Chapter 27: The Melanoma/Sarcoma Center: An Early Multi-Disciplinary Center

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Chapter 27: The Melanoma/Sarcoma Center: An Early Multi-Disciplinary Center

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In this chapter, Dr. Benjamin talks about the evolution of the Melanoma/Sarcoma Center, first established in the mid-nineties as one of the first multi-disciplinary centers at MD Anderson, predating the official institutional commitment to reorganizing care as multi-disciplinary. Dr. Benjamin explains that the cordial and collaborative relationships with surgical and orthopedic oncologists were well established and fit easily into the new model. Dr. Benjamin notes that he is very proud of the Center, which he headed from 1996 to 2006 and which he believes serves as a model of patient care. He talks about the approach that makes the Center so successful. He cites in particular MD Anderson's long-standing tradition of multi-modality treatment. He says that surgeons at other centers can be "very forceful" whereas at MD Anderson surgeons accept help easily from medical oncologists. He explains that this collaborative relationship emerged from trials he and others in Sarcoma conducted to demonstrate the value of chemotherapy. However he also notes that the tradition goes back farther, to earlier studies of amputation and then radiation as sarcoma treatments. . He tells some of the history of multi-modality treatments. Next, Dr. Benjamin notes that Winona Nelson has specific details on how the Center evolved. Dr. Benjamin explains that his role was to identify surgical, medical, and radiation people interested in collaborating. He says that the Center was originally located in Station 55 on the fifth floor of what is now called "the Main Building." Dr. Benjamin then talks about why the Center is a model of patient care. He explains that from the beginning, the Center worked from the model that a patient was "our patient," not a specific physician's, and passed easily between members of a team. He explains how teams work and that surgery can be the "last stop" in the multi-disciplinary process. He notes that medical oncologists spend the most time with patients. Dr. Benjamin then notes that it is difficult to speculate about the future of the Center as treatments will be much different in fifty years. He says he expects there will always be some kind of surgery, but that radiation treatments and cyto-toxic chemotherapy will be replaced with targeted medical treatments.

Identifier

BenjaminR_03_20150306_C27

Publication Date

3-6-2015

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; The Clinician; The Administrator; Discovery and Success; MD Anderson History; Building/Transforming the Institution; Growth and/or Change; Patients; Patients, Treatment, Survivors; The History of Health Care, Patient Care; Institutional Mission and Values; MD Anderson Culture; Multi-disciplinary Approaches; This is MD Anderson

Transcript

Tacey Ann Rosolowski, PhD:

Tell me about the Sarcoma Center, which was originally the Melanoma/Sarcoma Center, and it’s from my records that you were clinical medical director of that from 1996 on. Was that Center already in existence? Did you set it up?

Robert Benjamin, MD:

No, we set it up. It was one of the first multidisciplinary centers that we had here, and we had had longstanding good collaborations with the surgical oncologists and the orthopedic oncologists. So when the institution made the commitment to let’s have multidisciplinary centers, ours fit in very well, and it just brought us all physically into the same place. But since we’d already had the long collaboration and interaction, it was very easy to make that happen and to keep it going. And I think it’s worked out. It had worked out very well. I eventually gave up that role, I think probably when I became department chair or shortly after I became department chair, just because there are only so many things you can be running. But I’m very proud of the development of the Sarcoma Center because I think it’s a model for how patients should be taken care of.

Tacey Ann Rosolowski, PhD:

Tell me more about how it works, what it offers.

Robert Benjamin, MD:

So, I mean, unlike some of the areas where there are a large number of patients who end up needing just surgery or just radiation or just chemotherapy, I would say the vast majority of the patients that we see who don’t have just extensive metastatic disease end up needing all or at least several of the modalities available for treatment. So the majority of the patients that we have who have localized tumors end up getting, at the minimum, surgery and radiation, and more commonly end up getting chemotherapy, surgery, and radiation. And even patients with metastatic disease, who in most other areas are treated just with chemotherapy, frequently will have surgery added on to the mixture because the metastases in sarcomas are often localized in one spot or another, most commonly in the lungs.

Tacey Ann Rosolowski, PhD:

Can I interrupt you just for a second? Okay. My apologies for interrupting you.

Robert Benjamin, MD:

No problem. So I think what I was saying is frequently sarcomas metastasize to one organ system, most commonly to the lungs, and so even in patients with metastatic disease, it makes sense to use surgery in the management of metastases. So we have a longstanding tradition of multimodality therapy for our patients, and unlike some other centers where there is a very forceful surgical group that thinks they can do everything, the surgeons that we’ve worked with here are very willing to take help from the medical oncologists or the radiation oncologists, and so the interaction has actually been very good over time. We have a good group and very good interplay between the disciplines.

