An Interview with Beryl McCormick, MD, FASTRO

By Lauren Vallow, MD and Paul Wallner, DO, FASTRO

The following interview of Beryl McCormick, MD, FASTRO, was conducted on February 13, 2020, by Lauren Vallow, MD and Paul Wallner, DO, FASTRO.

Laura Vallow:  Why did you choose medicine, why radiation oncology?

Beryl McCormick:  Okay. After taking all those aptitude tests when I was in high school, I was actually cut out then to be an architect.  But I had to partly work my way through college and the idea of five years of architectural school really was very daunting.  So, I opted to just go to a four-year college.  I started out as a music major.  I didn't do very well once I had to start listening to more than one line of music at the same time because I only just played one instrument, the “cello.  I've never played the piano.  At the end I decided to take the rest of my required liberal arts courses because I was never drawn to science at all.  I ended up loving physics.  Remembering how often when I was a kid, when I was little, I got better when the family doctor used to come and do house calls at the time, I ended up taking chemistry for the first time - I never took it in high school - and deciding to go to medical school.  But it was a very roundabout not well-thought out career choice for me.

Laura Vallow:  It is interesting, the non-conventional path.  I think that's how a lot of women probably end up in Radiation Oncology.  What pushed you towards Radiation Oncology?  How did that spark your interest?

Beryl McCormick:  I did summer work in a research lab, of kids with leukemia and for the first time I realized there was something called radiation.  Then I did an elective in diagnostic radiology where the radiation part of the department was actually on the same floor.  I got very interested in that as well.  I don't think you'll remember him, Paul, but there was an old English radiation oncologist named Ralph Phillips.  He was the temporary chairman at Memorial ages ago.

Paul Wallner:  Yeah.

Beryl McCormick:  After he retired, he actually was a kind of the senior mentor in the Radiology Department that I had a two-month elective in.  He really was the first person that got me in contact with Memorial and really got me thinking seriously about going into radiation oncology.

Paul Wallner:  Was he at Memorial before D'Angio got there?

Beryl McCormick:  Yes.  At one point, I think before the first chairman was named, before D'Angio, he was an acting chairman after he came to the United States from England after World War II.

Paul Wallner:  Was that still when radiation was part of surgery at Memorial?

Beryl McCormick:  I'm not sure about that.

Paul Wallner:  Where did you grow up, Beryl, and where did you end up going to college?

Beryl McCormick:  I grew up in Essex County, New Jersey.  I really wanted to go to an Ivy League school.  I got into the University of Pennsylvania with a scholarship because it was one of the few Ivy League schools at the time that accepted women.  But when I looked at how much I had to borrow and how many hours a week I had to work, I ended up just going to Douglass College Division of Rutgers.  And I went to the New Jersey College of Medicine as well for economic reasons.

Paul Wallner:  A lot of us did that in those days.

Beryl McCormick:  I know.

Paul Wallner:  Worked in the summers to pay for school in the winters.

Laura Vallow:  In these days too.

Beryl McCormick:  Yeah, even these days I'm sure with a much bigger bottom line to pay off than we had.

Laura Vallow:  Tell us a little bit about your residency. Who was your chairman? Who were your mentors?

Beryl McCormick:  Dr. D'Angio was definitely the chairman when I was here.  One of my early mentors was another pediatric radiation oncologist, Mel Tefft. I did a lot of work with him with Ewing sarcoma and looking at whole lung radiation in kids.  So they were definitely early mentors. 

