By Christopher Rose, MD, FASTRO and Lior Braunstein, MD
The following interview of Anthony Zietman, MD, FASTRO, was conducted on June 1, 2017, by Christopher Rose, MD, FASTRO and Lior Braunstein, MD.
Christopher Rose: Anthony, why don’t we start at the start? Where were you born and where did you grow up?
Anthony Zietman: I was born in London in a, then, sleepy suburb that has has since become famous for the London riots, huge demographic changes, and poverty and drug-related problems. Luckily, I lived there at a time just before that all blew up. I went to a public school, and then ended up at Oxford for my college. As you probably know in Britain, medical school and college are synonymous. You go to medical school aged 18. You can qualify as a doctor aged about 23. It’s only a five-year-degree. You’re on the loose aged 23 when really, you should just be in college drinking. But you’re on the loose, on the floors, so being an intern and then being a resident.
In Britain, they keep all these very young, somewhat immature, newly qualified doctors occupied with multiple residencies. So I did a three-year residency in medicine in London. Then I did a residency in what in Britain is called clinical oncology, which is a mix of radiotherapy and medical oncology.
Christopher Rose: Maybe we could back up now just for a second. I mean you’re really peripatetic. There’s so much that that multidimensional person that you are. That must have started way, way back. When you were both in college and granted, they take a little bit away from that once you get the MD versus getting a BS or even a BA, what were the things that you were doing as well that weren’t medical that were shaping who you are right now?
Anthony Zietman: Well, actually, I went to Oxford not to study medicine. I went to study Politics, Philosophy and Economics, PPE. It’s the prime minister’s degree. Tony Blair did it. He took PPE. Harold Wilson and Edward Heath, took PPE. Many of the prime ministers have done PPE at Oxford. I just thought, because I was the only politically interested kid at my public school, that I would just become prime minister. When I arrived at Oxford, I realized there were 250 other kids in my year who also wanted to be prime minister. So it took about two weeks before this all registered. But then I flipped to something -- I didn’t flip, I changed from politics to medicine in just the second week of my first semester because medicine just seemed to be easier. There is still some politics in my DNA that expresses itself in public speaking, which has persisted in my behavior today so many years after this switch.
As I came to the end of my time at Oxford, which was three years at Oxford, I noticed on the college notice board a post for something called a “Commonwealth Scholarship”. Three of us who happened to be living together in a house in the countryside outside Oxford all decided we’d apply and did so somewhat impulsively the very next morning. One of us ended up in British Columbia in Vancouver. He went on to become a successful judge and was knighted for his services to the country. Two of us however, decided on a whim, to apply to study for a year in Nigeria. It was a sort of fanciful romantic thing. The other guy had been to Nigeria previously; I certainly hadn’t. I’d scarcely been outside London. Both of us won these scholarships. Shortly before we were to leave for Northern Nigeria, my friend, called Andrew Tait, backed out and decided he’d become a lawyer in London. And so aged 21, I left for Nigeria, with a place waiting for me at Ahmadu Bello University in Kaduna up in the Muslim North. I was quite unaware that, Kaduna was the flashpoint for the massacre that had initiated the Biafran Civil War just 13 years previously.
I went there in complete ignorance, with no idea what the hell I was going to do. I was supposed to be working in the MRC Research Lab studying Hepatitis B, but there were two big, unanticipated problems. First of all, they weren’t expecting me. This was before email, so arrangements were made by very lengthy airmail through the totally unreliable Nigerian postal service. And secondly, as I arrived they were actually crating the lab into boxes and moving out to the Gambia because the political situation in Nigeria had deteriorated so badly. So there I was, a 21-year-old kid, who shows up in Nigeria. I’ve got a scholarship that’s going to last me for a year. Actually, I didn’t realize that the Nigerian government would take at least six months to even pay the scholarship. But that’s a separate issue.
Now, I just had to find something to do for that year. I ended up working in the hospital immunology lab doing the Australia Antigen hepatitis tests, do you remember those Chris? and the Widal test for typhoid. At the same time I taught anatomic dissection dissection to undergraduates in the medical school. It is to my parents’ enormous credit that they did not raise an eyebrow before I left, as I was going to be out of meaningful contact for a long time. There was very little communication between Nigeria and Britain. I mean I couldn’t call home, there were no phone lines. I did write, but the mail took a month to be delivered and was outdated and irrelevant by the time it arrived. So I just disappeared off the map, off the grid for a year, and then came back.
