Chapter 07: Building Knowledge of Breast Cancer in the Division of Medicine

Chapter 07: Building Knowledge of Breast Cancer in the Division of Medicine

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Dr. Hortobagyi explains that he was focused almost exclusively on breast cancer when he finished the first year of his fellowship in Developmental Therapeutics, at which point he shifted to the Division of Medicine (’75 – ’76). He sketches his research projects: preoperative chemotherapy for breast cancer; clinical trials for adjuvant treatment of breast cancer; developing a database of breast cancer patients. He also describes the vacuum of knowledge about breast cancer among the four leaders of the breast service at that time, noting the main question in his mind, “Who was I going to learn from?”

Dr. Hortobagyi provides background on how George Blumenschein became head of the breast service, though he knew little about breast cancer, then provides a sketch of Blumenschein and of Nylene Eckles [M.D., Ph.D), who headed the service for many years.

Dr. Hortobagyi lists other individuals connected to the breast service who did teach him about breast cancer, despite the lack of immediate mentorship. Dr. Hortobagyi then describes how he organized biweekly case-review meetings for everyone involved in breast cancer to “bring together the discipline. ”He explains that it took ten to fifteen years before everyone felt there was a benefit to this multi-disciplinary review of cases. He also describes the process required to encourage specialists to open up to other specialists. He also reflects on what enabled him to get people to work together.

Identifier

HortobagyiGN_01_20121130_C07

Publication Date

11-30-2012

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - An Institutional Unit The Researcher Understanding Cancer, the History of Science, Cancer Research The History of Health Care, Patient Care MD Anderson History Mentoring Leadership Building/Transforming the Institution Multi-disciplinary Approaches Discovery, Creativity and Innovation Professional Practice The Professional at Work Personal Reflections, Memories of MD Anderson MD Anderson Past The Researcher Understanding the Institution Multi-disciplinary Approaches Institutional Mission and Values MD Anderson Past This is MD Anderson

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 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

Gabriel Hortobagyi, MD:

So, I did the two months in leukemia, and then I did the two months in the clinic—in the Developmental Therapeutic clinic. And then—so that was July, August, September, October. And either November first or December first, I went up to Dr. Blumenschein, and I said, “Okay, now I am ready to start with breast cancer. Do you have room for me?” He said yes. So then still being—the good fortune was that Dr. Blumenschein being in the Department of Medicine and Dr. Freireich being in Developmental Therapeutics got along very well. And I think the background of that—well, I will come back to that. So, he said, “Fine.” And nobody in DT got offended for my crossing over. In fact, they sort of—I think they looked at me as the Trojan Horse who went over to the Department of Medicine and was going to divide and conquer. So I did that, and the same day I started one of the fellows from the Department of Medicine, Aman Buzdar, who is my colleague in my department here, also started. And the two of us have worked together ever since. So, then I finished that first year in Developmental Therapeutics but working essentially full time in the breast section and doing all of my research in breast with immunotherapy, which was all based in DT and sort of walking that fence trying to stay out of trouble and minding my own business.

Tacey Ann Rosolowski, PhD:

So this—so you are no longer working on Jordan Gutterman’s project?

Gabriel Hortobagyi, MD:

No, I am still working with Jordan Gutterman’s project.

Tacey Ann Rosolowski, PhD:

Oh, okay.

Gabriel Hortobagyi, MD:

But it is immunotherapy but now fully applied to breast cancer.

Tacey Ann Rosolowski, PhD:

Oh, okay.

Gabriel Hortobagyi, MD:

And from that time on I just stayed with breast cancer. So—

Tacey Ann Rosolowski, PhD:

What was the project that you initiated within the Department of Medicine when you began then?

Gabriel Hortobagyi, MD:

Okay. Well, there were several projects. So, the first one was—and in fact I am going to talk about that next week in San Antonio—was the development of preoperative chemotherapy for locally advanced breast cancer. And that has been one of my major projects over the years. Then with Buzdar we also developed the same thing for inflammatory breast cancer. Then we developed the first clinical trial for adjuvant chemotherapy in primary, operable breast cancer. Then we did—then I started a database of patients with breast cancer to look at the natural history of patients with breast cancer and understanding a little bit more the subtypes and what happened. And then I became increasingly a bit busy, so—

Tacey Ann Rosolowski, PhD:

Not that you weren’t already.

