Chapter 02: The Department of Surgery in the 1970s

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Chapter 02: The Department of Surgery in the 1970s

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In this chapter, Dr. Copeland provides an overview of the Department of Surgery during his fellowship year (1971) and early years as a faculty member. He notes that Dr. Arlando Ballantyne was not a proponent of radiation therapy and then traces the increasing use of such treatments as their success was demonstrated. He notes the inauguration of the first mammograms as well as Eleanor Montague’s role in organizing breast conferences. Next, Dr. Copeland talks about his own collaborations with Dr. Frederick Ames to document the effectiveness of radiation therapy on breast cancer patients. He also discusses his work with Dr. Stanley Dudrick and Bruce MacFadyn on uses of hyperalimentation for cancer patients. He explains that some of his research was conducted in a dog laboratory that R. Lee Clark had established following the model of the Mayo Clinic research, where he had trained. Next, Dr. Copeland explains the connection between MD Anderson and the medical school in the 70s, noting that the latter paid his salary while he was effectively MD Anderson faculty.

Identifier

CopelandE_01_20190409_C02

Publication Date

4-9-2019

Publisher

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

City

Houston, Texas

Topics Covered

Overview; Portraits; MD Anderson History; MD Anderson Snapshot; The Researcher; Research; Collaborations; Survivors, Survivorship; Patients, Treatment, Survivors; Building/Transforming the Institution; Multi-Disciplinary Approaches; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Technology and R&D

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History | Surgery

Transcript

Charles Balch, MD

Exactly. So the other person who was first in general surgery on the faculty was Jay Ballantine, Alando Jay Ballantine.

Edward Copeland, MD

Jay Ballantine was a head and neck surgeon, as you obviously know. Jay Ballantine is an interesting person in a lot of ways. First of all, technically he was perfect; secondly, he was not a proponent of radiation therapy.

Charles Balch, MD

Yes. Actually, we have some jousting that had to be adjudicated by R. Lee Clark, between Gilbert Fletcher and Jay Ballantine, and even Bill McComb and Gilbert Fletcher, which surprised me.

Edward Copeland, MD

Well, that’s exactly right, and one reason for that is Dr. Ballantine had been trained Memorial Sloan Kettering. They were not a great proponent of the combination of radiation therapy and surgery. So he brought that philosophy with him and actually maintained the philosophy [that most head and neck cancers could be treated by radical head and neck surgery. The treatment philosophy of the MDAH in general was that surgery removed gross disease and that radiation therapy removed microscopic disease. This combined treatment paradigm was supported and taught by Gilbert Fletcher in radiation therapy and Richard Jesee, the Chief of Head and Neck Surgery during my time there. Interestingly combined treatment and now with the addition of appropriate chemotherapy is almost standard treatment for many solid tumors and Gilbert Fletcher should receive much of the credit for pointing out the benefit of radiation therapy for elimination of microscopic disease unseen by the surgeon and the reduction of bulky tumors to a size that made surgery possible. The latter treatment of locally advanced rectal cancer with preoperative radiation followed by surgery was just beginning when I left MDAH and is one of the many reasons that I selected the University of Florida as the palace to spend the remainder of y career. Rod Million, another Distinguished Alumnus of MDAH was Chair of Radiation therapy at Florida and had been trained at MDAH. The Florida treatment philosophy was the same as the MDAH, and remains so today.]

Charles Balch, MD

So about the time you were there, I remember that first mammograms were done at MD Anderson and the concept of radiation therapy, both adjuvant and breast radiation therapy, had many of its roots here at MD Anderson. Were you engaged in that at all?

Edward Copeland, MD

Very much so. Eleanor Montague was the person in radiation therapy that led [radiation therapy approaches. She ran the Breast Disposition Clinic attended by the surgeons and radiation therapist initially and then the physical therapist joined. In those days, all general surgeons participated in both soft tissue (breast, thyroid, sarcoma and melanoma) and GI (liver, colorectal, stomach, small bowel and staging for Hodgkin’s Disease [no longer necessary]. We alternated referrals for these diseases every 6 months; although, any person wishing to see any one of us could do so.

Chest wall recurrence was a major complication of mastectomy for any ablative procedure. In fact, Halsted became famous because his meticulous technique for radical mastectomy in the 1890s but still had a significant chest wall recurrence just less that others like Bilroth.