But I just got more interested in breast cancer as I went through my rotations.  I was here at a time when we had the most famous surgeons in the country doing extended radical mastectomies.  I was already getting exposed to some of the early work of Sam Hellman up in Boston and was just I think fascinated by the whole idea of doing breast conservation surgery.  But Memorial was so anti-breast conservation surgery and after D'Angio left, Florence Chu became chairman.  Even she did not support it.  So I actually did a three-year residency.  That's all we had to do at the time.  Then I went up to Albert Einstein Medical Center in the Bronx and worked for about a year-and-a-half with a radiation oncologist named Nem Ghossein He is Egyptian but I think he fled Egypt in one of the many, many, many Middle Eastern wars and uprisings that take place there so often.  I can't remember the details.  He worked for a long time at the Institut Curie and worked with one or two surgeons up at Albert Einstein that were perfectly happy doing breast conservation surgery.  That's really where I learned how to do what I do now.

Then when I came back to Memorial, fortunately we hired for the first time a physician-in-chief who was not a surgeon or a pathologist.  It was Sam Hellman.  So that made my life very simple and easy because he really was very encouraging.  He gave me research money and was a great role model.

Paul Wallner:  Was Florence still chair at that time or has it then converted to --

Beryl McCormick:  No.  It had converted to Zvi Fuks because Zvi arranged for Florence to go over and run the department which we had taken over at New York Hospital, Cornell.  Yeah, Zvi came and Sam came within less than a year of each other.

Paul Wallner:  Do you remember who any of the other residents were on your program?

Beryl McCormick:  I do but you wouldn't know who they were.  I was really the only American.  No one became anyone at all (Academically).  There was someone from Puerto Rico named Pollo Poussin He did some lymphoma work for a while, but I don't know where the others went.  They sort of went back in small private practices as many people did at that time.

Laura Vallow:  So I imagined there weren't many fellow females.  How did you feel being a female in the field at that time?  Did you have any discrimination against you?  Tell us about that experience.

Beryl McCormick:  No.  I think part of it is just my attitude.  I'm probably a lot less sensitive than some people.  But in my medical school class there were six women in a class of 120 or something.  I never remember at any point really feeling bad.  The same thing is true in residency.  I think almost without exception.  The exception is kind of considering the time, and the place, and what the norms were then.  No, I really never felt out of place or left behind or there was some place that I couldn't get to because I was a woman.

Laura Vallow:  Tell us a little bit about your employment history.  Where you started? How did you end up in your current position, maybe a little bit about your transition from clinical to administrative responsibilities?

Beryl McCormick:  It's really a very short history.  I was hired right out of residency at Memorial.  But, for the reasons I just told you, I already had an ASCO - - Junior Career Award at the time to work on breast conservation.  So, I left Memorial I think within a year of them hiring me and just went up to Albert Einstein and worked with Ghossein and then came back about a year before Zvi arrived, a year-and-a-half before Sam arrived.  And I've just stayed here ever since then. 

I probably transitioned into administration without officially being called an administrator because I worked very closely -- I was very close friends with Steve Leibel.  So, by the time he was president of ASTRO and president of the American Board of Radiology and all the other leadership positions he collected sometimes more than one at the same time, I was often the person here that he left running the department.  So that's I think how I ended up doing alot more administrative things than I had initially planned to do.  That was really because of Steve, then Steve not being around and somebody having to run the place.  I kind of grew into it that way.

Laura Vallow:  Certainly, your contributions to breast cancer treatment, have been quite major.  What do you consider your most significant accomplishment or contribution?

Beryl McCormick:  I think it's really two things.  I really think I contributed a lot as a founding member of the NCCN guidelines committee.  I was on that committee for more than 20 years.  I just stepped down at the time when the other Memorial person on the committee, Cliff Hudis, had to step down because of transitioning to ASCO leadership.  We decided that if we had only one representative on the committee, it probably should be a medical oncologist.  Not me because I just didn't have the depth of knowledge of some of the really cutting-edge clinical trials that we were doing in breast that a medical oncologist would.  So NCCN is really I think one of my major strengths; although, it's certainly a teamwork.

The other is really my role in reviving the RTOG breast committee which -- I don't know how many years they didn't have it.  I don't know if you know, Paul.  But I know at one point, when I was asked to revive it again, I was told that one of the more prominent radiation oncologists who had been involved in the early RTOG breastwork had just said there are “just no more local or regional problems to address.  They've all been solved and why do we even have a committee”.  So, I think they went about five years without the breast committee.

