Chapter 10: A Fellowship at MD Anderson to Work with Gilbert Fletcher
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Description
In this chapter, Dr. Komaki talks about her fellowship at MD Anderson in Radiation Oncology [1/1977-1/1978]. She provides a portrait of Dr. Gilbert Fletcher: she attended his planning clinic every morning and discusses how these worked. She explains that Dr. Fletcher determined all aspects of treatment. She also tells a story about questioning his approach, which resulted in him changing a treatment plan. She explains that her mentors in the department taught her to think critically about cases rather than “follow the recipes.” She shares her impressions of the faculty and staff in Radiation Oncology at that time and talks about a neutron treatment facility that MD Anderson used at College Station.
Next, Dr. Komaki talks about Eleanor Montague and tells a story about inviting her to lecture in Radiation Oncology at Columbia Presbyterian in 1987 to encourage a less conservative approach to radiation treatment. She explains why the surgeons there were resistant, noting that positive results from studies conducted at MD Anderson were often discounted.
Identifier
KomakiR_03_20181219_C10
Publication Date
12-19-2018
Publisher
The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - Professional Path; Definitions, Explanations, Translations; The Researcher; Personal Background; Mentoring; On Mentoring; Professional Practice; The Professional at Work; Professional Values, Ethics, Purpose; Portraits; The MD Anderson Brand, Reputation; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
T.A. Rosolowski, PhD:
So, when we ended up last time, you were talking about a whole lot of issues, but the period of evolution you were focusing on was really your time in Milwaukee, during your residency and fellowship. So, I wanted to see what was the process by which you transitioned, because the next stage was really coming to your fellowship at MD Anderson. So how did that all happen?
R. Komaki, MD:
So after I finished my residency program of Radiation Oncology at the Medical College of Wisconsin, [ ] I wanted to go abroad to get into a fellowship program, such as Institute of Gustave Roussy or maybe in Netherlands, outside of U.S. At that time, the chairman of Radiation Oncology Department was Jim Cox, who spent his fellowship at the Institute of Gustave Roussy, but he recommended me to come to MD Anderson Cancer Center and learn from Dr. Gilbert H. Fletcher, because I was very interested in doing gynecologic oncology at that time. So, he said, the best place for you to learn [Gynecologic Oncology] is at MD Anderson. That’s why I came to MD Anderson. I followed Dr. Gilbert H Fletcher, and I attended morning conferences, lectures for residents and visitors as well as deposition clinics for four months.
T.A. Rosolowski, PhD:
Now when you say followed, what do you mean?
R. Komaki, MD:
His clinic, the deposition clinic, and also I attended to the planning clinic every morning. Dr. Fletcher, he was sitting in front of the resident and attendings and the fellows and the visitors. He’s the one who decided, after the case presentation, this patient should be treated by which machine, and the dose, total dose, and the fractionation. Some of the inflammatory breast cancer patients, he said, well this patient should be treated twice daily, fractionation, five days per week, but twice daily treatment would be better, rather than once daily treatment, because rapidly growing type of cancer. But he’s the one who decided every treatment, equipment, the energy of the machine, and the total dose, fractionation—everything, he decided.
T.A. Rosolowski, PhD:
What did you learn from following him, kind of observing that style?
R. Komaki, MD:
So, I was just fascinated by his decision and then nobody argued or questioned [Dr. Gilbert Fletcher] at the planning clinic. He took me to gynecologic oncology, their deposition clinic, so that means he let me examine the patients. Like a patient who was 65 years old, an African American woman who had stage III B squamous cell carcinoma of the cervix, and she had extension of the disease bilateral parametrium. Those parametrial lymph nodes were involved by cancer, and he said this patient should be treated one shot of Radiotherapy. That means one big dose, and just let her go. I was very brave to ask him, “Dr. Fletcher, according to your articles and examples for the head and neck and GYN, you recommend big tumor to be treated more fractionated radiation treatment because there is hypoxia in the middle of the tumor when the tumor gets very big, and you cannot overcome the hypoxia by giving a big shot of Radiotherapy. Why are you giving this big dose only once to this patient?” So he grabbed my hand and he said, “Okay, examine this patient.” Do you think you can cure this patient?” I said, “Well, I examined the patient and the tumor was really, really big, and the tumor is totally fixed to the lateral pelvic wall. I said, “Dr. Fletcher, according to the lymphangiogram, which used to be done by Dr. Sid Wallace [oral history interview], there was no extension into the para-aortic lymph nodes, so she might have a chance to live [long enough to manifest bowel complication by the one big dose of pelvic radiation] treatment.” She was not a candidate for