Patients were expected to be presented at Breast Conference and a treatment plan was developed for each patient. Since modified radical mastectomy was the most prevalent operation, radiation therapy was used postoperatively and an algorithm for the areas to be irradiated was developed. For example, radiation was used to sterilize bulky level III lymph nodes and not combined with dissection because the combination of the two resulted in a 45% chance of symptomatic lymphedema with no change on recurrence or survival.]

Charles Balch, MD

Eleanor Montague.

Edward Copeland, MD

As far as I know. As far as breast conferences, we all have breast conferences at our cancer centers today. Eleanor Montague a lot of times had a breast conference: she sees patients and the surgeons will be there, the radiation therapists are there, and we created a new play on the perioperative plan, assuming nobody was having abatement, and we created a pre-op plan as to how to proceed, with either preoperative radiation therapy, which was not used often in those days, it was hardly at all. What we used with postoperative therapy, under the right circumstances. Fred Ames [Division of Surgery interview] and I [became interested in the concept of lumpectomy, axillary dissection and post-operative radiation therapy to the intact breast. We chose our own patients who had small cancers and could have the cancer completely removed or so we thought. For those patients who had already had a biopsy and the pathology report indicated the cancer had been completely removed, we sent to radiation therapy without any other breast procedure other than axillary dissection.]

[Upon review of our data, we noted several breast recurrences most of which were in patients we had assumed from the pathology report had been completely excised. With this observation, we began to reexcise the biopsy cavity of referral patients. To our dismay, 50% of patients had residual breast cancer in previously excised wound. We never published this rather revolutionary observation. Speaking of which, when I arrived in 1971, limb sarcomas were treated with wide local excision and radiation therapy. The standard treatment was amputation. The MDAH data showed that limb sparing therapy and amputation had the same local recurrence rate and survival. AND the patients got to keep their limb! In 1986, at the American Surgical Association Annual Meeting the randomized trial of amputation versus local excision and radiation to the intact limb was presented. The results were the same, a fact that the Richard Martin and the rest of us knew 15 years earlier!!]

Charles Balch, MD

So at that time in the 1970s, how many people were doing lumpectomies in the United States?

Edward Copeland, MD

As far as I know, [only the institutions were those fortunate to have both a surgeon and radiation therapist who were both trained at the MDAH. To repeat, one of the many reasons, I chose to go the University of Florida. I know Little Rock, Arkansas had such a combination. And I expect that Northwestern, did as well. ]

Charles Balch, MD

Yes. And one other aspect of that, do you remember Gerry [Gerald] Dodd [oral history interview] and the role of mammography, and how that might have affected your practice in localizing breast cancers for lumpectomy.

Edward Copeland, MD

Gerry Dodd was the chairman of Radiology and [ in his department were at least two radiologist who had had at least two years of training in general surgery. This training was more important with the advent of computerized tomography; nevertheless, communication with someone with surgical training makes interaction with radiation therapist much more productive.] Actually the first time I saw mammography was at the University of Pennsylvania, where I [did my surgical training under the direction of Dr. Johnathan Rhoads, a past President of the American Cancer Society and great friend of Drs. Clark and Murray Copeland.]

Charles Balch, MD

I think just for the record, Dr. Dodd was given many awards for initiating the first mammography for screening of breast cancer.

Edward Copeland, MD

He may have been, that’s not something I would have known.

Charles Balch, MD

Sure. So, another aspect of this Ted, that you contributed so much, is in the area of hyperalimentation, for which you were a leader in the field, especially for cancer patients, with both you and Stan Dudrick, Bruce MacFadyen and so forth. I wonder if you could just go over a little bit about the history of how hyperalimentation started at MD Anderson, and some of the laboratory work you did to document that.