I very happily took up that leadership position.  I think it's really true that we contributed a lot.  The CALGB elderly trial would never have completed accrual if RTOG hadn't adopted it.  I don't think most people realize it but that's the trial where, if you're estrogen receptor positive and you're 70 years of age or older, there's very little benefit to giving whole breast radiation if you're on hormone therapy.  But the way that trial was written, the patients didn't have to be hormone receptor positive.  So, we basically forced the CALGB to modify that trial to include only ER positive patients before RTOG would join.  Certainly, I think my work adapting and pushing all the PBI phase II trials and then putting together with Wally Curran and the NSABP leadership, the PBI Phase III trial was a big accomplishment.  And of course, my own DCIS trial I'm particularly proud of also.

Actually, the other thing that I jotted down here was something I did at Memorial with a resident who had been a fellow in an institution where they were doing a lot of prone breast MRI imaging.  That was to actually, I think, do the first prone breast treatments here.  We actually have a wonderful machine shop.  The resident and I designed the first prone breast board and had a prototype made in the department.  I guess we're the first ones to also report on prone breast treatment, so that's another accomplishment.

Paul Wallner:  For a while you're talking about clinical trials.  You want to sort of think back a little bit on some of the criticism of the early NSABP trials and of the radiation oncology in those trials and how sort of that impacted the specialty for 10 years or so?

Beryl McCormick:  I'm a great admirer of Eleanor Montague who I think was the person that was giving NSABP most of their guidelines for radiation in the breast clinical trials.  But as I think you know, Paul, which is why you're asking this question, the guidelines were very, very basic.  There was no QA.  Just almost nothing except this is the dose you give to the breast or the breast and the nodes.  RTOG has really taken the way we give breast radiation to a whole other step and taken NSABP along with us fortunately.  But, yeah, it was extremely basic for a number of years.  That was the big criticism of everything that NSABP did. 

I remember, I guess it was Barbara Fowble, who used to say NSABP doesn't have to do a boost because they don't use wedges and they're getting hotspots in the place of the breast where most of the lumpectomies are anyway.  So it was not a great time to give great breast radiation.  That's what I do remember.

Laura Vallow:  What other controversies have impacted your practice and research? 

Beryl McCormick:  There was a time when there was not an agreement for patients who needed radiation and needed chemotherapy as to what the order of those two treatments should be.  Working here at Memorial with Larry Norton, we always decided it was more important to give the chemotherapy first and then the radiation afterwards in patients with breast conservation.  I know Jay Harris, who remained up in Boston after Sam left, actually totally disagreed with that.  He and I are still good friends and have great admiration for each other's work, but there was probably a period of 12 or 18 months where he wouldn't even speak to me because he was so upset about the way that we were doing things here.  He was so sure he was right the way he was doing things up there.  So that's definitely our little controversy in the RadOnc world between us that I remember well in addition to the big things.  You know, the surgeons saying all kinds of things at the beginning about Bernie Fisher and how can anybody not remove the whole breast.  All the usual things that we all know about.

Laura Vallow:  That would be such an interesting time to experience.

Beryl McCormick:  The other thing you may want to put in the history, I haven't done ocular cases for a while but I worked really closely with Bob Ellsworth and then David Abramson doing a lot of work with retinoblastoma and also with a collaborative ocular melanoma study.  That was a whole part of my life (Eye cancers) until I just got so busy about 10 years ago.  I passed it off to one of our junior attendings.

Paul Wallner:  How did you treat the ocular melanoma?  With plaques or with external beam?