surgery. Then, he decided to change the approach. [ ] So he decided to do twice daily treatment for those patients who are within like one week. I thought that his change was very impressive. Even though I was a fellow, he listened. Usually, he was not a very good listener. He thought he knew everything. Even when we invited him to come to Medical College of Wisconsin (MCW), when I was program director for the residents, he came [to visit our program. Our] residents at the Radiation Oncology Department of MCW kept asking many questions, because they were encouraged, by Jim Cox, to ask questions. Jim Cox always gave [his answers to any questions from our residents or attending] and if he could not give any answers, he always said, okay well, let’s try to find out through the clinical trials or look up the references. So that was our training method and the attitude of our residents [at the Radiation Oncology of MCW] was totally different [from the one at Radiation Therapy Department of MDACC]. One of our residents asked Dr. Fletcher, “How do you treat this patient with cancer of the prostate?” He said, “Well, I am not going to answer those questions, read my textbook.” He was like that, and his textbook was very thorough, but like a recipe book. All the residents and attendings, they followed his recipes and that was different from what I was taught at MCW. All the attending at Radiation Oncology of MCW, including Dr. Cox and Dr. Frank Wilson and Dr. Larry Kun, and Dr. Don Eisert and [Dr. Roger Byhardt] were trained by Dr. Juan Del Regato at the Penrose Cancer Center, and they were taught how to think, rather than reading the recipes. Dr. [Del Regato’s philosophy was that] nothing really stayed the same [as your were trained], so you have to know how to think based [on cancer biology and human physiology/anatomy]. Then whatever is available, you have to adapt to use it, and wherever or whenever you are, you[ need to learn how to utilize new] equipment you will have. That’s what I have learned, but I was not really afraid to ask questions, even to Dr. Fletcher, but I learned so much from him. He was outspoken to the surgeons or medical oncologists or whoever was around. He was very knowledgeable about imaging. He used to be a diagnostic radiologist, but he sure had a lot of temper and everybody was so afraid of him. It was very rare --a person who was not really afraid. I was always inquisitive, I always wanted to find out why.
T.A. Rosolowski, PhD:
And somehow he accepted that from you, which is interesting. You must have had a way of presenting it that was not threatening or triggering whatever.
R. Komaki, MD:
Right. He really liked me a lot, because I was really trying to find the bottom line and I tried to read all the references available, and I was really, really serious, how to learn from him. I respected him so much. You know, I thought he had a very strong accent from Belgium. His mother was French and so he was raised in Belgium. Anyhow, I always read his articles and textbook. So I was very fortunate to spend some time at MD Anderson, and then I went back [to MCW].
T.A. Rosolowski, PhD:
What were your impressions kind of, of the larger environment at MD Anderson at the time, in radiation and in the institution at large.
R. Komaki, MD:
Okay. So, all those people I met at MD Anderson, this is 1980, they were so famous, very famous. I’m talking about all the Radiation Oncology attendings, including Dr. Fletcher, and there was Dr. Eleanor Montague, [who was treating patients with] breast cancer. Dr. Norah Tapley was an expert of the electron beam treatment and she was the program director of the residency program at that time. And then Dr. Lillian Fuller, who was doing lymphoma, and Dr. David Hussey who was doing the GU, so mainly treating prostate cancer patients. Also, he was doing neutron treatment at the College Station. The neuron facility was located at the College Station, and I had to go there to see how the patients have been treated [ ] The patients, all the fellows or visitors from outside of MD Anderson, Dr. Hussey as the attending, and Dr. Lester Peters, a fellow at that time from Australia [were put in the same shuttle bus to go to the Neutron Facility]. We all went to College Station. It took about two hours to get there, and I saw those patients in the Neutron Facility. They were treated in standing position, and Dr. David Hussey carried this huge, heavy custom cone to protect the normal structures and it was shaped for the tumor outline, that’s a very heavy material made of lead.
T.A. Rosolowski, PhD:
And you said it was a cone?
R. Komaki, MD:
A cone, yeah, yeah. So that’s made individually for the protection of the normal tissue. It was very fascinating, those patients to be treated by neutron. Those patients had prostate cancer, cancer of the cervix, some of the parotid gland tumors, head and neck cancer [and apical lesion of the lung cancer].
T.A. Rosolowski, PhD:
Why did they do the neutron treatments in College Station? Was it a matter of equipment that MD Anderson didn’t have?
R. Komaki, MD:
No, no.
T.A. Rosolowski, PhD:
What was the reason?
R. Komaki, MD:
Because the space.
T.A. Rosolowski, PhD:
Oh, okay.
R. Komaki, MD:
They could not afford to put this huge, big neutron facility at MD Anderson [Main Campus], so they created it at the College Station.
