Chapter 03: A Vision for the Department of Thoracic and Cardiovascular Survery (late Eighties): Building Research, an Oncology Perspective, and Multi-Disciplinary Collaboration, and Training Programs

Title

Chapter 03: A Vision for the Department of Thoracic and Cardiovascular Survery (late Eighties): Building Research, an Oncology Perspective, and Multi-Disciplinary Collaboration, and Training Programs

Files

Loading...

Media is loading
 

Description

Dr. Roth begins this chapter with an overview of his first steps to build the department. He notes he needed to recruit people to set up his own laboratory, provides an overview of the department’s areas of activity, and discusses the organization of multi-disciplinary conferences to establish treatment plans. He discusses some research that resulted from these collaborations. Next, Drs. Roth and Balch talk about the process of shifting the focus of the Division from thinking of surgery as a reactive process to surgical oncology and the challenge of overcoming institutional silos. They then discuss key discoveries and events in the Department of Developmental Therapeutics that had an impact on shifting surgeons to a surgical oncology perspective. Next, Drs. Balch and Roth discuss the creation of the training program, first designed for fellows in thoracic specialties. Dr. Roth discusses the collaborations with Texas Medical Center institutions that fed MD Anderson quality fellows.

Identifier

RothJ_01_20190314_C03

Publication Date

3-14-2019

City

Houston, Texas

Topics Covered

Building the Institution; Education; On Education; Multi-disciplinary Approaches; MD Anderson Culture; Leadership; On Leadership; Mentoring; On Mentoring; Discovery and Success; Ethics

Transcript

Tacey A. Rosolowski, PhD:

Yeah, absolutely, first days.

Jack Roth, MD:

I think we had—Charles had identified this lab space for me that needed renovation. I’m trying to think. This was being built at the time, so we had to renovate some old lab space to do this. That hadn’t quite been done yet. We needed some paint on the walls and so forth, so a little bit of a lag in getting the laboratory going. But I brought some people with me from NCI. Bob Ames was one, and a very excellent technician, and recruited some individuals as well, to start the laboratory program. We were based in this office that was about as big as this I think, and I think we had one or two IBC computers, AT computers. Do you remember those little disk drives? And that was about it in terms of resources. Meanwhile, we had Cliff, who is going all over the world giving talks, the clinical work being done primarily by Marian McMurtrey, who is a very good general surgeon, and Louis DeCaro. But a high volume of cases coming in and we had to look at this and say okay, are we giving these patients the best possible care, is there something else we can offer them? And so we organized a multidisciplinary conference as the first step and we got Radiation [and Medical] Oncology involved. [ ] Medical Oncology was [headed by David Carr]. Actually at this point, [Waun] Ki Hong [oral history interview] came into the picture [as the new chair of Thoracic/Head and Neck Medical Oncology].

Charles Balch, MD:

Yes, from Boston.

Jack Roth, MD:

From Boston.

Charles Balch, MD:

Ki Hong was recruited to do head and neck, but the way Irv organized this to recruit on this, he made it squamous cell cancers of the upper respiratory system. So it was head, neck and lung, as a means of recruiting him and giving him a big space programmatically, but also in order—because Ki Hong also had the mindset of doing clinical research and being a really good partner with people like Jack Roth.

Tacey A. Rosolowski, PhD:

Now, something as you’re describing getting this all started, what’s also your impression of the support you were getting from the divisional level in terms of leadership and resources, all of that, to help you implement what you needed to do?

Jack Roth, MD:

Well, we had this huge resource package, including laboratory space. We had the resources we needed, now it was really up to me to organize individuals, to start to break down barriers, to organize the clinical programs, clinical research programs and laboratory programs, and get them up to a level that they would be able to attract the funding necessary to continue them after the resource package was exhausted. So it’s now my— [laughs] The ball is in my court.

Tacey A. Rosolowski, PhD:

Yeah, it was. So what were some strategies you used? I mean talk about breaking down barriers. How did you go about doing that?

Jack Roth, MD:

Well, I remember the day Ki walked in my office. I didn’t meet him before I was recruited here actually, but I was sitting there, I think it was maybe a few months later and my assistant says, “Oh, this Dr. Hong wants to see you,” and I said okay. I didn’t know who he was. Ki walks in, very low key, and he introduces himself, says I’m going to be head of Thoracic Medical Oncology, I’m really interested in working with you. He told me a little bit about clinical trials he had done in Boston, which were very important randomized studies, in organ preservation, and it was clear that he and I had a very similar mindset. I said Ki, we’re going to work together on this, we’ve got to get our forces together in a multidisciplinary program, and so one of the first things we did was organize a multidisciplinary conference, a bring everybody together talk. It never happened before in lung cancer, here.