Beryl McCormick:  No.  With plaques.  I was very good in OR.  I used to be allowed to put in stitches and everything.  I really liked going to the OR too.  That's one thing I missed a lot, yeah.  With David Abramson I did - I don't know - hundreds of cases.  We were actually the biggest accruer in the collaborative ocular melanoma study (COMS).  It was a prospective randomized trial as there were two categories of patients.  There were large ocular melanoma patients where the trial compared preoperative radiation to none and then everyone got enucleated.  But with the intermediate sized melanomas, the randomization was to plaque radiotherapy or enucleation.  David and I were the biggest accruers to that trial in the United States.  I think there was one center in Canada that put more patients on than we did, but we put more patients on than any place in the U.S.  So yeah, that was a big part of my life for a while.

Laura Vallow:  Can you tell us about the major work you've done with organizations like ASTRO, RTOG, ABR?  I know you've kind of touched on RTOG but maybe ABR, ACR, PTCOG.

Beryl McCormick:  Going back to your question a while ago about not being able to succeed in doing what I want because I'm a woman, I have to say in ASTRO I think that I didn't go as far as I could because I think ASTRO is so heavily leadership leaning - at least until very recently - towards the men in the profession. 

I remember when Steve Leibel came up with the idea of the FASTRO designation.  I think, whenever he got back from the first meeting that that (FASTRO designation) was given out, he showed me the list of who had gotten FASTRO fellows.  I sat down with him and I said, do you see anything wrong with this Steve?  And he said, "No.  They're all leaders in our profession.”  I think out of the first 30 FASTRO designations, maybe one or two was a woman.  Sarah Donaldson.  I don't know who else. 

So the things that I've done for ASTRO had been with the head of the ASTRO/FASTRO selection committee.  I've certainly done a lot of work with the programs, but I never felt like I got the push to run for president or major office because people like Steve who were here bringing up other attendings in the department for major roles just I think unconsciously passed over women.  So that might actually be an area where I think being a woman didn't help me.  In RTOG, you know my role in RTOG.  ABR is basically been just working on questions, board stuff, and things like that.

Laura Vallow:  Do you have any suggestions?

Paul Wallner:  Do you think you're being too kind in suggesting that it was unconscious?

Beryl McCormick:  No, I really don't.  I was a very, very, very close friend of Steve.  I just think it didn't enter his mind.  He could look at the picture of leadership but not see that it was all men.  I think that's how people thought at the time.

Laura Vallow:  I was going to save this question towards the end, but I think it's a good time to jump in now.  Do you have any suggestions for women in the field now that may be feeling similarly?

Beryl McCormick:  I think it's really important for women who I think tend not to speak out as much or to stand up on a box and talk about their achievements to do so.  I think we still have to be more aggressive in the way we present our ideas, the way we present our accomplishments to get the attention that we do need.  I think it's still a long road ahead.

Paul Wallner:  Beryl, just out of curiosity, have you ever spoken to any of your female residents or colleagues about why there seem to be so few women going into radiation oncology relative to some of the other specialties?

Beryl McCormick:  In terms of right now?

Paul Wallner:  Yeah, over the last five years or so.  We're running at about 20.  I just did a manuscript with Reshma Jagsi and maybe know about this.  We're running at about 26, 27 percent.

Beryl McCormick:  Yeah, I know.

Paul Wallner:  The other specialties were in the 40 percent, 50 percent, 60 percent.  A couple were in the 80 percent.

Beryl McCormick:  I've talked to them.  I really get the same answer that I get from some of the men in the profession.  It's not so much I think radiation oncology, but the perception that there aren't going to be as many jobs out there when they finish is what I'm getting said back to me.  I don't think it's at all a specialty that can -- I think it is a specialty that can be practiced well along with balancing your family life or whatever else you choose to do outside of the hospital.  And I'm not hearing that from the residents.  It's more the general theme that I think you're well aware of too, that there may not be as many job opportunities or job opportunities in places where these residents who are obviously bright and could go into a lot of other specialties would want to work.  That's what I'm hearing.

Paul Wallner:  Okay.

