Chapter 06 : Surgical Oncology at MD Anderson, Part I: Changing Surgical Tradition

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Chapter 06 : Surgical Oncology at MD Anderson, Part I: Changing Surgical Tradition

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Dr. Balch begins this chapter by explaining how his research on melanoma raised his visibility and brought him to the attention of other institutions. Eventually he received a call from Bob Hickey at MD Anderson, and Dr. Balch explains that he developed a vision and plan for the evolution of surgical oncology. He describes the situation in surgery at that time (mid-eighties): excellent clinical surgery, but no academic programs, no research, no clinical trials, and a traditionalist approach that created a gap between the "MD Anderson way of surgery" and advances being adopted at other institutions. Dr. Balch explains that he presented a plan for super-specialization (to also guide recruiting), for database development, management, and biostatistics to support clinical trials, for multi-disciplinary care, and active competition for grant dollars. He also observes that he and his plan were not well-received in the Department of Surgery, explaining why. He give examples of the traditionalist approach in the department and the generalist focus. Next, Dr. Balch outlines his first steps in implementing his vision, first reorganizing the Department of Surgery as the Department of Surgical Oncology and tracking patient outcomes to set in place a system where "outcomes should be the same regardless of who did the surgery. " He talks about individuals he recruited.

Identifier

BalchC_01_20181022_C06

Publication Date

10-22-2018

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 - Building the Institution; The Researcher; Professional Path; Building/Transforming the Institution; Multi-disciplinary Approaches; Growth and/or Change; Obstacles, Challenges; Institutional Politics; Controversy; Definitions, Explanations, Translations; MD Anderson Culture; Leadership; Professional Practice

Transcript

Charles Balch, MD:

Sure. So in the '80s, I was pretty visible academically because of my research publications. I was also President of the Association of Academic Surgeons, which is comprised of the younger generations of academic surgeons. And in my presidential talk, I talked about the importance of surgeons doing clinical trials to validate new therapies. I was being asked to look at different leadership jobs [ ], and among those that I looked at, [I was most attracted to work with Dr.] John Durant, who'd gone to Fox Chase as the President, and Clyde Barker, the Chair of Surgery at Penn. They jointly recruited me to come to Fox Chase as the Chief of Surgery, and then a parallel appointment at Penn as the Chief of Surgical Oncology. So, because John Durant was my mentor, I wanted to come up and look. I went up about four times, including with my wife, Carol, to look at housing. And then I put together a resource package that was my vision for surgical oncology. And I remember when they looked at that, they said, "I'm not sure we can meet these resource needs that would match your vision." So I said, "Thank you very much, I'll put it on the shelf." Just a few months later, Bob Hickey called me and asked me if I would come and look at the job as Chief of Surgery at MD Anderson, and I said, "Well, I have a vision for what I'd like to do if I were to move from Alabama," because my programs were going very well, and I knew this would be a different job in that I would have to give up a lot of the research and the program leadership [ ]. So I actually sent him a draft of what I had in mind, and the resources it would take, and he called back and said, "That'd be a good fit. We can match that." [laughter] So I came out here and met with Mickey LeMaistre [oral history interview] and Irv Krakoff, and two people that really helped in getting me here were Josh Fidler [oral history interview] and Margaret Kripke [oral history interview]. Because, remember, I was doing translational immunology research. I [wanted to make sure that [Dr.] Kyoko Ito, whom I'd trained as a postdoc and who was now on the faculty with me and running my lab, would come with me, so I needed a slot in immunology. The Surgery Department here was an excellent clinical program. But it did not have much of an academic research program. It had some NIH funding, but not much. The program was a one-year fellowship program, and most, except for a few people over a 10- or 15-year period, went into private practice. [Most of the surgery departments] did not have clinical trials. The philosophy was that, "this is the MD Anderson way, and [that extensive experience should dictate the standards of care" because we are the best cancer surgery program in the country." But, in fact, [doctors] weren't necessarily copying that way, because [they did not publish a lot of their surgical experience.] [ ] Nobody knew who Richard Martin and Ed White were, because they didn't really organize their data [prospectively and get it published]. They didn't do clinical trials. Irv Krakoff had [championed clinical trials in the Division of Medicine], and Mickey LeMaistre had wanted something in parallel in surgery, and so did Irv Krakoff. [ ] He had really organized an excellent clinical trials program [in medical oncology and I envisioned], that I could organize clinical trials within surgery if I were recruited here. There was a solid backing by [Dr. LeMaistre] to build an academic program in the Department of Surgery, with trainees who would become academic leaders, along with support for the role of clinical trials and database management in the Surgery Department.