Tacey A. Rosolowski, PhD:

Was this pretty much right off the bat, in 1986?

Jack Roth, MD:

Yeah, yeah, very close to that. I remember getting up and introducing myself and telling people what we would try to accomplish and looking at the audience. It was really, you know, a little skepticism here, but everybody came along. Ki began recruiting individuals like Fahdlo Khurie and Roy Herbst and really bringing in very, very good people --Frank Fossella-- who were interested in organizing the clinical work, making sure that patients were seen not just by the first team that sees them but other teams as well, and organizing clinical trials. One of the first clinical trials we organized was a randomized trial to look at neoadjuvant chemotherapy and Stage 3-A lung cancer. This is a stage of disease where surgery really doesn’t benefit the patients very much. There’s probably a less than 20-percent five-year survival, but the Lung Cancer Study Group had some evidence that adjuvant chemotherapy might work in these patients, that is chemotherapy given after surgery. We thought maybe it would be better to give this chemotherapy before surgery because, first of all, the patients are going to tolerate it better than after they have surgery, because a lot of patients were dropping out and not getting the adjuvant, and secondly, if we can cause a response in the tumor, we may be able to do the surgery better than if the tumor is larger and more difficult in terms of surgery. So we started this trial and this was very challenging.

Charles Balch, MD:

Historically, this neoadjuvant therapy was done a little bit in breast cancer, but there were very few effective drugs to do this in, so what Jack and Ki did in this randomized trial was really a pioneering work, to test this for the first time in lung cancer.

Jack Roth, MD:

That’s right, and there was a good drug that came along, Cisplatin, it had been tested. Actually when I was a fellow in UCLA, we were giving this in the clinic. We actually gave some when I was at NCI. The medical oncologists were so disinterested at NCI, in our clinical trials, that the surgeons had to give the chemotherapy there.

Tacey A. Rosolowski, PhD:

Really?

Jack Roth, MD:

Yes.

Tacey A. Rosolowski, PhD:

That’s very interesting.

Charles Balch, MD:

Which just historically, this is why people like Jack and I view themselves as oncologists. I had the same experience at Alabama. The medical oncologist did not want to manage Stage 4 Melanoma, so I was assigned to give the chemotherapy and the immunotherapy, the BCG and so forth, to the Stage 4 Lung Cancer patients. I was only able to do this because John Durant gave me his chemotherapy nurse to really run this. But I think those experiences for Jack and I, had us think as an oncologist. Just to put this in context, this was a transformational time at MD Anderson, where people before, were working in their silos. They had some multidisciplinary interaction but not as formally, so Mickey LeMaistre [oral history interview] recruited Irv Krakoff to do this and recruited me to join Irv, to really move from a silo based delivery system, to a horizontal oncology-based, or disease based program. So this was a really transformational time in lung cancer, that they would get together and work side-by-side in the coordinated treatment of lung cancer for all stages of disease.

Tacey A. Rosolowski, PhD:

How long did you feel it took before this perspective that you and Ki Hong and Dr. Balch were bringing took hold and people began real buy-in?

Jack Roth, MD:

Well you know, it didn’t take all that long, because we were all recruiting new individuals. Charles was recruiting in surgery, we were bringing in new individuals in thoracic surgery, who had a similar mindset, and Ki was very active again, in developing his department along these research lines. He was very interested in chemoprevention. He had a strong association with basic science departments and so forth, to bring this forward and to do randomized trials. So I think I would say probably within about five years we had a much larger group of individuals who were now committed to translational research.

Tacey A. Rosolowski, PhD:

Was there kind of an “us and them” feel at all, as the culture was shifting. Were there tensions because of that? [00:46;57]

Charles Balch, MD:

Like when you came to the Division of Surgery meetings.

Tacey A. Rosolowski, PhD:

Well, I’m not asking for talking out of turn, it’s just you know—

Charles Balch, MD:

I think Jack will tell you that there were two different mindsets that we had to amalgamate over time, which I think we did. But at the beginning, Jack and I were kind of the odd people out because we were really having a broader view of the world at MD Anderson, in the implementation of prospective clinical trials in research that wasn’t there.

Tacey A. Rosolowski, PhD:

What was your impression of that?

Jack Roth, MD:

Well I agree. There were clearly individuals that were hostile and didn’t want this to succeed. And you know, there are a variety of ways that things can be undermined. I mean you can not cooperate in division meetings or with divisions sort of trying to get new types of initiatives and so forth together. You have to have cooperation. If you don’t --and obviously, you know comments, negative comments, particularly negative comments can really cast a pall over trying to do this. But to Charles’s credit, he was incredibly persistent in all this and positive. So gradually, as we brought in more and more people who were interested in this approach, saw the value of it and saw that this was the future, things began to change. Even one of the strongest opponents at the beginning, after a few years, came around to being a major supporter for the physician-scientist program.