Edward Copeland, MD

[ ] [Stanley Dudrick in conjunction with Johnathan Rhoads developed the technique of what was then called intravenous hyperalimentation, now more commonly called Total Parenteral Nutrition (TPN). Dr. Dudrick and his colleagues had shown that providing appropriate nutrients as glucose, protein, fat, vitamins and electrolytes by vein (approximately one calorie per cubic centimeter) in a patient whose gut was not available could result in the recovery of muscle mass and immune competence. Indolent wounds and chronic intestinal fistulas healed. They had not used TPN in cancer patients for fear of stimulating cancers to grow and to deliver the concentrated solution required venous access through a large bore vein such as the subclavian. The fear of infection from the indwelling catheters in severely malnourished cancer patients would further complicate any indicated cancer treatment. When I arrived at the MDAH there were a myriad of cancer patient who had treatment available for their cancer but were too malnourished to tolerate their indicated treatment. With this in mind, the ethical issue of use of TPN was moot since no treatment could be rendered without nutritional replenishment by vein (the gut was unavailable). TPN replenished muscle mass, restored immune competence and allowed for appropriate cancer treatment without stimulating cancer growth, in a word, the results were dramatic!! So dramatic in fact that we were allotted four nurses to the TPN team to provide proper care to the average of 17 patients that were on TPN throughout my tenure at MDAH. One of these nurses, Louise Cox, was the first person to develop home TPN for cancer patients, another feat previously considered impossible.]

A shout out to Renilda Hilkemeyer [oral history interview], the Nursing Supervisor who was initially skeptical since she felt that the regular floor nurses to take care of the catheters to prevent infection. And they could have except for all their other responsibilities. In fact, all the members of the TPN team were recruited from interested floor nurses. Sandra Norman started the catheter insertion clinic in a single place rather having the catheters placed in the patients’ rooms. I think this insertion clinic still exists today without any thought as to its origin.]

Charles Balch, MD

So let me just say for the record, during the time Dr. Copeland was here, from 1972 to ’82, he published 122 publications, which were cited in the literature almost 4,000 times, and the majority of those that were highly cited were in the area of what was them called hyperalimentation, both in dogs, mice, and in humans. These were some of the classic articles, some of which are still being quoted in the literature today. Ted, you had told me about your research in the animal lab.

Edward Copeland, MD

A lot of very interesting things befell me, with my relationship both with MD Anderson and with the medical school. The animal laboratory, let’s go back to Lee Clark. Lee Clark came from the Mayo Clinic and when Lee Clark came to MD Anderson, he set up a Mayo Clinic type structure and potentially, some of that is still reflected today.

Charles Balch, MD

Including a single group practice.

Edward Copeland, MD

Well, that’s true. So that’s all his doing, and there was no way you could change something that works, it’s kind of obvious to most people, [but, unfortunately not to all. One of the things Dr. Clark brought with him was the concept of a research dog laboratory. He had a very nice one built.] Three technicians were assigned there and an animal caretaker who took care of the animals just in that dog lab. There were three operating tables, an operating suite, a radiology facility and a budget. Dr. Clark asked me if I could put that facility to use, [since at that time large animals were not used for cancer research. I had an interest in gastrointestinal physiology probably stemming form my work on TPN. Three GI physiologist from the medical school and multiple medical students had unlimited access to the facility. I assume it had a budget but never ask and never used it up. There was occasional complaints from the medical school that the MDAH was not contributing enough to the education of the medical school. I was always quick to point out our lab, especially since one of my responsibilities was to point out the value of the MDAH to the school. Also, in my unique position, I could also point out the value of the medical school to the MDAH.]

Charles Balch, MD

One of your most frequently cited articles are those that you did with John Daly. I wonder if you could just make a few comments about John and his role here at MD Anderson.

Edward Copeland, MD

John Daly was with the first group of residents we recruited to the medical school at UT Houston. [He had worked in Stan Dudrick’s laboratory when John was a student at Temple and in mine at UT medical school. My eventual role at MDAH was to run a surgical service staffed only by UT residents, a chief and an intern. We had a great time. Operated three days a week and were in clinic two days a week. John rotated with me at MDAH for a total of 9 months during his residency. He was offered a job on the UT faculty but cut a deal to be a fellow at MDAH if he could spend the entire year on my service. This arrangement allowed us to have even more operative time. John joined MDAH faculty full time at the end of his fellowship as my partner. Many of the 122 articles you cited have John’s name as a coinvestigator. He moved on after Five years to join the faculty at the Memorial Sloan Kettering Cancer Institute, became the Johnathan Rhoads Professor at the University of Pennsylvania and then became the Chairman of the Department of Surgery at Cornell Medical School, my medical school alma mater. He finished his illustrious career as Dean at Temple Medical School. ]

Charles Balch, MD

And you earlier told me an interesting story about the sacrifice that John made in order to take the fellowship. Could you repeat that for me?

