Chapter 06: Radiation Oncology at MD Anderson
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Description
Dr. Cox briefly describes how radiation is used to kill cancer cells and mentions a few of the first studies to investigate its effects.
Dr. Cox then talks about the Dr. Gilbert Fletcher’s role in developing radiation therapy and its use at MD Anderson. He discusses the challenges Dr. Fletcher faced during this time when surgeons believed that the best treatment was to surgically remove cancer. Dr. Fletcher eventually convinced the MD Anderson community that radiation therapy could be successfully combined with surgery for positive patient outcomes. Dr. Cox talks about the attitudes of several surgeons: Dr. William MacComb, Dr. Richard Jesse, and Dr. J. Ballantyne.
Dr. Cox describes Dr. Fletcher’s strong will, his unique form of genius, and his honesty even about toxicities of radiation levels. He notes that MD Anderson people “had great affection for him.”
Identifier
CoxJ_01_20130103_C06
Publication Date
1-3-2013
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - Personal Background; Overview; Definitions, Explanations, Translations; The Researcher; The Clinician; Information for Patients and the Public; Building/Transforming the Institution; Building/Transforming the Institution; Multi-disciplinary Approaches; Controversy; Portraits
Transcript
Tacey Ann Rosolowski, PhD:
Let me go back to something really basic because you made a couple statements that I realize that I am probably much less educated about this than I need to be. How would you describe what radiation oncology is to a lay person? I mean, what is it as an intellectual discipline, and then what is (???)(inaudible)?
James D. Cox, MD:
It’s the use of ionizing radiations to kill cancer cells. One of the reasons why fractionation became such a big deal early on was when they first applied ionizing radiations they did it—you know—just for a long period of time with x-rays or later on with radium by just putting it on the skin—let’s say—and leaving it there. And what happened was essentially a burn—not a thermal burn and it wasn’t immediate—but it evolved into what would develop a crust and eventually a hole and be quite morbid. In France there were a couple of investigators that looked at what happened if you just gave three shorter applications instead of one, and it had a huge effect that was positive. They used the testes as the basis for a rapid cell renewal system that would be similar to a tumor, and they found that they could stop spermatogenesis without causing the necrosis of the scrotal skin whereas if they gave one application it would cause necrosis—I mean—it would cause death of the skin, but it would not turn out spermatogenesis. So it was the whole idea of selective cell killing and sort of looking at selective cell killing and dose distributions in the body by various—in various ways that is much of the history of radiation therapy. And really only in the last twenty years—well—I shouldn’t say that because the original interest goes back probably forty years, but mostly in the last twenty years that there has been the biggest interest in chemotherapy and radiation therapy together.
Tacey Ann Rosolowski, PhD:
Because originally radiation therapy was really partnered with surgery—is that the case or—?
James D. Cox, MD:
Yeah. It was, but not very—yes, it was. That is correct. Not what is very good. Not with very good results and not with necessarily very good strategy.
Tacey Ann Rosolowski, PhD:
So it sounds like maybe that was a partnership by default because there wasn’t anything else available at the time really—is that the case?
James D. Cox, MD:
Yeah. That is to some degree true. The very earliest clinical trial that was ever done in the United Kingdom was the use of postoperative x-ray therapy following mastectomy for cancer of the breast. There are still investigations going on in that whole general arena now with the intact breast, but it is amazing. That was begun in the late forties.
Tacey Ann Rosolowski, PhD:
Now when Gilbert Fletcher was here you had an opportunity to meet him?
James D. Cox, MD:
Uh-hunh (affirmative).
Tacey Ann Rosolowski, PhD:
You did? Yes? Okay. I know that he was very controversial, meaning kind of a flamboyant figure too as far as I understand, but do you think—what were the controversies surrounding his work? And understand please the spirit in which I am asking this because it is not really—you know—I mean—colorful characters are colorful characters, but what I am wondering is what were the issues really about radiation therapy that were driving these controversies and creating tension within MD Anderson about the use of radiation therapy?
James D. Cox, MD:
Well, the main controversy was the effectiveness of radiation therapy relative to surgery, and probably the single greatest area of disagreement and acrimony was with Fletcher and William McComb, who was the head of head and neck surgery. McComb came from Memorial Hospital in New York now called Memorial Sloan Kettering, and his idea was you could not cure anything with radiation therapy. You had to cut it out. And Fletcher, who had seen examples as I had of things—patients being successfully treated with radiation therapy with good long-term results, knew that that was not the case and knew that some of the operations that were being done by McComb and his colleagues were very morbid and were unnecessary because you could cure the same patients with radiation therapy. Fletcher fought like hell to get that across and eventually he succeeded. Now he succeeded partly because—I guess—McComb died. I don’t know when he died. But his successor—and I don’t know if it was his immediate successor or if there was somebody in between—but his successor was Richard Jesse, and Jesse was a much more open person and was willing to look at the results and advantages of radiation therapy and then figure out how to combine radiation therapy and surgery together to achieve the best results for the patient. So he was more of the—if you will—current philosophy or culture of MD Anderson that says ultimately it is really what is best for the patient that should drive everything we do, and anything else should take second place. And so Dick Jesse—and he was so respected by everybody—by Fletcher, by all the people in head and neck surgery, by people in other departments, he was a real leader. So that kind of gradually put that set of issues to bed, although when I first came to MD Anderson there were some carryovers from the McComb period, primarily Jay Ballantyne [Dr. Alando]. I don’t know if you know that name.
Tacey Ann Rosolowski, PhD:
I recognize it but not enough to (both speaking at once).
