Chapter 10: Research in Breast Medical Oncology: Pushing Against Medical Conservatism

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Chapter 10: Research in Breast Medical Oncology: Pushing Against Medical Conservatism

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Dr. Buzdar begins this chapter by describing the overall culture of medical conservatism he and others faced as they conducted studies with chemotherapy. He talks about the innovations led by J Freireich and Emil Frei in the Department of Developmental Therapeutics, and that it took a while to convince others in the institution about the value of combination treatments and aggressive treatments. Next, Dr. Buzdar sketches a picture of how small Breast Medical Oncology was when it began, occupying only a hallway with pull-down desks to write on. Despite such small beginnings, he points out, MD Anderson research had great impact on the natural history of breast cancer; he cites the publication of a recent book on MD Anderson treatments for the disease. Dr. Buzdar also cites the influence of R. Lee Clark on this research, noting that he instituted the policy of keeping comprehensive data on patients (following a patient to the end of his/her life, if possible). He describes Dr. Clark as "down to earth" and tells a story about sleeping in Dr. Clark's office.

Identifier

BuzdarA_02_20170216_C10

Publication Date

2-16-2017

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 - MD Anderson History; Discovery and Success; MD Anderson History; MD Anderson Snapshot; MD Anderson Culture; Controversy; Research; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Portraits

Transcript

Aman Buzdar, MD:

They were skeptical, very skeptical.

Tacey A. Rosolowski, PhD:

Right. That's amazing. Well, you're really pushing, doing something totally new, and pushing against that entrenched mindset that there wasn't anything you could do about these diseases at all.

Aman Buzdar, MD:

Oh yeah, because the thing is, the mentality at that point was, as I told you, that even you pick up the textbooks in this era, that thou shall not harm these patients. So their approach was that here, we're giving them the chemotherapy. Their hair will fall out, they are vomiting, some can end up with a fever in the hospital, and you are making their life much more miserable, but we had to show them that a proportion of these patients are alive, free of cancer, with this approach, and it took major act.

Tacey A. Rosolowski, PhD:

Now, what was special about the environment in Breast Medical Oncology? Obviously, there was a group of people who were willing to do this. What was that about?

Aman Buzdar, MD:

When I came at that point, at that point there were two departments. It was one department, it was called Medicine, which was the chair at that point was Dr. Shullenberger, C.C. Shullenberger, he was the chair of the Department of Medical Oncology. Dr. Freireich [oral history interview] and Dr. Frei had come a few years prior to that and they had developed a department, what was called Developmental Therapeutics, and they were very much into this newer approaches, that we need to evaluate these newer drugs, to see whether we can change the biology of the disease. Whereas in the Medicine Department, people were much more conservative, and our Surgery Department was much more conservative, that they didn't want to do. Their approach was that I shall do no harm first. But the reality was that these patients were dying. And we, in collaboration with a person --he has unfortunately died a few months ago, Dr. George Blumenschein-- he was a person who was the section chief, appointed. Prior to that, there was Dr. Nylene Eckles, and some of the other people, they were very conservative. They were just giving palliative treatment to these patients. And do no harm, that was their approach. Then I and Dr. Hortobagyi came as a fellow and Dr. Blumenschein, from the other side, came as a section chief. That was the nucleus of Breast Medical Oncology. We wanted to evaluate and offer these therapies to the patients, to see whether we can favorably change the outcome of the disease. I think it took us a while to convince it, but it became -- it was even not just within the walls of MD Anderson. Even when you went and presented some of this data in the national or international meeting, people will at times tell you to your face, oh yeah, everything works at MD Anderson.

Tacey A. Rosolowski, PhD:

What did they mean by that?

Aman Buzdar, MD:

It means that this is just BS, in other words, for lack of a better word, that they had to carry out their own clinical trials to confirm that. Because at that time, the national studies which were ongoing, when we were giving these fairly --what we called and our colleagues used to call-- aggressive therapy, the national studies were giving melphalan. This is a drug which has -- if you give it to the patient with metastatic disease, the very occasional patient will get any benefit. And they were giving it to the patients to see that it will prevent the cancer recurrence. Even Betty Ford was given that.

