Chapter 10: Advances in Radiology Continue to Raise Questions about Ethics and Consent
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Description
little oversight over doses of radiation administered. In 1986, however, the institution created new consent forms for oblating patients. Dr. Podoloff explains that this instituted a new process that eventually “humanized” radiology research by building in a view of the patient receiving experimental treatment.
As part of this discussion, Dr. Podoloff talks about the ethical complexities in Dr. Emil J Freireich’s work [Oral History Interview] and work in Developmental Therapeutics, where researchers often gave extremely high doses of drugs.
Dr. Podoloff says he faces a current dilemma in his own research, and he is considering whether questions about dosages of IPQA will prevent him moving forward with clinical trials.
Dr. Podoloff next observes that if you’re purely scientific about medicine, you treat a patient like a test tube, but “we have to be human.” He talks about attitudes of cancer patients when considering issues of consent: they want to feel better and function as they did before their illness. He also notes that it is hard to “sell” imaging to a patient as an experimental element of a treatment plan, as there is no direct outcome. He notes that he is very dependent on patients’ altruism.
Identifier
PodoloffD_01_20150402_C10
Publication Date
4-2-2015
City
Houston, Texas
Interview Session
Tacey A. Rosolowski, PhD, Oral History Interview, April 02, 2015
Topics Covered
The University of Texas MD Anderson Cancer Center - Institutional Change; The Researcher; Ethics; On Research and Researchers; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Patients; Patients, Treatment, Survivors; MD Anderson History
Transcript
Tacey A. Rosolowski, PhD:
Start us off recording again. OK. We’re back after a little bit of a break, about ten-minute break. It is now 11:15. And we were strategizing a bit before we turned the recorder on and thought it might be a good idea at this time to set a little bit of context. So if you could tell me, give me an overview really of the evolution of technology and how that’s had an impact on your own work. And obviously we’ll be touching on how it’s had an impact on the various institutions that you’ve worked in.
Donald A. Podoloff, MD:
Sure. Well, the development of computerized tomography is probably the most significant thing that happened in cancer diagnosis in this century—or last century.
Tacey A. Rosolowski, PhD:
And when did that—
Donald A. Podoloff, MD:
It became a clinically usable tool around 1972.
Tacey A. Rosolowski, PhD:
Wow.
Donald A. Podoloff, MD:
And it was originally just done for brain. But then body scanners came out like ’75, ’76. They were slow. The first ones took four minutes to make a slice.
Tacey A. Rosolowski, PhD:
Really.
Donald A. Podoloff, MD:
Yeah. And overnight it had enormous impact. We used to do seventy liver scans a day with nuclear stuff. When CT came along, it went to zero, because you could see the entire body, not just the liver. They actually performed the same, the early versions, in terms of liver lesions. But you saw so many other things, so many other organs, with the CT that almost overnight it went away. Same with the brain scan. We used to do forty, fifty brain scans a day. CT took that business entirely away. So at the same time that was happening cardiology was coming up and—
Tacey A. Rosolowski, PhD:
Now just so I understand, what’s the advantage for the clinician to see the broad context of the body?
Donald A. Podoloff, MD:
Well, for the surgeon it’s self-evident. They can see the whole organ system they’re going to be operating on. For the internist you could find other diseases in other organs. You could find that you had metastasis in your peritoneum, which you could never see that on a liver scan, even though you find liver mets. And for a while, some would say still, for a while our ability to see these things didn’t have a useful correlate clinically in terms—we didn’t have anything to treat. We went from doing liver scans to doing CTs of the liver, but we still had the same rudimentary kind of treatments. So if you keep that thought in mind, what you will see is that the biology starts to catch up with the anatomy.
Tacey A. Rosolowski, PhD:
Oh, interesting.
Donald A. Podoloff, MD:
Yeah. And that’s not true only for cancer. It’s true for all diseases.
Tacey A. Rosolowski, PhD:
Interesting. Do you need to take a minute to check in on what’s going on?
Donald A. Podoloff, MD:
Yeah, I want to make sure that I don’t have a really serious—
Tacey A. Rosolowski, PhD:
OK, let me just— [The recorder is paused.] All right. So we just paused for a few seconds. So the CT is obviously a huge advance. I mean what are some other advances that were taking place? Because obviously I mean there was development. That was in the 1970s. So there had to be others.
Donald A. Podoloff, MD:
Well, in the 1970s we learned how to use drugs better. I told you early on that cardiotoxicity used to be a huge problem with Adriamycin. The MUGA scan taught us when to stop giving it, or how to adjust the dose. And then we learned that if you give it over twenty-four hours rather than as a bolus the cardiotoxicity decreases. And they did that, that work came out of here. That was Bob Benjamin did that work here. So it changed therapy. But it was the imaging that helped with that. Before you had CT, the only way you could measure a lesion was on a chest X-ray in a two-dimensional way. CT gave you the ability to look at x, y, and z, the three-dimensional aspects. And tumors are three-dimensional creatures, they’re not two-dimensional. So that marriage of the technology to the diagnosis of the disease evolved very quickly because of improvements in the CTs. They got faster. They got better resolution. So there’s always been this technology-disease interaction that over time improves the detection.
Tacey A. Rosolowski, PhD:
What was the next big landmark advance?
Donald A. Podoloff, MD:
PET/CT.
Tacey A. Rosolowski, PhD:
PET/CT. OK. So tell me about that. You mentioned it earlier.