That Nigeria experience, marked me in a very positive sense, and was followed two years later by a sub-internship, which I did in Sierra Leone, another West African nation, soon to fall into chaos in civil war. I won’t take any credit for that. It just happened. But that’s the other piece of my DNA. That’s the West African connection that stayed with me. The politics of Africa and its health challenges have stayed with me throughout my career and reared their head 30 years later through the pages of the Red Journal, which is becoming more political. It’s becoming more policy-minded. It’s becoming more internationalist. We are now promoting in our own way, global health issues through special editions and articles within the Red Journal and strive to give a voice and outlet to folk who work in the developing world. So yes, you’re absolutely right. There were some formative experiences that antedated my qualification for medical school that have come back, have reemerged later in life.
Christopher Rose: You’re about to explain to us North American credence about clinical oncology in that kind of unique English specialty, which bifurcates into medical oncology or radiation oncology. Or at least at the time that you were qualifying for it, you can be a double threat and sort of do both. That was the initial residency that you chose --
Anthony Zietman: No, the initial residency was medicine.
Christopher Rose: -- for internal medicine?
Anthony Zietman: Yeah. Yeah, after internal medicine, I chose clinical oncology. That was the only option available. A small number of people, a small number of “eggheads” went into a specialty called medical oncology. But they were doomed to only treat leukemias and some lymphomas. That was about it for them. Now, medical oncology has expanded in Britain. But clinical oncology is still the dominant force, most oncologists in Britain do both.
Christopher Rose: Can we back up a little bit?
Anthony Zietman: Yes.
Christopher Rose: You’re like a thoroughbred. You’re galloping ahead. I’m just trying to get to the motivations. Maybe that’s too much. So there you were an internist or you could have been an internist at that point. But you doubled back. You said, no, no, cancer is interesting.
Anthony Zietman: No. I didn’t double back, Chris. Everyone who does clinical oncology has to do a medicine residency first.
Christopher Rose: Right. So how did you choose clinical oncology? That’s the point.
Anthony Zietman: Oh, I see. One of my intern jobs was at the Middlesex Hospital in London on an oncology ward. There was a charismatic professor of oncology called Roger Berry. You might even remember him. He’s your vintage.
Christopher Rose: He was an American.
Anthony Zietman: He was an American. There was a brain drain the other way across the Atlantic before it reversed in the 1960s. Herman Suit and Roger Berry and all the rest would come to Britain for their training and then take what they learned back to America. Then in the ‘60s, the brain drain reversed. Britons would go to America for their training.
Christopher Rose: Roger was from New York as I recall.
Anthony Zietman: He was from New York. He ended up staying in Britain. He became more British than the British. Indeed, he joined the Royal Navy. Then in 1982, he ended up serving on a nuclear submarine during the Falklands War. I had enjoyed my oncology internship and he encouraged me to consider oncology in the future. So as I was coming to the end of my internal medicine residency, I chose clinical oncology. I actually chose to stay in the Middlesex Hospital to do it because of him.
Christopher Rose: Then somewhere towards the end of that, is that when you made your acquaintance with Shipley, before you joined the brain drain?
Anthony Zietman: No. It was a very weird thing. I was coming to the end of my medicine residency. I went to see Prof. Berry with my thoughts about a future in clinical oncology. He said, oh, then you may want to do a bit of research first. I naively said “sure”. I was 24 or 25 at the time and if Roger Berry said I need to do some research, I’ll do some research. It was so informal in those days. It really was informal. He said how about Boston? I actually thought he meant Boston, Lincolnshire, so I said yes. I was thinking, well, it’s two trains from London. You change at Peterborough. It just never occurred to me he meant the U.S.A. I’d never been to the U.S.A. before, I never thought about the U.S.A., I had no interest in the U.S.A. I was a Europhile. Then before I knew what had happened, he had arranged a whole series of interviews for me: one being at the Mass General; another being at the NCI; another being at the Dana-Farber or Sidney Farber, as I think it then was. I was simply too timid and too inexperienced to say no.
Next thing I knew I was in Boston having these interviews. I had pretty much nothing unique to offer, Herman Suit, as you may remember, was always looking for keen and eager individuals for his lab. He had just received a new NCI grant and happened to need a pair of hands, ideally connected to a brain. He needed these hands, together with a strong capacity to endure pretty tedious work, for a big mouse project that he had had funded. I interviewed with Herman at just the moment when he had this particular need. Before I knew it, he’d invited me to come to the States to work in his lab at the MGH on the seventh floor of the Cox Building. Again, it was the timidity thing. I didn’t know how to say no.
Three weeks after the interview, I found myself back in the U.S.A., certainly with no intention of staying for any considerable length of time. I mean I intend to stay maybe a year or something like that. Then the research went well that year. So Herman asked if I would stay for another. Then he tried to get me onto the radiation oncology residency. I said, all right, I’ll do it but only for a year. After three years - two years lab, one year residency - I said, Herman, I’ve really got to go back to Britain, which is what I always intended to do.
