Chapter 10: A Summary of Research

Chapter 10: A Summary of Research

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Description

Dr. Goepfert notes that he has generally served a supportive role in research studies. He participated in a study of a chemoprevention protocol involving derivatives of Vitamin A (Principle Investigator, Waun Ki Hong, MD [Oral History Interview]). His research in the eighties and nineties focused on the preservation of functionality of the larynx. He notes that his main contribution was to determine how to use chemotherapy in combination with surgery to preserve the voicebox, though that procedure was not long in use due to improvements in treatments using concomitant chemo- and radiation therapy. Dr. Goepfert ends this chapter with a description of endoscopic surgical techniques and the new robot surgery in use by Dr. Floyd Holsinger.

Identifier

GeopfertH_01_20120827_C10

Publication Date

8-27-2012

City

Houston, Texas

Topics Covered

The Interview Subject's Story - The Researcher; Contributions; Career and Accomplishments; The Researcher; The Clinician; Overview; Definitions, Explanations, Translations

Transcript

Tacey Ann Rosolowski, PhD:

We have about ten minutes left. Would you like to just return briefly to the issue of research? I know that you’ve had a number of other types of grants that talk about adjuvant therapy and also preventative therapy. Is there one of those you’d like to address?

Helmuth Goepfert, MD:

I was not principal investigator on any of those, but I basically participated in development of those grants and had irresponsibility on a certain facet. For example, let’s take the chemo prevention protocol of Dr. Hong. That was in the time of the vitamin A derivatives used for “chemo prevention of head and neck cancer.” Yes, it was a randomized study that was done nationwide. My intervention basically was to define, when patients got a new cancer or recurrent cancer, was this patient a recurrence or was it a second primary? So, I was the chair of the committee to determine the nature of the treatment failure. That was my intervention. Interestingly enough, that study was randomized, and the patients either got the vitamin carotene derivative or not the carotene derivative. The interesting thing, after the study was closed, nobody knew which arm had received what. People were sort of it’s funny to know what happened. What is it? We need to know who got what. I said, “You don’t need to know who got what because, both arms, the results are exactly the same. So, no matter what the intervention arm it is—” Everybody said, “Oh, you are right.” (laughs) So before they sort of broke the code, you already could tell what had happened. Both had the same amount of recurrences, and both had the same amount of second primary, so that sort of put a lid on all of that chemo prevention stuff that Ki Hong had done with the vitamin A. Of course, there have been other chemo prevention studies, but this was the big thing because his pilot study that he had done prior to coming to MD Anderson was in Boston and had, according to him, shown that the use of beta carotenes or whatever carotene it was reduced the incidence of second primaries. Now, when you went to a national study that was sponsored by RTOG and of these organizations and had very rigorous parameters in it, including what I said—a rigorous committee that would determine is this a second primary or was it a recurrence—it didn’t show to be of any benefit. So that was a big flop for him, but to his credit it was published. Then you have another one that you mentioned?

Tacey Ann Rosolowski, PhD:

Yeah, there was one on the adjuvant therapy—the randomized adjuvant therapy of head and neck cancer. That was from ’98-2002. You were using biomarkers for patients with stage III and IV head and neck cancer.

Helmuth Goepfert, MD:

That was run by medical oncologists, and I was at the tail of it. I basically was the one that assigned patients to go into the study, but it was run by medical oncologists.

Tacey Ann Rosolowski, PhD:

What are some of the most significant studies that you feel you’ve done? You have lots and lots of publications, and it’s hard for me to kind of pick out—

Helmuth Goepfert, MD:

The research, I basically made sure it got done, but I, myself, spent little time in developing protocols. I was basically a clinician. I looked for the clinical part of it and for the vocational part of it, but research itself, more than anything, during the late ‘80s and ‘90s, became more complicated. I worked by the principle that if you’re not doing it all the time, don’t do it.

Tacey Ann Rosolowski, PhD:

And the complications that arose, were these the guidelines about use of human subjects? Or I should ask you what the complications in doing studies at that time were.

Helmuth Goepfert, MD:

No, the complexities, not complications—the complexities of research, not the complications. The complexities of doing research increased. They are more stringent and rigid now. In those days, it really didn’t matter because we didn’t know, but it became more stringent how research had to be done. But, no, it has nothing to do with complications.