Donald A. Podoloff, MD:
We had PET. The blobs I showed you. And we had CT. And you would have to do that to merge it. Or you could write software that would do it, computer. That’s the other big thing I forgot. The computer made computational things that used to take months to do easy to do in days or minutes or hours.
Tacey A. Rosolowski, PhD:
What kinds of computations are we talking about?
Donald A. Podoloff, MD:
Well, today we’re talking about sequencing a gene. It used to take a month to sequence a gene. Now it takes five minutes. And that’s all computational.
Tacey A. Rosolowski, PhD:
But I mean computational in terms of the imaging.
Donald A. Podoloff, MD:
Well, the early images were very crude, sixty-four-by-sixty-four matrix. Now things are done 512-by-512 routinely.
Tacey A. Rosolowski, PhD:
I’m sorry. What does that mean?
Donald A. Podoloff, MD:
It’s the resolution. It’s how little a lesion you can see.
Tacey A. Rosolowski, PhD:
Oh, I see, OK.
Donald A. Podoloff, MD:
And probably one of the most important things that I’ve learned while I’ve been here is cancer is a systemic disease. The tumor that you see is a local manifestation of that disease but it’s like an iceberg. What’s really going on with that tumor is hidden from view most of the time. That’s why our therapies have been so inadequate, even though they were very startlingly—and they changed childhood leukemia from a universally fatal disease to one that’s eighty percent, ninety percent curable today. And that was J Freireich [Emil J Freireich, Oral History Interview] who did that. And I’m sure you’re interviewing him.
Tacey A. Rosolowski, PhD:
I have interviewed him, yes.
Donald A. Podoloff, MD:
That must have been interesting and entertaining.
Tacey A. Rosolowski, PhD:
(laughter) He is a character, as everyone says. But delightful guy to interview, yeah.
Donald A. Podoloff, MD:
Yeah, I adore him. I wrote a note to him Sunday. I said, “J, it was a pleasure to see your smiling face on the front page of the Chronicle. You’re to be congratulated for your awesome work.” I said, “And secondarily it’s the first time in my remembrance that Todd Ackerman has ever said anything nice about somebody at MD Anderson, and by inference the institution.”
Tacey A. Rosolowski, PhD:
(laughter) That’s funny. So you were talking about a tumor being like the tip of an iceberg. So how have advances in imaging helped with that issue?
Donald A. Podoloff, MD:
Because we can now look at the function. Rather than just the anatomy, we can look at the genome, we can look at the metabolites and metabolomics. We can image the Krebs cycle, which is a chemical event by which tumors are nourished. So we’re beginning to merge, just like we do with PET/CT, medically in the real, nonimaging, world we are merging function and form. And that has led, along with the computational power, to answering questions that we didn’t have a clue about. The way chemotherapy was invented—and Jay can tell you about this better than I can because he did it—is that they poisoned cells. And because cancer was more rapidly dividing, it was more sensitive to the poison. But the poison killed everything. Jay has a bunch of postulates. And I think his number one postulate is responders do better than nonresponders unless they die of toxicity. And so with this new class of drugs we’re getting away from the toxic effects because we’re targeting things better. We’re only going after cancer cells in some of these targeted therapies. It’s a great time to be an oncologist. I wish I was fifty instead of seventy.
Tacey A. Rosolowski, PhD:
It’s interesting. I think I’m probably like a lot of people in that when I began doing the background research for this, even though I’ve heard words like PET/CT and that’s been in my consciousness, I still had this intuitive and misinformed sense that imaging is really a picture of something physical and static, and not that it’s a picture of a process or of the possibility for a process.
Donald A. Podoloff, MD:
I’m glad you’re learning that. Now don’t get me wrong. Ninety-five percent of both pathology and radiology is still looking at static images.
Tacey A. Rosolowski, PhD:
Right. And I imagine that’s going to be the workhorse still for a long time. But the idea that now technology has expanded that range.
Donald A. Podoloff, MD:
So you can look at function as well as form.
Tacey A. Rosolowski, PhD:
You can look at function. It’s a totally different way of thinking. I mean I can see how you’d be very intellectually excited by these advances.
Donald A. Podoloff, MD:
Yeah, it is. And the companies are beginning to think about that this way. So fifteen years ago, and this is relevant to CABI and its formation, GE partnered with us to build this wonderful building, because they thought we would be developing instruments that they could then sell.
Tacey A. Rosolowski, PhD:
Interesting.
Donald A. Podoloff, MD:
Well, they have acquired over this fifteen years some biologic companies, and some PET tracers, and so they were changing their focus from pure instrumentation to function, to chemistry. They ran into a buzz saw when they did that because the timeline for the development of instruments versus drugs is very very different. And the culture amongst pharma versus instrument companies is like North and South during the Civil War.
Tacey A. Rosolowski, PhD:
How are they different?
Donald A. Podoloff, MD:
Well, they’re different because the expectations are different. In the instrument world you expect that you’ll bring an instrument from a laboratory into clinical use in a year or two.
Tacey A. Rosolowski, PhD:
OK, so pretty quick.
Donald A. Podoloff, MD:
Yeah, compared to pharma. Now that’s changing too because government regulation is making instrument companies jump through a lot of hoops now too. And it’s all related to patient safety. And that’s another huge thing that just crept into my mind.
Recommended Citation
Podoloff, Donald A. PhD and Rosolowski, Tacey A. PhD, "Chapter 10: Advances in Radiology Continue to Raise Questions about Ethics and Consent" (2015). Interview Chapters. 738.
https://openworks.mdanderson.org/mchv_interviewchapters/738
Conditions Governing Access
Open