So I went back to Britain in 1989 to complete my clinical oncology training, which I did in two years. Then in 1991, when I was through with the residency, there was a huge job shortage in the UK. Attending physicians in Britain, as you remember, Chris, are called consultancies. The only consultant positions that were coming up in the UK were pretty terrible ones and certainly nothing academic.
So I was looking at the prospect of a consultancy in some godforsaken corner of the UK when I got a call from Herman Suit completely out of the blue, asking if I would like to come back to the U.S.A. to be an attending.
During those years from ‘89 to ‘91, something extraordinary had happened in the U.S. It was called PSA. You’ll remember this very vividly. All of a sudden, radiation oncology departments were being deluged with prostate cancer patients - deluged. Poor Bill Shipley at the MGH couldn’t cope. He had about 60 patients on treatment at any one time. He was drowning. So Herman called me up and asked if I would like to come back and join Shipley because he’s at the end of his tether. As there were no jobs in Britain, I said yes immediately. Before I knew it, I was back in the Boston and GU cancer was my charge. Now, I hadn’t wanted to be a GU oncologist. In fact in Britain, there was very little radiotherapy for prostate cancer. Prostate cancers were managed with observation followed by hormone therapy when symptomatic. It didn’t exactly feel like a very exciting field to be in to me. I negotiated with Herman that I’d do a bit of head and neck and it was that, I figured, that would keep me interested. Little did I realize that PSA had opened a completely new research field for me. At that time, 1991-1992, it was just starting to be understood that PSA was more than just a screening tool. It was potentially a biomarker. It could predict the outcome from radiation surgery. It could detect recurrence after radiation surgery. Pretty much no one was looking at this.
So for several years, I had this “PSA as a biomarker field” wide open and was in it with few rivals. With Shipley’s amazing provocation, I just launched into it. There were two other people, I think, who were doing this. There was Irving Kaplan, who was then at Stanford and he’s now at the Beth Israel in Boston. For a couple of years, he was very interested in radiation and PSA. And there was a guy called Joe Oesterling, who was a young Hopkins-based surgeon, who also became very rapidly a big cheese in this area. Joe Oesterling, after a stellar rise, fell from grace because of multiple financial issues and is now in exile in private practice in Saginaw. I’ve ended up in a better state better than Joe Oesterling, but we started off as equals at that time.
So, yes, it was all serendipitous. None of this happened by intent. Our current residents often know they have wanted to be a doctor since the cradle and a radiation oncologist since kindergarten. For me, it was nothing of the sort. I backed into medical school because I backed out of politics. I blundered into oncology because I met Roger Berry. I stumbled into Herman Suit’s hands because Roger Berry sent me there. I sort of backed into GU oncology because there was a jobs crisis in Britain, I couldn’t get the job I wanted. Then serendipitously, PSA was delivered like manna from heaven to me. I was given the most amazing research opportunity.
Christopher Rose: You know, you’re entirely too modest about this. So I’m going to have to be a little bit provocative, too. As you recall, now talking about PSA, that ASTRO, David Hussey kind of organized a series of workshops to try and help we, radiation oncologists, who didn’t have the luxury of an undetectable PSA as our marker of either success or failure. I believe that you were part of that experience.
Anthony Zietman: Yes. By then, I’d been tooling around for about four or five years in this area. I felt I had some reasonable ideas as to how we should measure failure after radiation. Then ASTRO and Dave Hussey, as you say, organized this consensus conference. It was constructed like a court to hear the evidence, with a judge and a jury. The judge was a very thoughtful urologist called Paul Schellhammer. The jury was a bunch of wise elders from radiation oncology. Shipley certainly put me up to this, and we presented a lot of our own evidence. I think Irving Kaplan probably presented. I can’t remember who else presented.
This consensus conference helped us to create cosmos from the we had had before. We came up with a definition of PSA failure, the so-called ASTRO definition, that really served us for a very, very long time, although it has been subsequently been modified. But it was very, very helpful to the specialty because we were being held to a standard that was set by surgeons that was just ridiculous. Little did I realize at the time that one of the most cited papers ever published in the Red Journal was the report of that consensus conference. Yes, that was a very nice thing to be a part of - very nice.
Christopher Rose: We’re at the earliest part of Anthony’s career. You were taking care of patients. You were thinking about the natural history of prostate cancer and how it’s perturbed by radiation. At the General, they don’t let you just do that; you have to teach. Who were some of the people in those early days who you were both interacting with and teaching? You are a superb teacher. You ran the Radiation Oncology Residency Program as well. Maybe you could speak to that part of yourself.