Laura Vallow:  What do you envision for the future of radiation oncology?

Beryl McCormick:  Being at Memorial where we have an amazing program we call Impact where we're really studying all kinds of markers and genes in cancers, I think every week when I hear a new lecture here, I’m more and more and more impressed by the ability of cancers to change and adapt.  I'm becoming less and less convinced that five or even ten years ago we were going to have a whole stable of perfectly matched individualized cancer treatments.  So radiation is a good treatment for cancer.  Cancer is going to be a growing problem in this country, as we all know, and we all age.  So, I think there's a very great role for it.  I think it's becoming more accessible to patients as we shorten our treatment times.  I definitely am very upbeat about the specialty going into the future.

Paul Wallner:  Beryl, since you're sort of at the epicenter of some of the biological advances and physical advances in oncology, what do you see is the role of the basic sciences for our residents going forward?  As you know, there's been a huge amount of pushback as far as the teaching and assessment of physics and biology.  Where do you see that fitting?

Beryl McCormick:  Before I answer that question, I have to be honest that I don't see that here at Memorial.  We still have the majority of our residents entering every year that are MD-PhDs.  They are very happy not only to have their year of research but to have a pretty rigid program in terms of physics and radiation biology.  I think from the point of view of someone who is going into training and not wanting to end up as a very academic person, I hope that the board doesn't change requirements very much.  Because I think it's so important, as our equipment gets more complicated and as our systemic treatments that are integrated with what we do become so much more varied, that we all understand how everything is interacting. 

I did a lot of reading when the issues came out, the Red Journal issues where a lot of those pieces are that you guys had written and some of the residents now had written.  I would be more conservative and say we really shouldn't be changing things that much.  I forgot the year where all the scores went down, but I think that was just –-

Paul Wallner:  2018.

Beryl McCormick:  Yeah.

Paul Wallner:  Yeah, 2018.  And they were back up in 2019.

Beryl McCormick:  That was what I would have supposed to hear from you when we talked about it.

Laura Vallow:  So, talking about the future of oncology, what advice would you give not just the females but just all the aspiring radiation oncologists?

Beryl McCormick:  I would just really encourage them, I think, to work very closely with colleagues outside of our discipline again so they really have a complete understanding of what the surgeon can do and what the medical oncologist can do.  I know here in our program in breast, we make sure that all of our breast residents spend a couple of days in pathology.  They would spend time in breast imaging or just really understanding I think the full picture of how to treat a given disease.  That’s why I feel very comfortable in terms of all the consults that I do with my breast cancer patients, because I really have a very good sense of what goes on from the time they get diagnosed to the time they finish their 10 years of hormone therapy.  I think that’s important to become a really well -respected doctor to your patients, to just know a lot more than just your own specialty. 

Paul Wallner:  Do you continue to follow your patients during the continuum? 

Beryl McCormick:  I can’t follow them all because I could be here 14 hours a day just making follow-up visits.  But yes, there are a certain percentage of my patients that I’ve treated through the years that I continue to follow up.  So, on my day for follow-up visits, it’s not unusual for a resident to see someone that I treated 20 or 25 years ago who come back.  I think that’s really important because they really have a sense of people survive their breast cancer.  Our treatments were good 25 years ago, but the breast doesn’t look as good as it does now with much better surgery and much more uniform doses using all the physics whistles and bells that we used to get uniform doses. 

But yeah, I follow a number of patients.  There are patients that just say I feel much more comfortable coming back to see you once a year, I don’t want to transition into survivorship.  They’re a handful, but I follow them too.  The downside of it is I get called about all their non-oncology problems, but that’s all right. 

Paul Wallner:  Right.  Yeah, I still have that.  When I went to the NCI, patients said can I continue to see you there.  I said it’s good news and bad news.  The good news is you can. The bad news is it’s free. 
Laura Vallow:  That’s inspiring. I admire that. Tell us a little bit about your family, your family life, significant others, children? 