T.A. Rosolowski, PhD:
So was that an MD Anderson creation?
R. Komaki, MD:
Yeah, yeah.
T.A. Rosolowski, PhD:
Oh, okay, interesting. I didn’t realize that.
R. Komaki, MD:
It was based on a grant which Dr. David Hussey got from the NCI. But this neutron was supposed to treat big tumors containing hypoxia right in the middle in the tumor. The radiation requires oxygen to kill cancer cells. If there is no oxygen, the radiation is not effective to kill cancer cells. That means [free radicals are required to break] double strand of DNA of cancer cells. [ ] So oxygen is very important. But if the tumor gets so big, always there is hypoxia. This neutron, it does not make any difference. Even if there is a hypoxic area, it will go through. That means that neutron has high Liner Energy Transfer (LET). So it gives an effective dose to kill cancer cells right in the middle of that hypoxic area. More recently, the same type of treatment is ongoing, is heavy carbon ion. It also does not make any difference, hypoxia or not. X-rays, which has a kind of similar BED, which means biological effective dose. With proton treatment, the huge big tumor which has an hypoxic area --or even a sarcoma or soft tissue sarcoma-- it’s not very effective just because it does make a difference of the hypoxic area. So, certain size of the tumor containing hypoxia , it’s better to be treated by the neutron or maybe carbon ion [as long as the treatment does not cause late normal tissue damage]. But when they did this neutron treatment, the major problem they faced was [the damage to late reactive normal tissue, such as subcutaneous tissue, muscle, nerve and bone etc]. Among the patients who were treated and lived long enough, they started to have incredible subcutaneous fibrosis such as at the apex of the lung, a tumor we call “superior sulcus tumor”. They lived long enough because treatment was effective to get rid of cancer, but they developed necrosis of the clavicle, and the patient suffered from the late effects. Eventually they had to shut down the neutron. What happened was that NCI had to review the randomized protocol initiated at MDACC, neutron versus x-ray treatment. They failed, and the maintenance of this neutron facility cost $2 million per year, so they had to shut down because the trial was negative.
T.A. Rosolowski, PhD:
It must have been really incredible, to be working with all of these individuals who were so famous, but were there certain ones who were very influential on you?
R. Komaki, MD:
[Yes, they were all very influential for me.] Eleanor Montague, who just passed away, on November sixth of this year at age of 92 year old, she was so kind to all those residents and visitors. She never sat in front of the audience, she was so modest, but when she gave a lecture to residents and visitors or fellows, her points were very clear. She made the summary very clearly how MDACC treats the breast cancer patients. She’s the one who really advocated for more conservative surgery for all the early stage breast cancer patients followed by radiation treatment. She was a part of the NSABP [National Surgical Adjuvant Breast and Bowel Project] protocol, but she never showed off that she was very famous or superior than others. She was very quiet and never argued with Dr. Fletcher. I think she had several like four children, so she had to balance her work versus her private life. She just loved her husband, Monty, and she was born in Italy.
T.A. Rosolowski, PhD:
Oh, I didn’t know that.
R. Komaki, MD:
Her parents immigrated to eastern part of Pennsylvania. I think she did a residency program at Columbia Presbyterian Medical Center. She did a diagnostic radiology training and then she started to do radiation oncology afterwards. She came to MD Anderson under Dr. Fletcher and she really started to do breast cancer, but when she was pregnant, she was sent to other medical center, I don’t know. Hermann [Hospital] or a different place. But anyhow, she was a very kind, appropriate and [polite person]. When Jim Cox invited her to give her lecture at the Columbia Presbyterian Medical Center in 1987, I was treating breast cancer patients, GYN and lung cancer patients there. [At the Colombia Presbyterian Medical Center, I was facing resistance] from very strong opinionated breast surgeons. They were all students of Dr. Haegenson, a very famous breast surgeon. They never accepted conservative surgery followed by radiation treatment for early breast cancer. I kept telling them, [treatment technique by Dr. Eleanor Montague at MD Anderson does radiation therapy after conservative surgery. I told them that] you have to read the NSABP protocol. [The NASBP trial and Breast Cancer Treatment at The Joint Center in Boston] and even California or Institute of Gustave Roussy advocated limited surgery followed by radiation treatment. Therefore you don’t need to do modified mastectomy or radical mastectomy for early stage Breast Cancer. That’s no longer applicable for the early breast cancer patient. They never listened to me, [ ] except for one breast surgeon, Frank Gump, listened to me, out of six. [He did the limited surgery for one of my patients who had a stage I Breast Cancer in her left breast which she developed as a second malignancy10 years after the first Breast Cancer in her right Breast treated by a Radical Mastectomy at the Memorial Sloan Kettering Hospital NYC followed by chemotherapy which damaged her liver. When she developed Breast Cancer in the opposite Breast, the same original surgeon said that you need a radical mastectomy. She said no more radical surgery since she could not tolerate to see herself after previous mastectomy. She was devastated from the Radical Mastectomy regarding her own image of feminism. She came to see me at the Colombia Presbyterian Medical Center. I and Dr. Gump treated her right breast cancer by limited surgery followed by Radiation Therapy.]