Lior Braunstein: Also, if it’s all right if I could add one more dimension to that as well - people from whom you learned during residency as well. There was a whole other tier of radiation oncologists who established the field, who I think many young physicians today may not be familiar with. That might be interesting to hear about as well.
Anthony Zietman: There are some people who were incredibly influential to me. There’s no doubt. If I go back to Britain, there was a wonderful physician at Mount Vernon Hospital, who was a Professor on my residency program called Stan Dische. You might remember Stan. Though British, he trained in Philadelphia, then went back to Britain. He was a master clinician. He just understood cancer having had his training before there was a specialty called medical oncology which has progressively muscled into what was once our domain. I actually remember, in 1986, when I first went to MGH, there were 11 radiation oncology attendings and only five medical oncology attendings. My, how things have changed.
Medical oncology was not the bear of a specialty that it is now. Certainly, in Britain, the clinical oncologists were the master clinicians. They could manage the patient from diagnosis to death. I mean absolutely everything: the radiation, the chemo, the palliative care, the hospice stuff. They did everything and even had little operating lists. We did our own cystoscopies, our own biopsies, our own endoscopies. Stan Disch taught me how to be a complete oncologist.
Then when I came to the States, obviously, in the GU world no one has been more influential or helpful to me than Bill Shipley, who just taught me the definition of the word mentor and who generously gave me every opportunity possible. I know he loves me like a son. I know this because in all the years we worked together, the 30-plus years, I’ve always been late due to over-commitments. He was always very punctual. I’ve been late for everything we’ve ever done together. Anybody else would have a strip torn off them for that. But he’s never, ever, ever so much as made a comment to me. We’ve become mutually supportive over the years. I can now help Bill in his late career in the way that Bill helped me in my early years.
Then there’s Herman Suit, who taught me that radiotherapy can be practiced without borders. He was a great internationalist. He just believed in talent and didn’t care where it came from. His lab was populated with Yugoslavs and Germans and Britons and Australians. He simply didn’t care. I think that was a huge lesson for me. Herman was an idealist globalist.
Then of course, CC Wang, who was probably the most charismatic and colorful figure I ever had the chance to know in radiation oncology. And that is saying something because it was a time of charismatic and colorful figures, Chris, you will remember him very well. Many decades after CC’s retirement and many years after his death, Tom DeLaney, Paul Busse and I, who were his students, still find ourselves in morning conference quoting CC, his colorful quotations. CC Wang, Bill Shipley, Herman Suit and Stan Dische These were the people who’ve made an indelible impression on me.
Who do I think I might have influenced or taught? I don’t know. There’s a rising group of wonderful people in the world of GU oncology, people like Ron Chen at UNC and Paul Nguyen here in Boston. There’s Jason Efstathiou who’s now in Boston. They’re all at the associate professor level. They’re the next generation of full professors and chairs, trial leaders and thought leaders. I feel that if I’ve influenced them to any degree, they are on the sort of on the cusp of their own greatness now.
Christopher Rose: One of the things that they want to have you speak to is some of the controversies in your career that impacted your practice and research. You know, you’re so thoughtful about the need to conserve resources and at the same time, you’ve been involved from the very start with protons. I’m just wondering. Could you talk about what you did, you and Shipley and the folks at Loma Linda, that original research project, and what’s happened with protons and where you think it should be and any of these other controversies that you think you’ve been right in the center of and your thoughts about that.
Anthony Zietman: There are two prostate cancer-based controversies that I’ve been very right in the middle of. They seem contradictory. On the one hand, I’ve been involved in proton therapy, not involved necessarily as an advocate but very involved in gathering the evidence to determine whether to advocate for or even against. On the other hand, I’ve also been very involved in pushing active surveillance as a reasonable strategy for many, perhaps even most. men with low-risk prostate cancer. So, I’ll start with the latter, and then I’ll move on to the proton thing.
As I said when I came from Britain I didn’t realize that there was any curative treatment for prostate cancer. You know, there was just hormone therapy when they got mets and we called it a day. When I came to the US, there was some part of me that wasn’t entirely comfortable with treating absolutely everyone with these tiny little, screen-detected cancers regardless of age or risk. I did it, because that is what we did in the USA, right through the ‘90s, but it didn’t quite sit well with me. So I always had a collection of patients who I wasn’t treating, and it was a collection of patients that grew progressively over the years until active surveillance, or as we then called it “watchful waiting”, became a big part of my practice.
I’ve been very involved in the ProtecT trial in Britain. Britain is a nation where you can get certain randomized trials done that nobody else can do. So I’ve now become involved in many British randomized trials, but ProtecT is the one for which I was particularly thrilled to be on the steering committee. I’ve been involved with it for about 17 years I think. It was a trial that looked at active surveillance versus radiation versus surgery.
