3 or 3 and 7 regimen-- 3 days of an anthracycline, 7 days of continuous infusional cytosine arabinoside, was developed in the early 1970s. And it was developed by Jim Holland, more than anyone else, when he was at Roswell Park. And it emerged from a series of randomized, phase III trials conducted by what was then called the Acute Leukemia Group B, what became CALGB and then the Alliance. In the early 1980s, the late Clara Bloomfield, who I considered a giant in the world of leukemia, invited me to write a review of the treatment of acute myeloid leukemia for seminars in oncology that she was editing. And, in preparing that, I started reading a series of manuscripts published in the early 1970s, which meticulously, step by step, examined the value of two versus three days of anthracycline subq versus IV push versus infusional cytosine arabinoside, 3 days, 5 days, 7 days, 10 days of infusional cytosine arabinoside. And this was all really work of Jim Holland. He was a magnificent scholar, a humanist, and a tremendous booster too and giant in the start of this field. Thank you. I agree. Bob, we've run out of time, but I want to just thank you for taking time today to speak to me and our listeners, but also thank you for what I consider the many contributions you've made, both scientifically-- we didn't really even get into that, your work on leukemia and GI-- but I think, more importantly, establishing a training program that's been the model for, probably worldwide, how to train people in oncology and the contributions you've made to ASCO. So, for all that, I and everybody else are very appreciative. Thanks a lot. My pleasure. It's a pleasure to be here with you. Until next time, thank you for listening to this JCO's Cancer Stories-- The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories-- The Art of Oncology podcast is just one of ASCO's many podcasts. You can find all the shows at podcast.asco.org.