Chapter 03: Dr. Edward White: Impact on the Department and Breast Cancer Treatment

Title

Chapter 03: Dr. Edward White: Impact on the Department and Breast Cancer Treatment

Files

Loading...

Media is loading
 

Description

In this chapter, Dr. Ames talks about Dr. Edward White, who became department chair when he joined the faculty of General Surgery in 1977. He first notes that Dr. White as very dedicated to patients and highly regarded by the institution. Dr. Ames next explains that Dr. White supported multi-disciplinary approaches and worked closely with radiation oncologists in developing treatment protocols for breast cancer. He goes on to discuss innovations on the breast service and tells stories about John Stehlin and Eleanor Montague. He talks about how the treatment of breast cancer evolved through the work of all these individuals, leading to more conservative surgery. Next, Dr. Ames lists the departments included under General Surgery and how the department was restructured when Dr. Charles LeMaistre became the second president.

Identifier

AmesF_01_20190807_C03

Publication Date

8-7-2019

Publisher

The Historical Resources Center, The Research Medical Library, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

Overview; PortraitsThe Researcher; Research at MD AndersonMulti-disciplinary Approaches; MD Anderson History; MD Anderson Snapshot; Leadership; On Leadership; Discovery and Success; The History of Health Care, Patient Care; Multi-disciplinary Approaches

Transcript

Tacey A. Rosolowski, PhD

Did you want to talk about Ed White?

Charles Balch, MD

Ed White is also known locally but not nationally, because he never went to meetings. He was the stay at home person.

Frederick Ames, MD

He was and he was around all the time. I was privileged to take care of patients with him and for him.

Tacey A. Rosolowski, PhD

What was his gift with patients?

Frederick Ames, MD

He was just very personable, this is my observation. He was a very methodical surgeon. The only things he ever did that I assisted him on were thyroid and breast. [Redacted]

Charles Balch, MD

I’ll be darned.

Frederick Ames, MD

I assisted him. So that’s an indication of the regard in which he was held. Because that young first chair of urology in the country --because there was not a department of urology anywhere, they were all divisions.

[Redacted]

Frederick Ames, MD

Yes, sir. Doug didn’t take people lightly, he did his diligence and I got to work with him a lot as well. I enjoyed very much working with Dr. White, he was a very personable guy.

Charles Balch, MD

How would you describe him as a leader?

Frederick Ames, MD

Quiet. People respected him.

Charles Balch, MD

But he didn’t say much.

Frederick Ames, MD

He didn’t say much at all but when he shared his requests with you they got carried out.

Charles Balch, MD

Yes. He was the chief.

Frederick Ames, MD

He was the chief.

Charles Balch, MD

And everybody knew he had the support of R. Lee Clark.

Frederick Ames, MD

He did, but even after Dr. Clark retired, he was still deeply admired and respected, and you know, I guess maybe attitudes then were perhaps a bit different than they are today, where there’s a level of respect. If you go back a generation or two, you held someone in high regard because of what they had accomplished and you respected them. Not so much today.

Tacey A. Rosolowski, PhD

That’s part of the reason for these interviews, is to get a sense of some of those subtleties, I mean the cultural subtleties, it is very different.

Frederick Ames, MD

Yeah. And in the course of my fellowship here, I became good friend with, among others, Gilbert Fletcher, Dr. Johnson, the new chair of urology, Dr. Jesse, the head and neck surgeon, I was his fellow for six months and I don’t think he took anybody for six months. He took me for six months. He took me for six months, and then at the end of three, the other two fellows, there were four of us. F. Sugarbaker being one and he was on GI, and John O’Brien and gosh, I forget his name, a physician from New York, both lobbied to stay where they were because they were having a good time, and Dr. Jesse said, “Well, it’s up to you if you want to stay with me, please.”

Tacey A. Rosolowski, PhD

I wanted to ask a question. One of the things that R. Lee Clark was really committed to was creating this environment where there would be collaborations amongst surgery, chemo, or the new and radiology, all these new evolving treatments. What was Ed White’s role in transmitting that message to the Surgery Department?

Frederick Ames, MD

Well, you’re jarring my memory as well as my frontal lobes and whatever else.

Tacey A. Rosolowski, PhD

That’s why we’re having the conversation. [laughs]

Frederick Ames, MD

Multidisciplinary care was key and it was practiced by all. The breast service was very close to the radiation oncologists, in those days there were just a handful, and the surgeons were involved in those days, with a lot of the diseases where they no longer are, such as Hodgkin’s Disease.