T.A. Rosolowski, PhD:

What were some of the talking points that you had, the specifics of that vision that you presented to Dr. Clarkor to Dr. LeMaistre and to Dr. Hickey?

Charles Balch, MD:

Well, it was about having excellence in surgery [ ] [through superspecialization of surgical care]. The surgeons here would perform surgery in multiple anatomical sites, but no one was doing surgery in any one area. So one of the things that I'd seen was necessary for the high-end complex cases was super specialization, [surgeons focusing on primary cancer involving] one or two organs. [This concept] was part of the agreement that I was going to recruit people to do just liver surgery, just pancreas surgery, just breast surgery, as a way of superspecialization, and of [clinical research] leadership, because they focused on one disease. There was also the vision of having database management, biostatistics, [staff for] clinical trials, and then the idea of setting up multidisciplinary care. [So I saw an opportunity, as long as the resources were there and the support was there from the president, to create something that I could envision happening at MD Anderson. And it was really around developing excellent programs and faculty in academic surgical oncology.] [Later on, we established] the first breast center [ ] with Eva Singletary and Gabe Hortobagyi [oral history interview]. And finally, the idea that we as surgeons do laboratory research that's NIH-funded, and you do that only because you could partner with good laboratory researchers [in basic science departments, for which at the time there were really three people: Josh Fidler [oral history interview] (cancer biology), Margaret Kripke [oral history interview] (immunology), and Garth Nicholson (tumor biology) who were [Chairs of the basic science departments]. Josh and Margaret were [great supporters and collaborators]. I was a Professor of Immunology in Margaret's department, and my laboratory was in the old Smith Building. In fact, just as one side note: they had to take out the side of the building to extract the old two-story freezer that R. Lee Clark had put in those buildings [laughter] in order to reconstruct a laboratory for me.

T.A. Rosolowski, PhD:

That's really funny.

Charles Balch, MD:

This is another story about how Lee Clark had a vision for food services for the entire University of Texas System. [ ]

T.A. Rosolowski, PhD:

Now, when you came, and you were speaking to people here, taking the temperature, what did you feel? I mean, obviously you wouldn't have come if you'd thought, oh my gosh, the leaders want this but the troops on the ground are just never going to make me able to create this vision in reality. But what was the temperature you were taking? What were some of the currents that you were envisioning about where stress was going to come from, or?

Charles Balch, MD:

Oh, I was not well-received [at first by some] in the Surgery Department. First, I was younger than any professor that was here. I was actually one of the youngest surgery chiefs in the United States. [ ] So that was part of it. Also, I was the first person to come on faculty in recent years who did not train at MD Anderson. And more than that, my training was more based upon Memorial Sloan Kettering than MD Anderson, which

T.A. Rosolowski, PhD:

What are the differences there?

Charles Balch, MD:

[ ] I'll give you one example. When I came here, that the surgeons at MD Anderson still had the concept that their surgical instruments [ ] would spread the cancer around and cause a recurrence. So each time they used an instrument they would put it in a pan, and a full-time person would go flash the instruments and bring it back. And when I found out about that, and the cost of administering that in every operating room, I ask about, "Well, why are we doing that?" And they said, "Well, that's what they do at Memorial Sloan Kettering." And I said, "They abandoned that a long time ago, and we're going to abandon it, also." Because there's no biological basis for it. So there wasa lot of my initial resistance was to changing the traditions of MD Anderson, which had been perpetuated for years. But in a sense, especially in the general surgery department, they'd become insulated to changes that were accepted in the outside world but weren't yet adopted here.