Edward Copeland, MD

I will. I had the best job in the country and probably always will have had the best job in the country. I was on the medical school faculty with my best friend, I worked at the institution where—

Charles Balch, MD

Your best friend being Stan Dudrick?

Edward Copeland, MD

[ ] [As I said before, my job at the MDAH morphed into my running a UT Medical School Service and without fellows. Although John could have worked at UT when he completed his residency, he preferred to be at the MDAH in the same capacity as was I. The institutions had worked this arrangement out and John was to receive a $40,000 salary.] Dr. Hickey was not in favor of having anyone join the faculty who had not been trained in surgical oncology with a fellowship. [Keep in mind that John had spent 9 months with me at the MDAH and at a senior resident level. Dr. Hickey remained firm in his decision, and John did take the fellowship, as I said before, if he could spend the entire fellowship with me. I think that Dr. Hickey found this a hard pill to swallow but yielded to higher authorities. So, John gave up a differential of $22,000 to comply with Dr. Hickey’s demands. As you know, John Daly is one of the most admired individuals to ever have a fellowship at MDAH. The fellowship made no difference. John ran an OR with my occasional supervision and would still have been considered a MDAH man. In fact, in my mind, he never would have left for Memorial Sloan Kettering had it not been for Dr. Hickey’s stubbornness.]

[Dr. Hickey and I were not the favorites of each other. On another occasion, he told me that TPN was keeping patients alive who otherwise would be dead and, thus, creating a bed shortage. Since each patient on TPN had a referring doctor, usually from medical oncology, I took out the list of patients and asked him to tell me which patients he wanted off of TPN and I would tell their primary physician that I had been directed by him to discontinue it. He walked away in a huff and I did not have to deal with him again!]

Charles Balch, MD

And he [John Daley] had a family that he had to support on that salary of $22,000?

Edward Copeland, MD

True. Six children. [You are making my point!]

Charles Balch, MD

Six children.

Edward Copeland, MD

So anybody in this country that I could say I probably trained, it would be John Daly. In fact, Steve Grobmeyer, who was trained by John Daly at Cornell, was later on the University of Florida faculty after his fellowship at Memorial Sloan Kettering and was my last partner before I retired.

Charles Balch, MD

And Steve is thriving now at the Cleveland Clinic.

Edward Copeland, MD

To say the least. I was helping him do difficult gastrectomy, because he was a faculty member, and he said, “Gee, Dr. Copeland, you do this just like John Daly does it.” [ ]

Charles Balch, MD

Let me just add for the record here, after you left in 1982, the relationship with UT Houston Department of Surgery languished and was actually nonexistent. Stan Dudrick stepped down and Frank Moody became the chair. When I came in 1985, Frank made me the associate chair at UT Houston so that we could have an integrated residency, and we picked up what you had been doing before, to start having UT Houston residents, including chief residents, come on to our service, the first of which was a person named Wiley Chip Souba, who was my first fellow that we selected. He did his chief year at MD Anderson and then we gave him a one-year fellowship instead of two. As you know, Chip Souba went on to become a chair of surgery and then executive vice president at Ohio State, and now he is, I think a dean at Dartmouth or the University of New Hampshire [now retired].

Edward Copeland, MD

[ Chip also had his faculty job with me at Florida and ran our metabolism laboratory, over time he accumulated 6 NIH RO- grants. For about a 10-year period we had Chip, Kirby Bland, another MDAH fellow, and me on the same service at the University of Florida. You got several fellows from our program to include Lee Ellis, Eva Singletary, Eddie Abdula (each of whom were on the MDAH faculty) and many others who have gone to have successful academic jobs at other institutions.]

Charles Balch, MD

Yeah, yeah.

Edward Copeland, MD

[ ]

Charles Balch, MD

Chip was one of the smartest people I knew.

Edward Copeland, MD

He is one of the smartest people I know, and always will be and once again, he is a very, very dear friend, I am very proud of him, if I’m allowed to be proud of anybody that I’m associated with.

Chapter 02: The Department of Surgery in the 1970s

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