Charles Balch, MD

Staging laparotomy, I did a lot of those.

Frederick Ames, MD

Absolutely.

Charles Balch, MD

Who was the breast radiation oncologist?

Frederick Ames, MD

Oh, Eleanor Montague for crying out loud.

Charles Balch, MD

Eleanor Montague.

Frederick Ames, MD

She has a Gold Medal from RSNA, and that book, you really must get it, I’m sure it’s in the library.

Charles Balch, MD

We’ll get it.

Frederick Ames, MD

On the history of the Department of Radiology, because radiation oncology, remember was part of that.

Charles Balch, MD

Was part of it.

Frederick Ames, MD

If I remember correctly, the first medical oncologist who specialized in breast was hired by Ed White, and it was oh, gosh, I knew her so well, Gabe Hortobagyi [oral history interview] holds her chair.

Charles Balch, MD

We’ll look it up, we can add it.

Frederick Ames, MD

Oh, I’m embarrassed I can’t remember her name because she took me under her wing. I can see her now.

Tacey A. Rosolowski, PhD

I can’t remember. Interesting. Were those collaborations, I mean because in my process of interviewing folks, I’ve gotten a lot of versions of what it was like setting up these collaborations, and sometimes … Well, yeah, what was it like?

Frederick Ames, MD

Well for me it couldn’t have been easier because the chairs all liked each other, and Nylene Eckles … And of course they didn’t have anything in those days but oophorectomy, I mean there wasn’t any chemo.

Charles Balch, MD

Yeah, 5-FU.

Frederick Ames, MD

Right, and then George Blumenschein came, and I believe he and Ted [Copeland] were in the same class at Cornell, but you can check the dates on that. He was the head of medical education here, he signed my fellowship papers. He was a medical oncologist and among the fathers of Adriamycin.

Charles Balch, MD

So he was after Murray Copeland, because Murray was in charge of all the fellowship programs educationally for a time.

Frederick Ames, MD

He was when I came, that’s all I can say.

Charles Balch, MD

Yeah, I understand.

Frederick Ames, MD

He and Ted are, I think of the same vintage, in any event, and he was one bright guy. I was deeply involved in breast, among the other things I was deeply involved in, so I became very close friends with George Blumenschein and Eleanor Montague and Nylene Eckles.

Tacey A. Rosolowski, PhD

I’m sorry, one of the things we were talking about was kind of this balance between conservative ways of thinking about surgery versus sort of the pressure to try new—oh, you’re smiling, tell me what you’re thinking sir.

Frederick Ames, MD

Well I was in the middle of that movement, and it was slow in coming because at that time, with the exception of Ted Copeland, everybody else was a generation older. When breast conservation, lumpectomy to be specific, was being proposed and consider: Bernie [Bernard] Fisher actually came here and had a meeting one evening at the Rotary House, which of course is not there any more, they’ve moved it, but that whole concept of lumpectomy, as well as organized randomized trials, was not popular. It was not embraced. I remember hearing George Crile Jr., who was an advocate, present at one of the major meetings and it was beginning to take hold. I had a more open mind. It took a while, because I was so strongly influenced by tradition and what my elders held dear.

Tacey A. Rosolowski, PhD

There was that phrase, “The MD Anderson way,” was that a phrase or was there a way of doing surgery and approaching it at MD Anderson, that old guard?

Frederick Ames, MD

Yeah there was, but to finish up the idea about the conservative, that is tissue sparing, limb salvage, breast conservation, to be specific. It was actually brought forth by the medical oncologists and the radiation oncologists, because they would get these VIP patients and all the while, Eleanor Montague would see these women who had had a lumpectomy, but would come to her for the radiation. They’d get it on what was called a short form. They weren’t regular patients but they’d come to her and I’m sure no small number of them came from John Stehlin, because he was arguably the first surgeon [in Houston] that did lumpectomy, and I was among the ones who followed. When Eleanor Montague and George Blumenschein found out I was doing that, the world turned upside down. In fact, speaking of the Anderson way, you had multidisciplinary conferences in every disease site. Dr. Fletcher, in the basement, down in that room, would examine all the patients and on one day, two patients of mine showed up, young women, post-surgery, who had had lumpectomy[GJ1] , and he lost it. He left the conference and followed Eleanor Montague up to the clinic, he wanted to meet me, and so that’s where it all took place. Curiously, Eleanor Montague, as the records will show, I believe was the referee, the radiation oncology referee for the NSABP, and we weren’t doing breast conservation at this hospital, her hospital, which is kind of interesting.