Tacey A. Rosolowski, PhD:

Can you name that—

Charles Balch, MD:

Now who was that?

Jack Roth, MD:

I think you know who I’m talking about. Helmut Goepfert [oral history interview].

Charles Balch, MD:

Sure, that’s who I was going to say.

Jack Roth, MD:

Is that what you were thinking of? Yeah.

Tacey A. Rosolowski, PhD:

Oh, okay, that’s—yeah, yeah, that’s amazing.

Charles Balch, MD:

But here’s the historical context. I think when Jack and I came here, a lot of the faculty resisted prospective clinical trials because they said patients come here for experience and we shouldn’t let a computer decide what treatment people get.

Tacey A. Rosolowski, PhD:

Well there was also a lot of controversy around Developmental Therapeutics and arguments about clinical trials coming out of—

Charles Balch, MD:

Yeah, I mean even one famous person in [the Division of] Medicine would stand up and say it is unethical to put patients into randomized clinical trials.

Tacey A. Rosolowski, PhD:

Right, exactly.

Charles Balch, MD:

So there was a culture that we had to go against that was embedded in the institution—

Jack Roth, MD:

That’s right.

Charles Balch, MD:

That I’d say between ’85 and ’93, in that period of time --or ’84, because it started with Medical Oncology-- and so Irv Krakoff had to fight that in Medical Oncology, but he was making changes a little bit ahead of me, so I had the confidence that we could do that because I saw it going on in Medicine, just as Jack saw that in Ki Hong, that he had a partner there. But this was a time of great cultural change and transformation of the institution, to be a bona fide academic institution in addition to clinical excellence.

Tacey A. Rosolowski, PhD:

Now what are some of the key events, as you’re thinking back in your department, over this sea change that’s taking place. What are the key events that mark that shift for you?

Jack Roth, MD:

Well this clinical trial for one thing, randomized clinical trials, or ability to actually see patients as a multidisciplinary group and begin to randomize them. As Charles said, this is a very difficult thing for clinicians. We’re going to give you a treatment, but we don’t know what it is, the computer is going to decide. But there’s a way you can present that to patients, and in fact, there have been studies that have actually come out, that show that patients in clinical trials actually do better in terms of outcome, than those who don’t enter them. You believe in this personally. You know that even if the patient gets the standard treatment, they’re still getting the best standard treatment and the experimental treatment might not work and could have disadvantages, so it’s absolutely fair and totally ethical to do this type of trial. But you’ve got to get this mindset. Getting that going was, I think a major step. The second step was success in the laboratory, our ability to attract fellows and our ability to get NIH funding. In fact, I remember, you know one of the things that really, this was very unexpected. I put in my first grant and it came back, I received an Outstanding Investigator Award, do you remember that?

Charles Balch, MD:

Yes.

Jack Roth, MD:

The very first grant that I put in, which was a five-year award, and I can’t remember all the terms of it but I think it means that you can easily renew it for another five years and so forth. And so this kind of success, in showing that it actually could be done, but at the same time we can maintain a high standard of clinical activity, I think also greatly helped. You show by example, right?

Tacey A. Rosolowski, PhD:

Right.

Jack Roth, MD:

You don’t make mandates, you show that as a leader.

Tacey A. Rosolowski, PhD:

Well particularly when you’re trying something new, you have nothing to compare it to.

Charles Balch, MD:

I was cheering for this because before Jack came and before I came, the sources of revenue to support laboratory research in surgery in all of the departments were internal funding, state funds and so forth. Part of our expectation is we would generate external funds, both for our laboratory research but also for our training programs. So when Jack got this very large grant with a high priority, several grants, it made a statement to everybody else; it’s a new standard, that the expectation is you don’t just depend on state funds or institutional funds, but you should compete with your ideas at a national level for peer review funding.

Tacey A. Rosolowski, PhD:

Were there other kind of landmark moments in making this shift for you?

Jack Roth, MD:

Well, one of the things that we needed to do was to upgrade the clinical care that the patients were receiving in thoracic surgery. I wasn’t happy with the way patients were being seen, even in the multidisciplinary context. I didn’t think that technically, [ ] the other faculty were doing the top level of surgery that we needed. So recruitment was very important, and so our ability to recruit outstanding individuals from the outside was very important. Bill Putnam was one of our first recruitments.