James D. Cox, MD:
Yeah. Well, Ballantyne was one of the last head and neck surgeons that thought he could do anything and should do it—could do anything and should do everything. And then eventually he died too.
Tacey Ann Rosolowski, PhD:
That was really kind of an old guard perspective.
James D. Cox, MD:
It was the earliest people in the history of MD Anderson because there was McComb in head and neck surgery, Lee Clark in general surgery, Fletcher, and then Felix Rutledge in gynecology. Now because radiation therapy and especially radium therapy was a standard part of gynecologic treatment of cancer of the cervix and endometrium, Fletcher and Rutledge came to working together much more easily, and they evolved the joint clinics as actually did the people in head and neck cancer.
Tacey Ann Rosolowski, PhD:
I actually didn’t realize that. How was radium used to treat gynecologic cancers at the time?
James D. Cox, MD:
It was put in the uterus.
Tacey Ann Rosolowski, PhD:
In what form?
James D. Cox, MD:
They were usually tubes of radium—and you know what a wine cork looks like?
Tacey Ann Rosolowski, PhD:
Uh-hunh (affirmative).
James D. Cox, MD:
Well they would put the wine corks inside the vagina, and then they had a tube of some various lengths that would go into the uterus itself, and that would be used to sort of surround the area where the cancer of the cervix was, and it was shown to be curative as far back as 1920.
Tacey Ann Rosolowski, PhD:
Really? I had no idea.
James D. Cox, MD:
Yeah. I might even have a picture. Here, move it over there. Okay.
Tacey Ann Rosolowski, PhD:
All right. There I go.
James D. Cox, MD:
But in the—
Tacey Ann Rosolowski, PhD:
I have to say it always surprises me when I hear stories like this because when evidence is mounting and there is a demonstrative effect from using something and yet there is an entire discipline that is resisting it—it just seems very strange. You know—again—how slow cultures are changed, how slow disciplines are to change.
James D. Cox, MD:
Well, one of the problems with surgery and radiation therapy was that at some institutions surgeons were the ones who used the radium to treat cancer, and so they thought they knew everything about it.
Tacey Ann Rosolowski, PhD:
I see.
James D. Cox, MD:
Let me see if I can find it. I’m not finding the chapters. Somewhere it’s buried in here—I’m sorry I can’t just pull it out right now.
Tacey Ann Rosolowski, PhD:
Oh, that’s all right. I can search—or we can look for it afterwards—after the recorder is turned off. What were your impressions of Gilbert Fletcher?
James D. Cox, MD:
My impressions of him—well I had two different impressions. One, I knew that he was a very strong-willed man who would argue with anybody about anything if he believed strongly in it. And del Regado was very similar in that regard. And strangely, as time would prove, they evolved a considerable amount of respect for each other. So one of Fletcher’s longtime associates—a guy who was here for many, many years—Bob Lindberg—did his residency with del Regado, and del Regado’s whole idea of a residency was you spent three years with him and then you ought to go to another place with a different philosophy, and you ought to spend at least one year there and only then were you fully trained. Not a bad idea. So he encouraged Bob Lindberg to come to MD Anderson and work with Fletcher. And so—I mean—he had a lot of respect for Fletcher, and I had a lot of respect for Fletcher although I knew him to be a tough customer. Then I worked with one of Fletcher’s trainees when I was in the Army, and he was a fabulous, smart, terrific guy—Len Shukovsky—Leonard Shukovsky. And so Len and I were in the Army together, and we argued a lot and so on and so forth, but we really got along well. I mean—I sort of brought my viewpoint from del Regado, and he brought the experiences with Fletcher. And—again—there ended up a lot of respect on both sides. I spent an evening at his home with Fletcher visiting, and so that was another impression of Fletcher. And then when I went to the Medical College of Wisconsin, I needed a favor relative to a certificate of need thing, which I won’t go into, that had to do with high-energy x-rays, and I asked Fletcher to write a letter for me. He was very generous, and he wrote a letter. And so we were friends almost from the very beginning. Then when I came to Houston I used to visit him, and I would go by his office and see what was going on. Then when he developed leukemia I would visit him at home. But he was an interesting character.
Tacey Ann Rosolowski, PhD:
How would you describe his intelligence—his genius—you know his—how—?
James D. Cox, MD:
He was a genius in many ways. His grasp of physics was great. His grasp of human radiation biology was even greater, and his observational skills were extraordinary. So he examined patients far more frequently than people do now, and he watched the evolution of how tumors respond. He was particularly interested in head and neck and cancer of the cervix. And so in both cases you could observe what was happening to the tumor as it was responding to radiation therapy. So he was really a very careful observer and with that a real scholar about what was happening. He was incredibly honest. So when they did treatments at MD Anderson that ended up being toxic, let’s say, or having bad effects—usually long-term effects—he would publish them. He would not shy away from the fact that they had done things that were not good for the patients, and he published them so that other people would not do the same things. So—I mean—he had many, many skills. And the people who were around him—you know—as tough as he could be—they had great affection for him. I mean—I found that out when I came here. I had more than a few people say how much Fletcher meant to them personally. There were a handful of people who did not feel that way, but I saw every reason to think that he was an extraordinary man. I mean—he was a leader. He was a leader within the institution. He had the respect of even people who did not agree with him.
Recommended Citation
Cox, James D. MD and Rosolowski, Tacey A. PhD, "Chapter 06: Radiation Oncology at MD Anderson" (2013). Interview Chapters. 788.
https://openworks.mdanderson.org/mchv_interviewchapters/788
Conditions Governing Access
Open