Gabriel Hortobagyi, MD:

Not that I wasn’t already, but that—and then I found out within just a few weeks or months of my being in the breast section that my boss, Dr. Blumenschein, had only arrived a year earlier, and before that he was a hematologist at the National Cancer Institute at the National Institute of Health. So, he didn’t know much more about breast cancer than I did or that Dr. Buzdar did, which was a revelation, but also a little surprising saying, “Now what? Who am I going to learn from?” And he was a delightful guy, a wonderful human being, and a very good doctor, but he was also very busy. So, George Blumenschein married the daughter of the dean of the medical school at the University of Chicago before going off to the NIH. So, when he was finishing his fellowship in hematology I think his father—his father-in-law who knew Lee Clark, who was the first president of MD Anderson, saying, “You know, my son-in-law is finishing his hematology. He is looking for a job. Would you have something for him?” So, he was hired as Director of Education at MD Anderson because the previous chief of the breast service was retiring. They also threw him the chief of the breast service. Now at that time, being the chief of the breast service meant that he was there, the retiring past chief was there—Nylene Eckles—and there was a Hawaiian Japanese guy—a Charlie Tashima—that was it. That was the breast service. So did he know much about medical education? Probably not, but that was the job he got. And did he know much about breast cancer? No, but that was the job he got. And he was one of those who could never say no, so he said, “All right, we will just grab the bull by the horns, and we will get it done.” And he was a very bright guy, and he did a good job. But all of the sudden we were now Blumenschein, Tashima, Buzdar, and I, and we were the four who were leading breast medical oncology forward. And of course, we knew relatively little about breast cancer, and then we had to learn very quickly on the job. The previous chief of the breast service, Nylene Eckles, was a petite—well, I wouldn’t call her petite but a short woman. She must have been four foot eleven or maybe five feet tall [redacted]. She had an MD PhD. And she always wore these horrible-colored sneakers, and makeup and dress were not ever a priority. She was a wonderful physician. She really knew about breast cancer, but she had two serious shortcomings—one that despite being the head of the breast service for twenty-some years she never wrote anything. So if you ask around the breast cancer community about Nylene Eckles, nobody knows who she is or who she was, and yet she took painstaking care of her patients. And she kept her private medical record of each patient, carefully taking notes; and in fact, later when she retired, she gave them to me. So, I have them in a deposit box somewhere. And the second she had was that she was a very poor teacher. So, you would be in the clinic with Nylene, and they would walk into a room where a patient was and Nylene would say, “Oh, this is Ms. Johnson. We need to give her some estrogen.” So, you would finish the thing, and you would step out to the hallway and say, “Nylene, why should we give her estrogens?” “Oh, because that’s what she needs.” You’d say, “No, no, no. Can you go through the thought process of what made you think that she would benefit from estrogens better than from A, B, C, D, E, F, G?” “I don’t know. That just popped in my mind.”

Tacey Ann Rosolowski, PhD:

She just didn’t have the gift.

Gabriel Hortobagyi, MD:

No.

Tacey Ann Rosolowski, PhD:

Didn’t have it.

Gabriel Hortobagyi, MD:

So here’s this treasure—this incredible brain that went to—well, not to waste but to waste for us as a junior faculty.

Tacey Ann Rosolowski, PhD:

Did she have that information in her notes at all?

Gabriel Hortobagyi, MD:

No. No. She was a very decisive person. In fact, she was very curt and even with the patients who loved her. But she was not a warm and fuzzy person. She would just go in and rake the patient over the hot coals if they hadn’t done what she told them exactly to do. And then she was usually right, and she was very respected within the institution because she held her ground with all of the other specialties. None of the surgeons would talk down to her because she would get back to them with the same coin.

Tacey Ann Rosolowski, PhD:

And that is tough, too, for women at that time.

Gabriel Hortobagyi, MD:

Exactly. She was a very tough woman. She was a very tough woman—very gifted—but those who—those of us who surrounded her did not benefit much from that wisdom except by watching and trying to learn by extrapolations or something like that.

Tacey Ann Rosolowski, PhD:

Let me—I’m sorry to interrupt you, but I just wanted to let you know it is twenty-five after two.

Gabriel Hortobagyi, MD:

Right.

Tacey Ann Rosolowski, PhD:

And we are scheduled to stop at 2:30.