Paul Wallner:  And now grandchildren. 

Laura Vallow:  And grandchildren. 

Beryl McCormick:  Yeah. My husband, as I mentioned, he’s retired now but he was a radiation oncologist.  He did primarily head and neck work.  We'll be married for 40 years this year.  We have two boys, none of who was remotely interested in going into medicine.  One is very successful at Google, and the other one is a finance person.  Now I do, as Paul know, have two little granddaughters as well.  They keep me very busy.  I’m working 80 percent of the time now and I watch the little girls on Monday. 

Laura Vallow:  That’s nice.  They’re close by.

Beryl McCormick:  They're very close by, yes. 

Paul Wallner:  How old are they now? 

Beryl McCormick:  One is just over two, and the little one is about nine months.  They’re good ages and they’re really cute together.  And, yes, everybody’s back.  My Google son and his Google wife just transferred back to the New York Google office from Mountain View in California after six years.  So, everybody is back in the New York-New Jersey area which is great. 

Laura Vallow:  When you were really active and had young children at home, how did you maintain work-life balance? 

Beryl McCormick:  We were really, really lucky.  My husband is from Colombia.  We had a nanny.  She came for the day.  But if we wanted her to stay overnight because we were going out late, she would.  She basically was with us from the time my oldest son was born until our kids almost went off to college. 

We never had anybody else.  She really made things happen.  She died a couple of years ago.  But I know one of the best weekends I had with my two boys before they got married and long after she retired, she retired with her son and his family in California, the four of us just went out there and spent the weekend with her.  That’s really amazing. 

Laura Vallow:  Yeah.  That's wonderful. 

Beryl McCormick:  So, yeah, I was very lucky.  Most people don’t have that happen.  That really allowed me to do anything that I wanted to do.  And my husband was actually very good, too, with the kids and cooking if I was at the office late or ordering out.  Because we lived in New York, so it wasn’t as stressful as you might imagine. 

Laura Vallow:  Did he work full-time as well? 

Beryl McCormick:  Of course, yes.  Definitely. 

Paul Wallner:  Where does he work? 

Beryl McCormick:  My husband? 

Paul Wallner:  Yeah. 

Beryl McCormick:  He worked for a long time at Roosevelt-St. Luke’s on the West Side.  Then, probably in the last 10 years, he was working at Cornell with Datta Nori. 

Laura Vallow:  We have a little bit more time.  Paul, did you have anything that I missed or that you want to revisit? 

Paul Wallner:  Well, I guess it’s very early in the sort of developmental cycle.  Since so many of your patients are earlier breast cancer, do you sense there will be any change in your practice or in the overall practice of radiation with the newer targeted agents? 

Beryl McCormick:  I think there’s a good possibility that this trial that we have up and running through NRG, the trial that looks at whether or not we need to give regional nodal or post mastectomy radiation to patients who had a complete response to neoadjuvant chemo, might change things.  Certainly, the number of patients that have complete pathology responses to Herceptin-based systemic regimen is astounding.  So, I could see needing less radiation in that set of patients if they continue to show an extraordinarily high rate of complete response.  But other than that, I don’t see any major changes. 

I know that the PBI trial has been interpreted in many ways by different people just because of the way the specifics are set up and the way the conclusions have to be written, but I still am not offering a lot of partial breast radiation to my younger patients just because I think there still is subtle but real chance the cosmetic outcome may not be quite as good.  I know we have a PBI trial that we just opened here where we’re giving 800 cGy x 3 to see if super convenience would be more appealing to patients than 10 treatments of PBI.  We were just talking about this on Tuesday amongst ourselves.  We’re having a real hard time recruiting patients to it because they hear the doses and they kind of shrug their shoulders at the not terribly different number of visits to the hospital.  It’s really becoming a trial that I’m beginning to think we may not accrue to. 

