By Gustavo Montana, MD, and David Hussey, MD
In 2000, ASTRO established the History Committee for the purpose of documenting and recording the history of radiation oncology in the United States. The following interview with Herman Suit, MD, was conducted at ASTRO’s 44th Annual Meeting in New Orleans by Gustavo Montana, MD, and David Hussey, MD.
Dr. Suit: I was born in 1929 in Houston. I had an early connection with medicine in that my mother was the first person in Houston to have a Caesarean section. The OB/GYN who did the procedure took an interest in me so I got to know him. As I was growing up, I had three potential career goals. One was to be a physician or scientist, to be a rancher or a musician. And my interest was very strongly toward the science and medicine but my mother wanted an orchestra conductor.
Being born in 1929 turned out to be very fortunate because I was too young to go into World War II (i.e., I was only 16 at the end of the war). I did take an accelerated program and I graduated from high school in two and one-half years and did the same for a B.A. in Biology at the University of Houston. This was competitive with very intense veterans being a large portion of the student body. The cost was very low and I made the money to pay college, books and miscellaneous by selling ladies’ shoes. This was followed by four years at Baylor Medical School. When I applied for medical school at Baylor, Professor Herman Johnson, the OB from my delivery, was the chairman of OB/GYN. He and I bonded a little bit and he took me to meet the dean of the medical school. Johnson told him that I was a very bright boy, but the dean didn’t look too impressed. He said to the dean, ‘Now, I want you to understand that if there’s any trouble with this young man getting into the next freshman class at Baylor Medical School, I, as chairman of the Admissions Committee for Advanced Placement, will embarrass you because Herman will be admitted as a junior.’
Question: Did you go to medical school after the war and the Manhattan Project?
Dr. Suit: Yes. I commenced medical school in 1949 at 19 years of age. A lot of radiation biology was already out by Alexander Hollander and those people involved in the Manhattan Project. Due to the enthusiasm for organic and biochemistry at the University of Houston, I decided to become an endocrinologist. At Baylor, I met with a professor of biochemistry about a Master of Science course. For this, I took physics and math for years one and two. For the second summer, I went to UT for atomic and nuclear physics. I had one special course to read about radiation biology. There I learned about radiation therapy and that patients with laryngeal cancer could be treated with radiation alone and retain an anatomically and functionally near normal larynx. This was combined with a real excitement about nuclear physics and the powerful machines employed. This was combined with the fact that some cancer patients were being cured, but only the exceptional medical patients. The vast majority were only controlled symptomatically. At the start of senior year, I told my friends that I was going to go into radiation therapy. So there was some talk about my unusual career interest.
The reaction from a few of the faculty was strong disapproval. Stuart Wallace, chair of pathology, called me into his office and he asked, ‘Herman, what is this I hear about you wanting to do radiation therapy? You’re supposed to be a smart boy. Now you tell me about this.’ Professor Johnson also called me into his office for the same questions and suggestions that I reconsider. They couldn’t believe that I did not realize that the new drugs would eliminate cancer as a problem prior to my completion of residency.
Question: You got your Doctor of Philosophy at Oxford in England. What happened when you got back from Oxford?
Dr. Suit: When I came back, I presumed I was going to be drafted and sent to Korea. But two months before returning, I heard about the relationship with the National Cancer Institute and the Public Health Service. I went to Washington and applied and was accepted immediately. There were very few radiation oncologists in those days, especially native Americans with a research degree and English training.
In 1959, I went to MD Anderson; Gilbert Fletcher had one of the best attitudes for trying to support people to work in the laboratory. He took me by the hand and introduced me to the therapists and the nurses at each of the machines. He said, ‘Dr. Suit was hired by MD Anderson to do radiation biology, and as a concession from the administration, we’ve been able to wrangle half of the time for him to work in the clinic. When Dr. Suit is on the clinic, he’s down here to see patients, take care of them and plan them. But when he’s working in the laboratory, you are not to think that he is escaping his duty here. He is not to be disturbed while doing laboratory research.’
Question: We also want to cover the twice-a-day fractionation. I think that a lot of people don’t realize how instrumental you were at the beginning of conceptualizing on the twice-a-day.
Dr. Suit: Well, it was a simple concept if tumor cells were dividing rapidly, say in an extremity, and the cells of normal adjacent tissues were not dividing, or if so, quite slowly, then an accelerated fractionation schedule would be predicted to yield a gain. The first patient was a young man from Central America and with a large high-grade rhabdomyo sarcoma on the thigh. He was given chemotherapy to little effect. So I said, “Well, we should treat it on a twice-a-day schedule to 60 Gy. However, I used only four hours between fractions to overcome the rapid tumor cell division relative to the normal cells.” The whole idea for shortening the time primarily is very simple. It’s just to reduce the proliferative advantage. He achieved local control, but with significant fibrosis. He later succumbed to metastatic disease.
Question: I’d be interested in your general thoughts on your activities at Mass General with regard to protons.