Tacey A. Rosolowski, PhD:

Wow. So, when did you really start to see a change within the institution, you know that the conservatism started to shift? Obviously, the evidence was coming out, you're talking to people saying yes, this is a reality. Were there other things that had to happen in the culture, to kind of move the institution away from this more conservative approach?

Aman Buzdar, MD:

I think that once they saw walking, talking, living patients who, in their books would have been dead, then things started to change within our own group. In the beginning, our surgeons will operate and they will send the patients home.

Tacey A. Rosolowski, PhD:

Oh really? So no collaboration.

Aman Buzdar, MD:

Very little collaboration. We will get patients who were operated outside, and the surgeons outside recognize that they were doing poorly, they will send it to us. But then once we showed them, and I published the first data, then the ball started to turn, that patients started to come who had surgery at MD Anderson. [013:52]

Tacey A. Rosolowski, PhD:

Interesting, okay, okay. Now, when did you start holding, in Breast Medical Oncology, the kind of conference style?

Aman Buzdar, MD:

Well, that was even before we came, that was a long time. Even in those conferences, Hortobagyi and me, and Blumenschein will go and sit there, and I will be the only one, because I was doing these adjuvant drugs. I said we need to give them the chemotherapy. And the people --surgeons and the radiotherapist-- tell me to my face, they will say, "Dr. Buzdar, I am sick of you talking about this chemotherapy." I said, "This is here to stay and we need to offer this, to change the natural history of the disease."

Tacey A. Rosolowski, PhD:

So you had to just keep hammering that message.

Aman Buzdar, MD:

Oh, yeah.

Tacey A. Rosolowski, PhD:

Wow, that's amazing. When did you notice a change in those meetings, you know people opening up their minds?

Aman Buzdar, MD:

I think it didn't take very long. Two, three, four years later, because we had at least a small number of patients, more than 100-plus patients. We published those data.

Tacey A. Rosolowski, PhD:

Right, right.

Aman Buzdar, MD:

And there was a group which was in University of Arizona, in Tucson, and they started a meeting which was called adjuvant therapy of cancer. So, first meeting, me, and Dr. Blumenschein, presented our own experience in patients with breast cancer, who were at a very high risk of recurrence after local therapy. And Dr. Blumenschein presented the patients who had one isolated recurrence and were given chemotherapy after removing the isolated recurrence, that here, we have natural history, and that book was published in, I think 1977.

Tacey A. Rosolowski, PhD:

Wow.

Aman Buzdar, MD:

After that, we published it also in the peer review journals, all this information, that slowly, things started to change.

Tacey A. Rosolowski, PhD:

How did that affect, I mean just in a very practical level, you're talking about what was going on in Breast Medical Oncology and how small it was, and I'm dying for you to tell again, how small Breast Medical --

Aman Buzdar, MD:

Well, Breast Medical Oncology, when I came as a fellow --even as an attending-- the Breast Medical Oncology was these two tables put together. They were actually not even tables. These were like these things which were hinged to the wall. In the morning, they will come down, in the evening, because it was a hallway, there was no room, they would put it up, and we would stand over there and then you had a little dictation room where you went and dictated all your notes and chemotherapy orders.

Tacey A. Rosolowski, PhD:

I love the look on your face, it's like oh wow, those were the days.

Aman Buzdar, MD:

I could even show you where it was. It was a hallway in which you go to the library, that hallway which is now nothing but offices, closed. That's where these desks were.

Tacey A. Rosolowski, PhD:

That's amazing.

Aman Buzdar, MD:

That's where our desk was, and then there was Developmental Therapeutics. Frei --they had one room which was about the size of [gestures] maybe, if you put a wall over there. That was the whole department.

Tacey A. Rosolowski, PhD:

So like 12’-by-12’.