So, at the moment I don’t think there’s going to be any huge differences.  I would love to see more targeted agents that are just foolproof, that they accomplish exactly what they accomplish without needing radiation or surgery.  But we’ll have to see.  You may or may not know it, there’s a trial in this country and two in Europe.  One in the UK.  One through EORTC. You could see they’re actually asking these questions for DCIS - do you have to even do surgery for DCIS?  Is it non-life threatening? 

Then the trial is really just biopsy to establish the diagnosis and just imaging follow-up.  Physical exam follow-up versus actually doing a lumpectomy plus or minus radiation.  So there definitely are research arenas out there testing no RT.  Leaving more and more radiation out, but I’m not sure it’s really going to happen. 

Paul Wallner:  What are your personal feelings about DCIS given all the controversies in the literature and dialogue? 

Beryl McCormick:  Half of all of the recurrences, whatever the absolute numbers are, come back as invasive breast cancers.  Certainly, if you look at some of the work of Mel Silverstein - for example - who has a very large personal patient group that he’s treated, yes, the patients that have recurrence that are invasive, some of them do go on to die.  So, I think the patient should certainly be given the risk of local recurrence, but I think many patients are going to continue to opt for radiation. 

A lot of people are not risk-takers especially when it comes to a cancer diagnosis.  So, I plan to continue to discuss radiation with patients.  Certainly, if I have patients with even what we’ve defined as low risk or good risk DCIS and they’re not willing to take hormone therapy, I recommend radiation to them.  Because when we eventually get that paper out (RTOG 9804), the recurrence rate in the women with DCIS who were randomized to no radiation and opted out of taking Tamoxifen actually doubled.  It wasn’t 1 percent per year.  It was 2 percent per year.  So, at 12 years it was not 12 percent but closer to 25 percent. 

Women don’t want to have recurrences.  They don’t want to have more surgery.  Actually, even in one of the studies that I did, one with Dr. Steve Edge looking at NCCN institutions on how often, after the CALGB 9343 results came out for older women, the institutions were actually leaving out radiation in these older women -- there's been a series studies that shows the same thing.  Despite all these clinical trials that we do and invest time and money in, if they trial concludes that patients don’t benefit that much from the addition of radiation or whatever treatment, that doesn’t mean that clinicians are actually moving in the direction of leaving it out; which is I think a testimony to how conservative many clinicians are.  I don’t think things are going to change that quickly in medicine. 

Paul Wallner:  What about your feelings about techniques for PBI or APBI? 

Beryl McCormick:  In any patient where the surgeon is thoughtful enough to leave behind clips, I think it’s really easy with all of the onboard imaging that we have to really target very tightly what we need to do.  I think we’re going to have better and better cosmetic results as doctors think more about how to do PBI.  I know here at Memorial, because of Simon Powell, we’re not doing treatment twice a day.  We’re doing it just once a day.  I think just that 24 hours between radiation fractions rather than the minimum of six hours that was required when you were doing it twice a day, actually has resulted in much better cosmesis.  With PBI, I think the patients are going to be looking better as we all get more experience and change around how we do it.  

Paul Wallner:  But you’re doing most of your PBI by external beam or you’re doing it with brachy?
Beryl McCormick:  No.  We’re doing it all with external beam.  We did brachy here years ago.  Actually Sam Hellman, when he came down here, was doing all his boost with brachy because he did not have electron beam treatment at the Joint Center in Boston.  I did a number of cases back then with him as boost.  I don’t like what almost looks like pockmark that you leave in the skin when you’re doing traditional catheter brachy. 

Balloon brachy we never really did here.  I think this technique leaves a much better cosmetic result.  But most people I think just prefer, as patients, not to have catheters or balloons or whatever in them for a week at a time.  I think, by and large, external beam will be the way to go with PBI. 

Paul Wallner:  You’re doing IMRT or 3D? 