Tacey A. Rosolowski, PhD

Oh, wow.

[00:39:39

Frederick Ames, MD

But the time was right and the moment. Someone stepped forward and was willing to do that. I became the favorite son of the chair of Radiation Oncology and Breast Medical Oncology, because that’s the way the world was going.

Tacey A. Rosolowski, PhD

What convinced you to turn away from tradition and follow that path?

Frederick Ames, MD

Oh gosh, I don’t know. Why do your kids go off to college and study law, as opposed to journalism or medicine? I mean they just do what they do.

Charles Balch, MD

So let me ask you in the context—

Frederick Ames, MD

My mentors on the other side of the aisle if you will … What got my attention was Eleanor Montague, because she was among the greatest teachers I ever had the pleasure to work with. She examined all the patients and I knew I’d better go over them carefully, because if I missed a lymph node that she could feel, she would bring me back in the room and show me, in front of the patient, the lymph node. So I learned early on, I’d better do my best because she had my back and if she found something she thought she needed to —she took me like her own stepson, would march me in there in front of the patient and show me what I had missed. Which by the way is what Charlie McBride and the others did often, in the breast clinic when the fellows would present a case. Or in the melanoma clinic, the same thing. I learned those lessons, but I was just a little more open because I was younger, I think that’s the difference. I hadn’t been so long in practice that I was too set in my ways not to look in a new direction.

Charles Balch, MD

So, let me ask you, just to tie a few things together in that time, because at the time you were doing that, I was at Alabama, where we were doing the only randomized study between radical and modified radical.

Frederick Ames, MD

I remember reading about that, that was the B-06 trial.

Charles Balch, MD

We’d come in as I’m doing a modified radical and saying you’re going to kill somebody someday by leaving the muscle behind, that’s how much pressure there was on us young people as we were trying to move towards conservative therapy.

Frederick Ames, MD

Ed White did only radical mastectomy if I remember correctly, and I know exactly how he did it. When people started doing modified radical, then they would do what was called a Patey modified radical, where you would take out the minor to be sure you could, you know?

Charles Balch, MD

Yes, exactly, get to level three nodes.

Frederick Ames, MD

When they started doing the—or maybe that was—was that the Patey?

Charles Balch, MD

Yes, that was.

Frederick Ames, MD

Where you left the pec minor, oh gosh, that was a radical departure. But all the while, and I’m sure I’ve told you this: locally advanced disease was so common here. By locally advanced I mean multiple matted lymph nodes, but especially disease involving the skin and worse than that, inflammatory breast cancer. It was quickly learned that you needed radiation, again no chemotherapy at that time. They would do radiation first and then mastectomy, but because of the morbidity and the tissue necrosis and all of this, that and the other, they began to do less surgery, interestingly enough, first, with the locally advanced, and they’d do what they called the extended simple, which basically is a mastectomy with a level one dissection. They were doing that for locally advanced disease and then they’d radiate everything else, and they found out that they had a better regional control than they did by any other combination of methods. So at least where I was, when I was --the first move toward less surgery, combined with radiation, was paradoxically with the locally advanced disease, so why shouldn’t it work for earlier disease?

Charles Balch, MD

Yeah, so let me ask you in the context here. Because Gerry Dodd [oral history interview] did the first mammography, and that allowed, with screening, for us to see patients with smaller tumors. Because when you and I were in practice, almost everybody was at the minimum Stage 2, but most of them were Stage 3, if they got to us as a surgeon at all. But with mammography, we started seeing patients with smaller tumors, and I wonder how, for you, how that influenced the push to do more conservative surgery, not only in younger women but with smaller tumors.