T.A. Rosolowski, PhD:
Why do you think they weren’t listening?
R. Komaki, MD:
Because they were always thinking about effect of the radiation, because they did not have adequate equipment, so they just kept telling me that radiation causes cancer. So if you conserve the breast, a second malignancy will show up in the breast, so it’s better to take it out. They never ever believed radiation will kill microscopic cancer cells, and if we use adequate equipment, sparing skin and not causing terrible skin reaction or fibrosis, we can cure those limited stage breast cancer patients without doing mastectomy, without causing second malignancy. They always blamed a second malignancy to radiation, rather than susceptibility. Somebody who has one cancer, there is already 3 percent higher than normal population they will develop a second malignancy somewhere, or in the same breast or the other side of the breast.
T.A. Rosolowski, PhD:
Not necessarily from radiation.
R. Komaki, MD:
Right, right, and they never ever think about maybe chemotherapy might cause a second malignancy, but always the radiation was the bad thing. Always they talked about bad effects of the radiation. Coming from Hiroshima, I always thought about what’s the effect of the radiation to human beings. Balancing with killing cancer, with protection of the normal tissue. I tried to convince them and it was a very, very difficult place. So we had to invite Eleanor Montague. I still remember that was in like 1987. I was at the Columbia Presbyterian Medical Center between 1985 and ’88, just before we came here. So 1987, we invited Eleanor Montague to give a talk about the management of breast cancer. She came and she gave excellent talk and she said straight, “This will be my last professional talk. The next time when you invite me, I will give my talk about art.” She was passionate about art and she said next year I’m going to retire, so this will be the last, my professional talk related to medicine.
T.A. Rosolowski, PhD:
Interesting. What was the reaction of the surgeons when she gave her talk about management of breast cancer?
R. Komaki, MD:
Well, they thought MD Anderson always has very, very good results and they never truly believed the results. Anything coming from MD Anderson, results were too good. Head, neck, breast, everything, GU, so they never really believed. That’s an East Coast attitude.
T.A. Rosolowski, PhD:
Really?
R. Komaki, MD:
Oh yeah, but their treatment was not optimal and so that’s [one of] the reasons we left there.
T.A. Rosolowski, PhD:
Interesting.
R. Komaki, MD:
Jim Cox accepted the position of physician-in-chief and the vice president of patient care at MD Anderson in 1988, because his predecessor, he was shot in his office, which we didn’t know until he accepted his position. [ ] They never found the person who shot him. It was very scary for me to know that it happened in his office and nobody found this murderer.
T.A. Rosolowski, PhD:
Yeah, yeah. No, I know they never did, it was always a scandal.
R. Komaki, MD:
And the reason why I was appointed to be [the Section Chief of Thoracic Radiation Oncology] was that Dr. Tom Barkley, who was the previous section chief of Thoracic Radiation Oncology, passed away in 1987, because of the eosinophilic granuloma rising from the lung. He was a heavy smoker with terrible COPD, and he had been waiting for the lung transplant but he passed away. So at that time, Dr. Fletcher already stepped down from chairman and Dr. Lester Peters became the chairman of the Radiation Oncology. He asked me to be the section chief of the Thoracic Radiation Oncology, to succeed Dr. Tom Barkley. So that’s the way we came to MDACC in 1988. Dr. Eleanor Montague had already retired but she was coming in and out a couple days per week. She said oh, I am so happy to see you, and she was always talking to Jim. She said “Retirement is so good, I should have retired a long time ago.” She was only 62 years old.
T.A. Rosolowski, PhD:
[00:032:40] Oh that’s funny, yeah.
R. Komaki, MD:
She was very happy to visit her parents in Italy, so she traveled back and forth between Houston and Italy, and she was very happy about her retirement. [She loved the history of art.]
Recommended Citation
Komaki, Ritsuko MD and Rosolowski, Tacey A. PhD, "Chapter 10: A Fellowship at MD Anderson to Work with Gilbert Fletcher" (2018). Interview Chapters. 1291.
https://openworks.mdanderson.org/mchv_interviewchapters/1291
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