Dr. Suit: First, due to my laboratory work with murine tumors, I appreciated that there was a very orderly relationship between the dose and tumor control probability and between dose and normal tissue response. Oddly, quite a number of persons denied such a relationship. Hence, I was quite keen to use techniques that permitted a higher tumor dose or some reduction in volume of dose to normal tissue. As you know, I became very interested in protons when I realized that the Harvard Cyclotron was available for treatment of cancer patients. I arrived there in June 1970 and by January 1974 our first patient was treated. We had staff for proton therapy and had completed a substantial amount of radiation biological studies to estimate RBE value. I wish to mention my colleague, the physicist Michael Goitein. He was remarkably innovative. At the time, virtually all of the interest in particle beams was neutrons and high LET. But I was not convinced that high LET radiation would yield a gain because of limited evidence of a higher RBE for late injury and possibly cancer induction.
Question: Do you think there’s enough additional advantage with protons as compared to the IMRT? Where are we going to be 10 years from now? Fifteen years from now?
Dr. Suit: Well, I would say in about 15 years there will be substantially more proton experience for a very simple reason: any reduction in the volume of normal tissues irradiated or the dose to normal tissues, patient tolerance is raised. The consequence is a higher dose to target and a lower dose to non-target tissues, a higher tumor control probability and less severe or frequent normal tissue injury. The gain may not be large, but it is real. That is, demonstration of a small gain may not be feasible by standard Phase III trials. The entire history of radiation oncology is that technical advances which achieved smaller PTVs have been adopted. Supervoltage, simulators, CT, computer-based treatment planning, etc., were not demonstrated to yield superior results. They are judged to be required in modern radiation oncology.
Question: So where do you see the direction of biology, both radiation biology and molecular biology?
Dr. Suit: Although we’ve been able to clone genes for more than 10 years, there has been no patient that has been cured of a single gene mutation. There is serious potential and some evidence of clinical gains from genetic methods in diagnosis, prognostication and planning treatment strategy, e.g., chemotherapy. Having rose tint to my glasses, I do expect major gains from genetic studies. Cancer is a multi-gene disease and maybe then we’ll be able to make more advancement with cancer. And there are certainly very intelligent, informed and conservative people who are saying that in another couple of decades cancer is going to be eliminated, and we all hope it’s true. But based on the difficulty with single gene mutation of these, my own wager would be that we’re going to have major advances in identifying the probability of their distant or local spread patterns and response to drugs or radiation. But we will probably, for many tumors, still need some local procedures, whether it’s surgery or radiation, for quite a long time period.
Question: What do you think we should do with regard to training in biology for residents?
Dr. Suit: Well, I would like to see the residents given additional instruction in anatomy and formal courses in statistics so they know how to interpret data. More importantly, residents should be given courses in biology and radiation biology. Further, they need to be encouraged to perform either some kind of experimental or clinical investigative work to have an understanding of a little bit of an idea of the problems involved in designing experimental protocols, getting and analyzing the data, and then publishing the results. The idea is to make it feasible for them to read and understand the literature. Also, they must realize that radiation oncology extends beyond the technology. As you know, I’m very strong on having the highest technology around, but that is not sufficient because the radiation oncologist should be able to discuss oncological aspects of overall management with colleagues in other disciplines and be well informed of developments across oncology. I do appreciate that this is difficult because of the truly vast literature related to oncology. I would think that one of the best things that could happen would be if ASTRO would have an unambiguous statement that the responsibility of the faculty toward the resident is education and when there’s an educational experience available in their institution, or one nearby, that the residents be told that they must go to and the staff could care for the patients in their absence.
Question: Of the many things you have done in your professional life, which ones have given you the most satisfaction?
Dr. Suit: I guess as much as anything, being around young doctors and serving as a mentor and particularly young doctors who want to do something in the laboratory. I’ve enjoyed so much the opportunity that I’ve had to work in the laboratory, and not that anything I’ve ever done has been so earthshaking or anything like that, but it has been a great deal of fun. I’ve also had a great deal of satisfaction of working with the sarcoma patients and the role that I’ve been fortunate enough to play and what I think is an important gain is being in the proton therapy department. I also think being a physician and having an opportunity to treat patients that we can cure, and that couldn’t be cured otherwise without horrendous surgery, is one of the nicest experiences a human being can have.
I know that now I see patients that I’ve treated 25, 28 and 29 years ago, and to see those people come back and know what was recommended for them before we treated them, and looking just splendidly is just great.
Question: Is there anything else you want to add?
Dr. Suit: Well, I would like to just pay enormous respect and gratitude to Vincent Collins and Kenneth Loeffler for helping me get to Oxford. Also, I am deeply appreciative to my chiefs and mentors at Oxford, Frank Ellis, Lazlo Lajtha and colleague Eric Hall. Likewise, the quite wonderful experience I had at the NCI and then Gilbert Fletcher and his people at MD Anderson. This has been followed by the incredible support I had at the Mass General. I would like to say for the Mass General, I was chief there for 30.5 years and during that time, no one came to me and said, ‘Herman, you’ve got to do this and you’ve got to that because we need this kind of money or that kind of money.’ Never once. And always the question was, ‘Herman, what is best for the patient?’ My colleagues in medicine, physics and biology are a spectacularly capable group. The department has been remarkably stable with many stars on the faculty. There is much pride in the impressive success of our residents and fellows. I have been unbelievably lucky.