Frederick Ames, MD

All of that played a big role but what I do remember is when I used to give lectures and I’d look at the old NSABP trials. The median size of the tumors was two and a half centimeters, because it had to be palpable. That’s an inch, if you pull out your plastic ruler. Mammography was slow in taking hold and the films weren’t that good, but what I do remember is early on, we would see the occasionally pure noninvasive cancer. Occasionally we would see one at the nipple, which is called Paget’s disease, and I’ll tell you a brief vignette about that. I remember reviewing, in the literature at one time, one of the largest series of pure noninvasive cancer of the breast. DCIS was, if I remember correctly, 44 patients, 44, biggest series in the literature, from this institution, by Steve Gallagher, who was the breast pathologist. When I was really fast busy, when you just became chair, I would do 44 myself a year, just to put that in perspective. [Redacted]

There was nothing left in the specimen, the biopsy had taken it all. I had to go look at myself in the mirror, what have I done? And I went to Steve and I said Steve—he had done the whole organ sections, where he would do a whole breast and make one block of paraffin and spend a month going through it, to map out everything. I asked him, I said, “Steve, do you suppose, if I did a nice little elliptical excision of the nipple and got a centimeter margin all the way around and gave it to you for a month and you mapped it out, there might be some of those patients that wouldn’t need a mastectomy, would you be willing to explore that?” He said, “Absolutely.”

Tacey A. Rosolowski, PhD

Oh wow.

Frederick Ames, MD

So you know there again, I think it was my youth, because we see the same thing now, Charles, in all other diseases; the young generation comes forth and they begin to question everything. Good for them. I mean at every turn they’re doing less surgery, and they’ve taken it now to where they’re doing total skin sparing, nipple sparing, which at the time would have been --no one would have been able to imagine that. It’s like going to Mars or going to the Moon.

Charles Balch, MD

That’s why I told you that story that my senior partner, my mentor, had said I was going to kill people by leaving the pectoralis muscle behind.

Frederick Ames, MD

Absolutely, absolutely.

Charles Balch, MD

Fred, let’s go back to Ed White, just to get a context here. You had Gynecology, Urology, Head and Neck and General Surgery. Those were the four.

Frederick Ames, MD

And Thoracic.

Charles Balch, MD

Thoracic was part of General Surgery.

Frederick Ames, MD

No.

Charles Balch, MD

It was because Jack Roth [Division of Surgery Interview] was the first department.

Frederick Ames, MD

Okay, that may be.

Charles Balch, MD

That’s a story because—

Frederick Ames, MD

Whatever the history reveals, but I remember that it was all done.

Charles Balch, MD

No it was but it was in the Department of General Surgery.

Frederick Ames, MD

They did it all, and the only crossover was Marion McMurtrey, who had been trained in thoracic surgery.

Charles Balch, MD

My impression is that at the time you came, there were four departments. Neurosurgery was in Head and Neck. Plastic surgery was in Head and Neck.

Frederick Ames, MD

Plastic for sure was.

Charles Balch, MD

Milam Leavens was—it’s hard to put them into—because there was no neurosurgery department.

Frederick Ames, MD

Correct.

Charles Balch, MD

But my question is, if there are four departments, do they report directly to Lee Clark? Or were they reporting to Ed White, because there was no Division of Surgery at that time, is that correct? What was the reporting relationship that you recall?

Frederick Ames, MD

I’m struggling to remember, because I was Dick Jesse’s deputy sheriff for six months and actually, by the time I finished that, I did every operation except the major bone resections, base of skull, some of them unattended.

[00:50:0\0]

Charles Balch, MD

[00:50:02

See, I was trained in head and neck too, it was part of our training

Frederick Ames, MD

Well it was and in any event, I don’t know what the reporting relationship was. I think, to put it in military, it was like a couple of brigade commanders reporting to the post general, but they were of equal rank and they got along just fine. There was a lot of harmony, there was not disharmony, and thinking about that, that probably has a lot to say about Lee Clark’s administrative methods.

Charles Balch, MD

I suspect that Ed White was the chief, and in fact there was some correspondence that said, Chair, Department of Surgery, it didn’t say general surgery, and he ran the operating room.

Frederick Ames, MD

Yeah. I’ll go back and look at my letter of appointment.

Charles Balch, MD

This is in the context of when did the Division of Surgery come. Because as I understood it, Bob Hickey assumed that position for the purposes of recruiting a new division head, which was Mickey LeMaistre’s organizational chart.

Frederick Ames, MD

I don’t know. That could have been the two years I was gone, from ’75 through ’77. I would bet Ted Copeland would have some thoughts about that because he was here. He was here from ’73 on, for ten years, and then was recruited as the chair at Gainesville.

Chapter 03: Dr. Edward White: Impact on the Department and Breast Cancer Treatment

Share

COinS