The results came out last year but we had a strong sense of the results long before they were published. Really, they’ve redefined the way we approach men with low-risk, screen-detected prostate cancer. I mean first of all they don’t have to have surgery. They can have radiation. They don’t necessarily have to have any treatment at all. They could simply be watched. I’ve written a lot on the subject of active surveillance and using time as a test really to determine who needs treatment and who doesn’t. And finally, over the last few years, things have changed dramatically in the United States. And we’re finally practicing the kind of evidence-based, what I would also call conscience-based, medicine that I would have liked us to have been practicing all along.
Now, proton beam fits into this because not only did I have some discomfort about treating everyone with low-risk prostate cancer, I also had some discomfort about using the most expensive therapy in our armamentarium on these folks. I realized back at the time when there were only two proton centers in the USA, us and Loma Linda, that it was my responsibility to gather the data. We will gather the evidence and others can decide the policy.
Bill Shipley, to his enormous credit, persuaded Loma Linda to participate in trials with us. And then Bill Shipley, through his great generosity, allowed me to lead this trial of radiation dose, which we did in the ‘90s and through into the early parts of the 2000s, in which we not only studied dose escalation. That was the important part of the trial. But we also looked at quality of life and other outcomes for our patients. Certain things became clear. Number one, proton beam is a good treatment, but it is not a perfect treatment. There is morbidity. It’s not a magic wand. And over the years other forms of radiation were being developed which seemed very comparable to proton beam.
So, I could have built my career out of proton advocacy because we were one of the few centers around to have it. But I chose to build it out of an examination of the evidence. I actually ended up taking a neutral position. I said I’d go wherever the evidence led me. Increasingly, the evidence and the economics was leading me away from proton treatment for prostate cancer, and I’ve written a lot about this.
I was deeply concerned about a decade ago about a great proton expansion that was being built on a prostate cancer business model that I felt was intrinsically flawed and desperately unstable, desperately unstable. I wrote an editorial in the JCO entitled “The Titanic and the Iceberg” in about 2008 which really highlighted the instability of this economic model. It’s now coming to pass with many private centers built on a prostate cancer business model either collapsing or at the edge of collapse. You know it disturbs me. To this very day it disturbs me.
So, yes, I wanted to go where the evidence led me and where my conscience led me. And where did the evidence led me? Well towards active surveillance and away from proton beam for prostate cancer.
Christopher Rose: I mean lest the people get from this interview 20 years from now that you’re a therapeutic nihilist.
Anthony Zietman: Not at all, I just think we misdirected resources. When I think of all those patients on whom I spent thousands of hours treating, and in some cases harming, I think how much more I could have given to the patients with the locally advanced prostate cancer. I mean that’s really where the money is. That’s the disease that kills men. That’s where the advances are being made and that’s where I want to spend the rest of my time and the rest of my career.
Lior Braunstein: Was there a sense of that in the early days where people had trepidation about doing that? Or was the feeling that if you didn’t treat patients you’d end up in a much worse situation down the road?
Anthony Zietman: The “party line” made most passionate believers in screening. Screening finds cancer early, you treat cancer early, and you reduce the burden of metastatic disease down the line. We actually thought we were going to eliminate advanced disease, and so if there was any nihilism it was centered on the advanced disease. Our positive thoughts focused on the low-risk disease. It turns out we might have gotten that wrong, largely wrong, not totally wrong, but largely wrong. Because most of that low-risk cancer doesn’t go on to become locally advanced disease.
Christopher Rose: Anthony, we have only 15 minutes left, and there is so much that we can cover. Perhaps, you might speak to your involvement and just briefly because there’s so much more to cover in organizational radiation oncology and organizational oncology and the ABR.
Anthony Zietman: This gets back to my original intention of having a career in politics and policy way back when I was 18 years old. Over the years it became clear to me that in the clinic, I was doing good one patient at a time. That’s okay. That’s a good way to do good. But if you participate politically and in policy, you can actually do good thousands of patients at a time. If you made a big change at some national or even international level, you could really help people in large numbers.
And I got into ASTRO first of all through the Scientific Program Committee. I became the scientific program chair after Ken Russell in the late 1990s. I can’t really remember when. I don’t even know who put me up for that. I don’t even know how it happened to me, so this is that serendipity thing happening again, the leaf in the wind. I did that for three years.
I loved that job. I loved organizing the ASTRO annual meeting. It brought me into contact with so many people. It’s like organizing a wedding or a bar mitzvah. When it’s done, you feel so proud. And after each ASTRO meeting I would just feel so proud of how well things had gone. Then the very next day with the incoming president, I’d start planning the next year. From there, I was elected onto the board and I served two terms, the second term, the second four years being on the presidential track.