Tacey Ann Rosolowski, PhD:

So were there any other studies about preservation of functionality?

Helmuth Goepfert, MD:

Yeah, but the preservation of functionality—when I came to this department there was no expertise in what’s called conservation laryngeal surgery, in which you do take out the cancer and keep the voice box. My contribution was to combine the best of both worlds—take care of the big cancer by doing a partial laryngeal surgery followed by radiation therapy. Now, this demanded a very stringent protocol. It was not randomized, but it proved it could be done and it was very effective. The series that we developed was significant. Of course, nobody believed that it had no complications, and we had somebody else review it. It was interesting. We had some failures in a sense of people not being able to get rid of their tracheostomy tube. We had some failures in a sense of people not being able to swallow because the voice—the larynx is a complex organ. It has to do with speech, it has to do with deglutition, so both of them you have to preserve. Basically, that is the issue of that protocol, and we are able to preserve the normal voice in many patients, but the protocol did not survive very long because parallel to it evolved the improvement of concomitant radiation and chemotherapy, so that other one went by the wayside. Now, the other part that needs to be said is that a traditional open laryngeal surgery, in the sense that you cut through the neck to do it, has disappeared. More and more now it’s done through the endoscopic approach—going through the mouth with a scope and with the laser and so forth. These tools cut out the cancer. Now, there is a place for that still, but other treatments have made it less important. Yeah, there may be a renaissance now with this so-called robot surgery. The robot surgery, the one that is involved in that here, Dr. [Floyd C.] Holsinger, is trying to prove that this is a way to proceed with the treatment of primary tumors in those areas, so the advances certainly have been parallel on different disciplines so that some of these treatments that we created and were successful in those days became obsolete.

Tacey Ann Rosolowski, PhD:

Why would the robotic surgery create a renaissance?

Helmuth Goepfert, MD:

Because it has less morbidity, it can work around corners, and the fine tuning of the robot is that you basically can do a magnification of something without having to rig your fingers in there. It is an interesting surgery, but the learning curve is very steep, so you have to leave it for people who do it all the time. That’s why I’m glad that Dr. Weber decided to assign one surgeon to do it and established the principles of credentialing and re-credentialing so that it would not impair safety. So it’s now done pretty safely by a group of surgeons here, but even Dr. Weber, who has become certified, he says, “I’m not doing it because it has to be done all the time.” Now he’s certified, yes, but you immediately, after you haven’t done it for several months, you lose your certification. You have to be honest about that.

Tacey Ann Rosolowski, PhD:

Wow. That’s amazing. So I gather that the instruments that are used in the robotic surgery must be very tiny and very flexible. So it’s kind of like a complement to endoscopic, but—

Helmuth Goepfert, MD:

It is endoscopic. It is through the mouth. It is endoscopic, but the availability of special optics, special illumination, allows you to almost work around the corner. With the rigid scope you couldn’t, so it is quite an accomplishment what can be done with it, but again you have to select the patient properly, and you have to have a surgeon who is well-trained and able to manage it.

Tacey Ann Rosolowski, PhD:

What kinds of patients would be candidates for that kind of surgery?

Helmuth Goepfert, MD:

Certainly larynx cancer patients, tonsil cancer patients, base-of-tongue cancer patients, limited patients of the pharyngeal wall cancer—those are the principal patients for that. I mean, the ones that have made the biggest headway with robotic surgeons are the urologists, with the prostatectomy. Other surgeons are attempting to use that tool for the purpose of doing certain things in the abdomen and so forth.

Tacey Ann Rosolowski, PhD:

Well, we’re almost at 4:00. Would you like to stop for today and then we’ll resume tomorrow?

Helmuth Goepfert, MD:

Let’s resume tomorrow.

Tacey Ann Rosolowski, PhD:

All right. Thank you very much.

Helmuth Goepfert, MD:

I appreciate you doing this. Thank you, Tacey.

Tacey Ann Rosolowski, PhD:

Sure. Thank you.

Helmuth Goepfert, MD:

So tomorrow we look at the issue of education to see what else you find in the summary that can be related to what I do or not do.

Tacey Ann Rosolowski, PhD:

Sure. Let me just say it’s about 4:02. I’m turning off the unit. (End of Audio 1)

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Chapter 10: A Summary of Research

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