Tacey Ann Rosolowski, PhD:

I remember you telling me about when you were working on some of those drug studies about collaborating really effectively with surgeons, and it sounds like that interaction, the cordiality of that kind of interaction was really evolved over a very long period of time of involving all kinds of people in treatment. I mean, is that correct or—

Robert Benjamin, MD:

No, I think that’s probably true. We had some good luck early on in a few cases that definitely got the surgeons to open their minds to the use of chemotherapy and the incorporation of it into the treatment of the patients. But that mindset in our surgeons goes back even before the use of chemotherapy and certainly before I came to the institution, where the traditional treatment for a sarcoma of the extremity was an amputation, because one of the earliest papers on just resection of soft-tissue sarcomas comes from Dr. Clark, among others. I think it was Clark, White, and Martin. But what they found was when they just resected the sarcomas, they came back 75 percent of the time, and so their recommendation was that the only way to really treat these effectively was with amputation. Now, that’s in the days before we had good imaging to be able to tell exactly where the tumors began and ended and all sorts of other factors. But that was the traditional approach.Dr. Martin, one of those authors, who later became Chief of Surgery here, worked with Dr. Herman Suit from Radiation Oncology, and Dr. Suit said, “Well, let me try radiating these people and seeing whether we can get away without amputation, because I can radiate a bigger area than you can effectively remove.”So probably in the late sixties or—I think probably in the late sixties, they did their initial studies and showed that, yes, if you gave radiation, which wasn’t supposed to work for sarcomas, in addition to surgery, you could get away with saving limbs. And that had been pretty well established here before I came in ’74, and Dr. Suit had already left, I think, in ’73 or ’72 to go up to Harvard. So the surgeons were open to ways of trying to not have to do mutilating surgery, especially when patients usually died anyway. So when we found some chemotherapy drugs, which sometimes had a really good effect on sarcomas, they were willing to say, “Oh, okay, let’s try that.”

Tacey Ann Rosolowski, PhD:

So tell me more about setting up the Sarcoma Center. How did you go about planning it, and what was the history of it evolving? How many patients did it treat originally and how did that—

Robert Benjamin, MD:

Oh, boy, I can’t tell you that.

Tacey Ann Rosolowski, PhD:

Oh, okay. I mean, you know, did you—

Robert Benjamin, MD:

The person who might be able to give you some of the actual details is Wenonah Ecung, who was the initial Center administrative director and was with us until she got moved into some of her current positions. But she was there when we started it, and she would know from the point of view of numbers and how the physical units got set up. But our job was simply to identify the surgical people interested, the medical people interested, and the radiation people interested and make sure that we could—

Tacey Ann Rosolowski, PhD:

So, building the teams.

Robert Benjamin, MD:

—we could work out a situation where we had clinics which at least existed immediately adjacent to each other so that we could easily move patients back and forth among the people there. And as I recall, before we moved into our current space, we basically took the space that we had used medically for Melanoma/Sarcoma and separated out the Melanoma group medically and put in the Sarcoma group surgically into the same physical area.

Tacey Ann Rosolowski, PhD:

Where was the clinic located—or center located?

Robert Benjamin, MD:

It was Station 55. So originally down on what then was called the fifth floor, but pretty much the same area, more or less.

Tacey Ann Rosolowski, PhD:

And that was in the Main Building?

Robert Benjamin, MD:

That was in the Main Building. There wasn’t another building.

Tacey Ann Rosolowski, PhD:

There wasn’t another building. Right. (laughs)It’s really hard. I was just doing a presentation on kind of earlier iterations of MD Anderson, and there’s a picture from the 1960s, late sixties, early seventies, and not only is MD Anderson so much smaller, but Houston is so much smaller. There’s trees all around, kind of amazing. It’s hard to imagine it.

Robert Benjamin, MD:

Even in the seventies, when I came here, it was infinitely smaller.

Tacey Ann Rosolowski, PhD:

Yeah, yeah. So tell me about now when the Center split into a Melanoma and a Sarcoma, did that follow the split of the departments into two or—okay. So tell me how that [unclear].