It was a time of great change. We were looking at improving and elevating practice across the nation through quality measures and guidelines. It was really an exciting time to be a part of ASTRO. I built my presidential address, and I thought my whole presidency was going to be based around advocacy of evidence-based and conscience-based practice. That was certainly what I talked about in my presidential address. Actually, my presidency was hijacked by the safety crisis of 2010 which, Lior, I think you were a resident at the time when we had a run of damaging Philadelphia Inquirer and New York Times articles. It seemed like the credibility of the whole specialty was kind of melting before our eyes, and I think ASTRO, to its enormous credit, rallied to this.
I remember, shortly after the Times articles about therapeutic safety came out, there was a board meeting at which we just tore up the agenda and brainstormed an action plan in response. We ended up spending a lot of time on Capitol Hill talking about this. The RO-ILS came out of this, many other practice-changing initiatives, safety-inducing initiatives came out of that crisis. It was reminiscent of the time when three Korean Airliners went down in rapid succession in the 1980s. There clearly had to be a culture change. And I think we’ve repurposed the specialty very rapidly. We produced a document entitled “Safety is No Accident,” which is the measure by which we now accredit radiation oncology facilities.
So, I thought my presidency was going to be all about evidence in practice. It was ultimately about safety in practice. So in that sense, as part of the big ASTRO team, I definitely feel that was transformative for the specialty. At the same time I was also working as a trustee of ABR. This really is God’s work in a funny way because it comes with no credit or visibility. You just devise exams and try and make them meaningful and relevant. You know, the oral exam and the written exam have been greatly modernized in just the last couple of years, and vastly improved.
And then we’ve also transformed the whole MOC, Maintenance of Certification, process. The American Board of Medical Specialties locked us into a format that didn’t suit our diplomates. It was becoming incredibly onerous for diplomats to maintain their certificates, and we’ve really freed them up now. The exam has become less important and then was faded out. We’ve developed a quality improvement process that’s relevant and easy for our diplomates, and we’ve repurposed this towards quality and safety. So it ties in with the ASTRO measures on safety and the needs of their own institutions and state licensing boards.
So, yes, I’ve been part of organized medicine, and I’ve been so delighted to be involved at a time of great flux in the specialty. I think I can look back and say, not as a result of my individual endeavors, but as the result of our endeavors as a group that radiation oncology is in a much better place, and radiation treated patients are in a much safer place than they were say a decade ago.
Christopher Rose: Anthony, perhaps you might speak to your other great enterprise right now which is the Red Journal and then beyond the Red Journal in general to the ways that radiation oncologists and all physicians need to acquire knowledge in the future.
Anthony Zietman: The Red Journal was an impulsive decision of mine. I was coming off the ASTRO presidency and chairmanship. I imagined there was going to be this enormous void in my life, forgetting that I was still running a residency program and had my research and a whole clinical practice. But I imagined there was going to be a big hole. At that very same time Jim Cox decided, after 15 years as the editor, to stand down. So I, again, impulsively threw my hat into the ring and ended up being selected to be the editor of the Red Journal.
Jim inherited the Red Journal as a paper journal. Everything was handled on paper. You will remember the days when we used to review. The whole review process took six to 12 months. You send in a paper, multiple copies. They’d be sent out, mailed out to reviewers and the reviews would be mailed back, and then mailed to you. Jim transitioned it into an efficient electronic journal. But by the time his 15 years were done, because of the popularity of the journal and the popularity of the specialty and the research output of the specialty, the journal was absolutely deluged with papers and it almost ground to a halt. So, there was a backlog of about 18 months’ worth of accepted papers that hadn’t yet come out.
I realized, as a priority, that we needed a process to rapidly manage papers, and we established that. I have a very structured editorial board now. I have ten senior editors that are young, enthusiastic people usually at the assistant to associate professor level who are dynamic, and who see this as real work. Each of them owns a disease site and has a team of five or six associate editors. The associate editors are younger, and have proven their worth to the Red Journal by being great reviewers. And everyone is term-limited so nobody gets exhausted. Everyone is term-limited at three years and good reviewers become associate editors and great associate editors become senior editors. So, people are incentivized to work hard as there is an escalator upwards.
We’ve gotten the review times down to about 21 to 24 days on average. You submit a paper and, whether it’s going to be accepted or not, you’ll know within three weeks. So if it is not going to be accepted, the data is still fresh and you can submit elsewhere. We vastly improved that process by having a working editorial board that is dynamic and keeps the wheels turning.