Beryl McCormick:  Well, I’m hesitating because I was involved with a lot of the controversy over what is IMRT for billing purposes with UnitedHealthcare. 

Paul Wallner:  That’s why I asked.  Right.

Beryl McCormick:  Yeah.  So here at Memorial, and I think it’s true of a lot of other medical centers, if we’re just doing two tangent fields, we are doing it with full-blown IMRT.  Not field within a field.  Because, one, it’s faster for our medical physics team.  Two, as you know, it gives you a much more uniform dose.  But because we’re not actually fulfilling the billing requirements of contouring much of anything, we have a treatment planning system here where we can just look at the breast or look at the lungs and put the tangent fields on ourselves in a computer.  Our billing department allows us to bill it as 3D.  For the more complicated cases, for regional nodal radiation, in some cases we are using IMRT, but it’s been a real struggle to get insurance clearance.  So, I would say the majority of them are still 3D plans as well. 

Paul Wallner:  Do you see any role for proton beam in breast cancer? 

Beryl McCormick:  I spent one day a week at the ProCure Center near New Brunswick when we first knew we were going to build our proton center on 125th Street here in New York.  I mostly did retreatments there of women that had previous lumpectomy and radiation failed, had a mastectomy and failed again.  From a cancer point of view, I think we had really good results and the plans are superb.  But definitely we saw a lot earlier skin toxicity and a lot more late fibrosis which probably isn’t reflective so much of the protons but just the retreatment.  But I think for breast, that's the major role that protons would play, for retreatment.  For retreatment, it gives you some really beautiful dosimetry. 

Paul Wallner:  Laura, do you have any other questions?  Or, Beryl, do you have anything that you'd like to add on the record or off the record? 

Beryl McCormick:  No.  I certainly enjoyed this process.  Hopefully I will get to speak to Alain Fourquet.  This will be a good training for me to follow when I do that.  But no.  I think you guys asked great questions.  Laura, it was great to speak to you because I know your name from -- you’re an author I think on the DCIS trial.

Laura Vallow:  Yes on the 9804.

Beryl McCormick:  Yeah.  That’s not come out.  Well, the main reason that hasn’t come out yet is because RTOG spent all its time in the last calendar year getting out the PBI trial which didn’t get accepted to the first journal we sent it to.

And the second journal had completely different requirements.  Now it’s been two years since I did that analysis (RTOG 9804) and we may just write it up with the numbers from before, but I’m actually pushing for a year or two of more follow-ups if it's easy to do.  So, you should be hearing about it soon but not quite yet. 

Laura Vallow:  Awesome.  I refer to the trial at least three times a week. 

Beryl McCormick:  Yeah.  Now it’s moving ahead finally.  I think the statisticians did whatever they have to do to get ready for ASTRO abstract this year.  This is like the next project up, so you would be hearing from us soon. 

Laura Vallow:  When you think about the impact, from a physician standpoint, that trial is so important for us because it gives us tangible information on these low-risk women.  Like you were saying, it’s amazing how many women are really averse to taking any risk.  When they see those numbers, they’re on board.  It’s just nice clean data to show patients. 

Beryl McCormick:  Thank you.  Yeah, I actually must have been living in another world.  Because after I gave that presentation at ASTRO, I expected people to say, yes, we can finally leave radiation out now.  I think almost everyone that came up to me just after the talk, said see you proved that even a low risk patient, needs radiation.  We’ll see how the final discussion comes out. 

Paul Wallner:  In my experience especially with younger patients, if you say there’s a 5 percent chance or a 3 percent chance of recurrence, they don’t want to live with that chance. 

Beryl McCormick:  No. Of course not.  And we’ve made radiations very easy.  I just do everyone with hypofractionation.  I don’t give any boost for DCIS if the margins are clear.  So, they’re basically done in three weeks. Okay.  Very good.  Bye-bye everybody. 

Paul Wallner:  Thanks very much, Beryl.  Take care. 

Laura Vallow:  Thank you.