Aman Buzdar, MD:

Yes. It was a whole Department of Developmental Therapeutics.

Tacey A. Rosolowski, PhD:

In a 12’-by-12’ room. A smaller institution, but of course, demonstrating the value of the work and the paradigm that you were bringing changed that pretty quickly.

Aman Buzdar, MD:

But the thing is, it has to change. The whole [field of] oncology has changed. And now you could see that so many patients with so many disease --at that point, we were not even telling a woman with breast cancer that we may be able to keep you free of disease, until we showed the data. But now, you look at it, it's 80 to 90 percent of the patients with breast cancer can remain alive, free of disease, if appropriate therapy is done, unless a small number of patients unfortunately have de novo resistant disease. So that is a dramatic shift of the natural history of the disease. Actually, we published -- there is a book called What Has Been the Natural History of Cancer Treated at MD Anderson Hospital. I can show you, just use this piece of paper.

Tacey A. Rosolowski, PhD:

Sure.

Aman Buzdar, MD:

This paper actually, even you can look at the book, Dr. Alma Rodriguez is one of the co-authors of that, and editor of the book. MD Anderson is a very unique place, where you could look at the patients who were treated in the '40s, '50s, '60s, '70s, '80s, '90s, 2000s. So what we looked at? Patients’ outcome’. [draws] This will be the '40s, '50s, '60s, '70s, '80s.

Tacey A. Rosolowski, PhD:

Wow. So, just the increase in the number of patients.

Aman Buzdar, MD:

Yeah, these data are published. I can even give you the whole book monographed.

Tacey A. Rosolowski, PhD:

Yeah, that's amazing, that's incredible, and Alma Rodriguez edited that book for publication?

Aman Buzdar, MD:

It is just looking at -- this is in breast cancer. We looked at patients even with metastatic disease. Metastatic means disseminated cancer. You saw the shift this way.

Tacey A. Rosolowski, PhD:

That's amazing.

Aman Buzdar, MD:

And in early stage breast cancer, like say operable breast cancer, this same way. These are graphs and when I saw these things, because these are the data from our -- we have very -- you can look at the patient number one chart, pull it out today and look at it, what happened to the patient. Because one thing which Dr. Clark --and they had tremendous amount of vision, that we have the most comprehensive data on patient follow-up. If a patient comes once to MD Anderson, every attempt is made to get follow-up until the patient is deceased, we have follow-up on the majority of these patients. So this is how we can say that what has happened from the '50s, '60s, '70s, '80s, '90s.

Tacey A. Rosolowski, PhD:

Wow, that's an amazing tool. I'd never really heard anyone say that, and it was Dr. Clark who insisted on that.

Aman Buzdar, MD:

It was under his vision, because that has been there from when I came, in the '70s, and Clark was alive at that time.

Tacey A. Rosolowski, PhD:

Right, sure. What did you think of Dr. Clark?

Aman Buzdar, MD:

He was a very down to earth person. Actually, this is a very interesting story because a year before we came --at that point, because oncology was still evolving, mostly surgery and radiotherapy, so the medical oncology was in its very infancy. So there was --even though fellows were there, trainees, they didn't have anybody who was in the hospital if something happened. It was just a year before that, they started that --Oh, we need to have somebody on call 24 hours, seven days a week. They had no place for us. I remember sleeping on a little cot, which would be put in Dr. Clark's office at night. You went and slept there, and every 15 minutes the phone will ring. And Dr. Clark, being a surgeon, usually the phone quits ringing about four or five o'clock in the morning, because the shift of the nurses is changing. At that time, Dr. Clark will show up and you have to get out of there. [both laugh]

Tacey A. Rosolowski, PhD:

That's pretty great, he let you sleep in his office.

Aman Buzdar, MD:

It was a unique thing. Things evolved and they have evolved dramatically.

Tacey A. Rosolowski, PhD:

Yeah, yeah, that's pretty incredible.  

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Chapter 10: Research in Breast Medical Oncology: Pushing Against Medical Conservatism

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