I’ve also got an editorial board that reflects the future of radiation oncology. The senior editorial board will increase to 12 this fall. There will be six men and six women which is very important to me. Every sexual orientation is represented. There’s black, there’s white. There’s Indian, there’s Asian, there’s Jewish. We’re all there. So it’s a representative board.
Then what was I going to do to change the journal itself? Well, we are the International Journal of Radiation Oncology * Biology * Physics, so I wanted the international piece and this gets tied back into my very early internationalism. So we now have many international representatives on the working editorial board, and they’re very important. We highlight international research, but we also highlight the practice of radiation oncology around the globe. We have a feature article called “Around the Globe” every second or third edition in which I get the folks, for example, in Japan to write about what’s unique about radiation oncology in their country, or the Philippines, or India, Israel or Nigeria for that matter. Everyone has got something unique to say. The article from Nigeria focused on what it is like to work in a collapsing economy? How do you practice radiation oncology when you can’t maintain machines? From Japan we learned what is it like to practice in a country that has a very, very bad relationship with radiation? Hiroshima, Fukushima, that’s what their article was about. What is it like to practice in Italy, under the crushing weight of a medical bureaucracy? Lebanon, what is it like to practice in a nation that has been destroyed by a civil war? So we’re really featuring the unique practice of radiation oncology in unique environments around the world.
I’m also emphasizing the quality of evidence. The associate editors really have some strict guidelines about what we accept, ideally it would be randomized trials, but realistically most of those go to JCO, Lancet Oncology, and the New England Journal, but good phase I, phase II studies, prospective work, good quality, big data studies. So we’re emphasizing the best evidence and writing a lot of reviews and editorials to assess the evidence and set it in its context.
We’re having special editions. We have had one special edition on global medicine. We had a wonderful special edition last year on proton therapy in which everyone was represented: the proton evangelists; the proton nihilists; the biologists; the physicists. It was a fantastic edition. And we’ve got one coming out in July of this year. Perhaps this is representing where I am in life. We’re calling it the Silver Edition. It’s on radiation oncology in the elderly, and how we adapt our therapy for those in a frailer part of their life. We adapt radiation therapy for children because we regard kids as different. We should regard the elderly as different also, but how? These are the things I’m trying to emphasize.
Then the other transformation we’re going to through is the transformation of journals themselves. I’m not even sure that journals as we know them will still be here in a decade. I think much scientific research is going to be simply published in open spaces, in data repositories. This is certainly what’s happening in basic physics and biology, and in time, I suspect, clinical articles will be published that way also. I can imagine a day when NRG will publish its trials on its own website. Why wait for anything? Just get the information out there. Everything is searchable now. So, what will happen to journals? I think journals will move away from being the place in which we publish scientific research, to the place where we critique it. I think scientific journals will require more journalists than the original scientists. We’re certainly writing more editorials and more critical pieces in anticipation that this is where we’ll be in a decade.
Christopher Rose: This is fantastic and given that this is for posterity, I think it’s crucial and maybe underweighted unfortunately, if you let our readers and correspondents know about the other side of your life, your family, your interests outside of medicine.
Anthony Zietman: Sure. Well, I met my wife when I was 16. She was at my high school. We didn’t go to medical school together. We did travel in Nigeria and Sierra Leone together. We got married when we were 22, and so we’ve been married now for 36, 37 years. We have two kids both of whom were born extremely prematurely, extremely prematurely, one at 29 weeks, the other at 25 weeks. Both of whom spent their early life, their early months in ICUs. Both of whom were in randomized trials. You know, I was very impressed with much neonatal ICU care is trial- and evidence-based. It came up in my presidential address in 2010. I went back and looked at the randomized trials that my wife and the kids had participated in. Very interestingly, one of them was ultimately a positive trial; one was a negative trial in the wrong direction. The other one was a wash. It shows you how randomized trials inform practice. Our presumptions are often wrong, indeed we get more wrong than right. So, I’m a great believer in trials and evidence development.
And so my kids in their own way have helped influence me in those early experiences in my practice. My kids are now in their late 20s. One is a steel artist, an artist in metal, and the other one has just started at Harvard Law School, finishing his first year. My daughter got married to her partner a couple of months ago. And Jack, my son, is getting married to his fiancé next month. So that’s all happening.
My other passions, my principal passion actually, has been dancing. My wife and I are reasonably competent salsa dancers. Wherever we go in the world, wherever I travel for academic purposes be it Tokyo, Beijing, Madrid, San Diego, the first thing we do when we arrive is “Google” the salsa clubs and we go out dancing. I may not be able to speak a word of Japanese, but I can dance fluently with any Japanese salsa dancer which is a great pleasure for me. So we dance a great deal.