T.A. Rosolowski, PhD:

Interesting. Could you give me a couple more examples of things like that? Nobody's ever gotten that granular about it, and it's just interesting to have that on record.

Charles Balch, MD:

I think one of the major things that I had seen is that surgeons on the outside had begun to super-specialize, especially around the difficult cases: liver surgery, pancreas surgery, regional perfusions. We were doing limb perfusions here based upon tradition, but without any convincing evidence [on the indications], and I really questioned the indications [especially when used prophylactically]. Sometimes patients were referred for prophylactic perfusions, even though the risk of getting recurrent disease [ ] was low to nonexistent. And yet there was a cost and complications for these patients. What I observed didn't really have a legitimate indication other than "the doctor referred the patient for that reason." When I came here [in 1985] we were the Department of General Surgery, which [was the tradition] first, with Ed White and then with Dick Martin. And the training was that surgeons did everything, outside of the specialty areas of gynecology, head/neck, and urology, [ ] but everything else was in the Department of General Surgery. There wasn't any [disease specific] specialization, and there wasn't any training of surgeons to become superspecialized surgeons, or to have a disease site area of expertise, clinically, academically or in their research.

T.A. Rosolowski, PhD:

And that was behind the times.

Charles Balch, MD:

It was way behind the times.

T.A. Rosolowski, PhD:

Okay, yeah.

Charles Balch, MD:

So one of the things I did early on was to reorganize the Department of General Surgery into the Department of Surgical Oncology, and set up sections within this: Section of breast surgery, Section of colorectal surgery [and so forth]. I recruited Mark Roh from Memorial Sloan Kettering, because I wanted to break that mold of "the MD Anderson way." Some of those traditions were good, but some of them needed to change, because the surgical field had changed. So I recruited Mark Roh from Memorial to do full-time liver surgery. And instead of restricting anybody's practice, I said, "If you do liver surgery, your outcomes have to be the same as Mark Roh's, so be careful on the patients you select, because we're going to be monitoring and looking at the outcome, including complications and mortality rates of the patients that you choose, and that the outcomes should be the same regardless of who does the surgery in our department." That was a philosophy of outcomes as part of credentialing, and not legislating what the faculty would do, but by telling them that you had to meet certain quality indicators if you're going to do high-end cases. [For many complicated cases,] you really can't do that and be a general surgeon.

T.A. Rosolowski, PhD:

It also kind of, in terms of culture, it seems like it would help soften that whole environment of the ego, the superstar.

Charles Balch, MD:

And you know what? People found that, "wow, Mark Roh does really good liver surgery." The nurses in the operating room started that, said, "He's really good." And it began to give a contrast with some people who were doing it occasionally. So I recruited two other people from Memorial that are part of the story. One is Michele Gadd, to do breast surgery here. Michele Gadd later married Ken Tanabe after he'd finished his fellowship, and they both are at Massachusetts General Hospital. And I also recruited Peter Pisters to come from Memorial Sloan Kettering for his first job to do sarcoma surgery here. In fact, that's an interesting story, since Dr. Pisters is now our President. So he and his wife Kathy, who is a medical oncologist in lung cancer, had finished their training and were considering staying with Memorial Sloan Kettering. So I flew up to New York with a written offer for Peter from me, and a parallel letter from Irv Krakoff for Kathy Pisters, to recruit them both to MD Anderson. I went to their apartment, and asked them to consider coming here, which wasn't, I don't think, on their radar screen at the time. So they did come down and visit, and they signed on, and the rest is history.

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Chapter 06 : Surgical Oncology at MD Anderson, Part I: Changing Surgical Tradition

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