Gabriel Hortobagyi, MD:

Right.

Tacey Ann Rosolowski, PhD:

So I didn’t want to take more of your time today. I mean I can go a little later if you would like or we can stop.

Gabriel Hortobagyi, MD:

I can’t.

Tacey Ann Rosolowski, PhD:

Okay.

Gabriel Hortobagyi, MD:

I can’t, so within the next few minutes we probably need to stop.

Tacey Ann Rosolowski, PhD:

Okay.

Gabriel Hortobagyi, MD:

Because I have some other things that I need to do.

Tacey Ann Rosolowski, PhD:

Absolutely. Absolutely. We have another session scheduled next week.

Gabriel Hortobagyi, MD:

All right.

Tacey Ann Rosolowski, PhD:

So that’s fine. So, did you want to continue with some more observations about Dr. Eckles or tell me more about how you kind of managed this sort of vacuum of experience with breast cancer that happened in the Department of Medicine?

Gabriel Hortobagyi, MD:

So I got as much out of Nylene’s experience as I could under the circumstances, and then there were some very talented people from other disciplines. There were a couple of wonderful breast surgeons like Charlie McBride and Ed White and Marvin Romsdahl, and there was a fantastic radiation oncologist, Eleanor Montague, and a fantastic breast pathologist, Steve Gallagher. And so, I learned a lot from them. They were much better at teaching, and they were much better at sharing their experiences. And they had worked together for a long time, so I learned a lot from them. I had my shortcuts, too, because while I didn’t necessarily have the immediate mentorship that my junior faculty that I would have today, I did have mentorship from other sources. And then realizing that one of the things that I worked on and insisted was to actually bring together even closer those various disciplines, realizing that we were so interdependent, and our patients depended so much on the decisions we made that it would be best to make those decisions jointly than as opposed to in sequence and independently.

Tacey Ann Rosolowski, PhD:

How did you make that happen?

Gabriel Hortobagyi, MD:

We organized a weekly or twice-weekly meetings in which specific patient cases were presented, and they would be discussed by the group—sometimes acrimoniously, sometimes harmoniously. But it really took probably a decade and a half until that was—that came to the point where everybody felt that there was benefit in doing that.

Tacey Ann Rosolowski, PhD:

Really?

Gabriel Hortobagyi, MD:

And that people were not just challenged unnecessarily, but that this was a patient-focused thing.

Tacey Ann Rosolowski, PhD:

Why do you think it took so long for people to be convinced about the collaboration?

Gabriel Hortobagyi, MD:

Because physicians are fiercely independent—and especially physicians in certain specialties—and I point first at the surgeons. Even within that surgical group of very accomplished and highly skilled surgeons, there were no two who did the same thing. And each of them felt that they knew better than the other two or three how to treat breast cancer. And therefore, to question why was—to question their integrity—to question their skills. And in retrospect, perhaps some of that is because they couldn’t tell me why they did it differently than the next person, why they cut here as opposed to here. But that is just my theory. But it takes a process until you are comfortable enough in your skin to say, “Okay, so this person from a different specialty is asking me something that goes to the fundament of my—what I think is my knowledge about my specialty. How dare he?” And as opposed to reacting like that say, “Well, he is asking me either because he doesn’t understand, and I haven’t explained it well enough or because there might be another option that I should consider.” But that takes taking a step back and looking at the bigger picture. And I think that ability to step back is what helped me tremendously over the next several decades to bring our group together and make it a more productive and more interactive group. But it means sometimes—and I am not exactly a humble person—but it sometimes means swallowing your pride and swallowing your tongue and just becoming a better listener and sometimes just serving as the lightning rod for other people to vent and do their thing until they realize that I am not trying to threaten them or take anything away from them.

Tacey Ann Rosolowski, PhD:

Dr. Hortobagyi, it is 2:30 now, so why don’t we finish for today, and we will resume next week.

Gabriel Hortobagyi, MD:

All right. Well, thank you very much—very enjoyable. I hope I didn’t ramble too much.

Tacey Ann Rosolowski, PhD:

No. Not at all. It has been a pleasure speaking to you. And I am turning off the recorder at 2:30.

(end of audio)

Conditions Governing Access

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Chapter 07: Building Knowledge of Breast Cancer in the Division of Medicine

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