Robert Benjamin, MD:

No. So, no, because there were people who worked in both Centers from the medical side, and there may have been some people that worked in both Centers from the surgical side, but I don’t think so. I think they were pretty much separate already. Those of us who worked in either one or the other for outpatient management did it there, but our inpatient service was a united service. And we had an attending-physician structure so that, you know, somebody was on the inpatient service for a block of time, I think usually a month. Or maybe not. Maybe we had it where we just took care of our patients, but on weekends we covered the whole service. So those of us who did primarily sarcoma would still be seeing melanoma patients on the weekends.

Tacey Ann Rosolowski, PhD:

Interesting.

Robert Benjamin, MD:

And then later it split completely when the departments split.

Tacey Ann Rosolowski, PhD:

Now, you said that you felt the Center was really a model for how care should be delivered. Why is that? I mean, what is so exemplary about it?

Robert Benjamin, MD:

So I think the key thing is when it started was there wasn’t the concept that a patient who came in to see me was my patient. He was our patient, and if he needed primarily surgical management, he would pass easily to the surgical team. People who needed multidisciplinary management passed very quickly from one team leader to another during the course of the therapy. There was just a very cordial interaction and much more so than I’ve seen certainly in other institutions and probably—I don’t have sufficient direct exposure to some of the other departments and groups within this institution, but I think some of the interactions that I’ve witnessed in some of the other groups are, let’s just say less cordial. (laughs) I think there’s much more of the sort of typical possessive nature that a patient who comes in to a surgeon is a surgical patient, and he’ll do surgery and then refer off to a medical oncologist or a radiation oncologist or whatever. Here we actually talk about the patients in the beginning, and very frequently the surgeon is not the first treating physician. So if we’re going to do multimodality therapy, we usually do chemotherapy first so we can see what the chemotherapy is doing, and then frequently we’ll also do radiation before surgery, and then do surgery as sort of a last step in the multidisciplinary process. It’s very different from the interactions that I see in a number of the other departments.

Tacey Ann Rosolowski, PhD:

What’s the experience like for the patient? Because I think a lot of patients have the ideas like, “Oh, X is going to be my doctor.”

Robert Benjamin, MD:

Yeah.

Tacey Ann Rosolowski, PhD:

What’s the experience like being flipped between different physicians?

Robert Benjamin, MD:

So, no. So it’s not usually a problem. X, who is his doctor, usually will continue to see him over a long period of time, but there are just times when, okay, your treatment now needs to be this, so for this period of time, Dr. Y is in charge, and when he’s finished, you’ll come back to me. It actually works out very well.

Tacey Ann Rosolowski, PhD:

Wow. Interesting.

Robert Benjamin, MD:

And the people who end up usually spending the most time with the patients, just because of the nature of the modality, are the medical oncologists, because a surgeon goes in and does a surgery, and a big surgery may be twelve hours and two weeks or three weeks in the hospital, but once you’re through with that, you’re through with it. And the chemotherapy goes on for months at a time, so there’s a lot more repetitive visits with the medical oncologist than there are with some of the other disciplines of treatment.

Tacey Ann Rosolowski, PhD:

Is there anything else—well, let me ask you this. I mean, what’s kind of in the future for the Center? How would you like to see it evolve? How will it evolve?

Robert Benjamin, MD:

Very, very difficult question to ask, and it’s all going to depend on how much we learn, you know. Fifty, a hundred years from now, the treatments are all going to be much, much different than they are right now. So it’s hard to predict. I expect that we will always have some form of surgery for the majority of patients, but what it will be I can’t tell you. I expect that maybe in a naïve fashion I expect that maybe radiation therapy will disappear, and I expect that the current approaches of cytotoxic chemotherapy will disappear because we’ll have much more specific, highly targeted medical treatments that will get used. But I think even fifty years from now, we’ll still be doing surgery, just probably not quite so much, and we’ll be doing some forms of systemic therapy. So how everyone will interact and how we’ll do things, I don’t know. I won’t have to worry about that in fifty years, since I won’t be along for that long. Or if I’m around, I won’t remember.

Tacey Ann Rosolowski, PhD:

(laughs) Well, as we’re—I’m sorry, go ahead.

Robert Benjamin, MD:

I’m just thinking in the interim, I just think we’ll continue to evolve slowly and get a little bit more specific about the ways that we use drugs, and what gets done surgically will always be a function of how effective the general systemic therapy is. I mean, we rarely use surgery for lymphoma. We just cure it with drugs. So maybe we’ll get that good at treating other things.

Tacey Ann Rosolowski, PhD:

Interesting. Yeah.

Robert Benjamin, MD:

But I think it’s got a way to go before we do that.

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Chapter 27: The Melanoma/Sarcoma Center: An Early Multi-Disciplinary Center

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