Again, dance affects my work and Lior will remember this. Each year the residents put on a performance in front of the entire department. We have a winter party in January. There are usually 300 or 400 people who come to this party. For the last dozen years at least, we start rehearsing something in December. Either I teach myself or I bring in choreographers, and the residents hit the stage in late January. They start off as non-dancers in December, and by the end of January, when the party comes around, they perform magnificently. I think, maybe they will disagree, Lior can comment, but I think it’s a great team and spirit building exercise. We do it every year. We’ve done it again this year. They’ll dance salsa. They’ll dance jazz dances. This year, we did an Indian Bhangra dance.
It’s a great way of taking these amazing residents, who are Harvard and Yale and MIT graduates, putting them into a space in which they are totally uncomfortable, and then proving to them that they can do it. It is taking successful people, putting them into an unfamiliar situation, and then we make them successful again. It’s just a wonderful thing to watch. So, yes, my private life and my work life are very blurred, you would say. AS Herman Suit practiced radiation oncology without boundaries, so I’m to some degree without boundaries.
Christopher Rose: Lior, do you have any closing questions for Anthony?
Lior Braunstein: I mean there’s so much that we could touch on and I’d say it’s been a real privilege just to hear this and participate. One thing that I was thinking about was you’ve talked about the innovations that you’ve brought into residency programs, and how you’ve seen training change over the years. You mentioned that you were involved in the ProtecT trial for 17 years. And it struck me that you became the program director at MGH 17 years ago.
Anthony Zietman: Training has changed dramatically, and Chris can address this as well. Training used to be immensely hierarchical. You know, the trainees were apprentices. They were there, the gift of the training director and the chair of the department. They were the vassals of the chair of their department. They worked incredibly hard. They got very little thanks, and they were pumped out the other end having passed their board exams, and hopefully having learned something.
Now, training is so much more structured. I think training is infinitely better than it used to be. Feedback is now more rigorous and works in both directions. We have resident feedback of faculty. We have faculty who are engaged and they want to improve. The ACGME has launched a whole new program of self-study whereby we actually have to analyze our programs, look for areas of improvement, and then set ourselves targets, and meet those areas. I think it’s all wonderful stuff. So I think we’ve gone from the vertical and hierarchical towards the horizontal where residents have far more of a say, and are treated far more as equals. And I do think that they get more out of residency training. So that’s all good.
I’ve been involved in some initiatives. I’ve been very concerned about the whole match process, which I think is in many ways very destructive. Because we’re such a popular specialty, everyone is applying to every program. The whole thing is totally out of control. There are all sorts of behind the scene nefarious behavior in which programs were putting pressures, unseemly pressures, on the applicants to try and get them to rank their program highly. I managed to put together a consortium of all the major residency programs last year to pledge to stay away from these post-interview behaviors. We actually used the Red Journal writing a collaborative editorial entitled “Taking the game out of The Match”. So all the major radiation oncology residency programs this year and last year pledged to have no communication with the candidates after the interviews. There will be no undue pressures and threats placed upon them. This is a system that seems to work incredibly well. I do hope this becomes a permanent part of a new culture and will spread to other specialties.
In terms of a training, the way we treat residents I think has changed for the better, the way we educate residents trained for the better. Their research opportunities have improved vastly. I’m sure they’re going to carry on improving. Now I’d like to work on the medical students to try and give them a more meaningful exposure to radiation oncology and a kinder interview process. But that’s for the future.
Christopher Rose: The very last minute, is there anything that you would like that we forgot, or that you think is important for posterity that you’d like to speak to? This has been an amazing tour de force that you’ve sent us.
Anthony Zietman: I think you’ve hit on the high points. I’m actually looking forward to doing less in the years ahead. I’ve just rotated off the ABR. I’ve just signed another contract for five years to the Red Journal. But I’m looking forward to passing the baton to the next generation of amazing people, and there’s a big bulge of talented people right behind. Radiation oncology became immensely popular about 12 years ago, and we’ve had just the cream of the crop of the candidates for these last dozen years. These people are now graduating and they’re moving up into positions of, at the moment, juniority but soon to be seniority. They are going to do wonderful things in the specialty. Lior, I count you amongst that next generation. So I actually want to sit back and see what happens next. I think it’s going to be incredible.
Christopher Rose: Thank you so very much, Anthony. You will get the unedited transcript of this and you can, as the senior editor, you can chop away and --
Anthony Zietman: Thanks, editing is my specialty these days.
Christopher Rose: Lior and I will perhaps prune just a tiny bit and then send it back to you for final approval. It will be both up on the website, and then 50 years hence, these unedited recordings will be moldering somewhere that historians can look at them. Thank you so very, very much.
Anthony Zietman: Thank you, Lior, and thank you, Chris. It was a great privilege.