Charles Balch, MD:

Part of what I told Jack at the beginning is everyone in your department should be a board certified thoracic surgeon. I saw early on that, although people worked very well and had a level of experience, when you’re in general surgery, easing into the chest, which usually isn’t part of your training, that you’re not going to be able to rise to the level of doing complex care with good outcomes as somebody who has gone through the process and is board certified. This was a sea change.

Jack Roth, MD:

Yeah, it’s a sea change. My goal was to treat all thoracic malignancy in our Surgical Department that required surgery, and this meant everything; not only lung cancer but esophageal cancer, lung metastases, thymic tumors, chest wall tumors, the whole spectrum of things I thought we should have expertise in these areas. So, Bill [Putnam,] came from University of Michigan program. Mark Orringer was the chair of that program, and at the time, they developed a new operation for esophageal cancer, called the transhiatal approach. This is before minimally invasive surgery, but it’s a way of taking out the esophagus and doing the reconstruction without actually doing a thoracotomy. Now as a thoracic surgeon, you’re trained in general surgery and you’re trained in thoracic surgery, so you can work in the abdomen, you can work in the neck and so forth. So Bill brought this level of expertise in and this then allowed me to highlight the department and highlight our clinical activity and make it attractive to other clinicians to come in. People like Garrett Walsh for example. But we knew that if we’re really going to achieve the highest level, we need to have a training program in thoracic surgery. As Charles mentioned, there was this movement to develop a thoracic track program. You know, why do you need all this cardiac training if you’re not going to do cardiac surgery? But at the same time the cardiac training was valuable, because you’re in the chest, you need to be able to be comfortable around the heart and the great vessels. So with Bill Putnam, we designed this Thoracic Track Program, and it was one of the first programs in the country to be approved by the American Board of Thoracic Surgery. This allowed us to give thoracic surgeons 18 months of training in thoracic, six months in cardiac, and we worked with Denton Cooley, to help with the cardiac portion of this. He was very amenable to this because our program provided really, the only non-cardiac training for their residents in cardiac surgery, which they needed for their boards. They had to get a few esophagectomies, they had to get a few lobectomies, and so we provided that training. Now at the same time we began to expand this program to Baylor. I think this got Denton a little bit upset, because he was worried that we might compromise the training for his residents by bringing in these other programs, whereas I saw it as a Texas Medical Center wide thoracic surgery program that would integrate all the resources of this huge medical center and all these great programs, because Baylor obviously had a terrific program as well.

Charles Balch, MD:

Let me add a context here. When I came, the only residents were those that came from St. Joe’s, and that there were no—

Jack Roth, MD:

That’s in general surgical, yes. Charles Balch, MC In general surgery, and there was very little relationship with either Baylor or St. Luke’s, Texas Heart and so forth. So part of what I did just before Jack, is I became the vice chair of the Surgery Department at UT Houston, with Frank Moodey, so that we could start to have residents from UT Houston come here. Then I did the same thing at Baylor, to have the Baylor residents come, because part of it, if you’re going to have really good fellows come, they don’t want to go back to being an intern. They want to be able to teach residents as well, so a component of developing fellowships is you had to have some residents that were there too, both to handle many of the routine things, to be assisted at surgery, to do some of the easier, the earlier surgery. That helped us in attracting the kind of fellows, but this was also a sea change of developing these formal training relationships with both Texas Heart, Baylor and UT Houston, that didn’t exist before we came.

Jack Roth, MD:

And actually, Charles helped greatly in sort of smoothing things over and calming the political waters.

Charles Balch, MD:

But we had the same vision of we should have trainees from all over the Texas Medical Center. I looked at this and said, what a great opportunity, why are we not doing this?

Jack Roth, MD:

Yeah, yeah. We actually were able to get in a general surgery resident from UT as well, into our program for training and that persists to this day. In fact it’s one of their favorite rotations, they get to do a lot of our surgeries. Bringing all these programs together, well you recall that there was probably a little bit of bad blood between Dr. Cooley and Dr. DeBakey.

Charles Balch, MD:

It’s well known.

Jack Roth, MD:

I’m understating. Bringing those two programs together, in our institution at least, was a bit of a challenge, but it did work out and now this has come to the point where now we’re having joint meetings every few months, with the Baylor thoracic surgery team and the [UT Hermann] team. We’re getting together on a regular basis. We choose our residents together, scientifically we meet to try to develop clinical protocols, so it’s really expanded now and very much beyond what even we were to achieve.

Chapter 03: A Vision for the Department of Thoracic and Cardiovascular Survery (late Eighties): Building Research, an Oncology Perspective, and Multi-Disciplinary Collaboration, and Training Programs

Share

COinS