By Naomi Schechter, MD and David Horowitz, MD
The following interview of Bruce Minsky, MD, FASTRO, was conducted on September 10, 2020, by Naomi Schechter, MD and Arjun Sahgal, MD.
Naomi Schechter: Welcome, Dr. Minsky. We usually just start with your background, where you grew up. Anything that you think even in that period may have contributed to where you are today.
Naomi Schechter: Okay. Where were you born?
Bruce Minsky: I was born in Haverhill, Massachusetts, which is a small town about half hour north of Boston. When I was in 3rd grade we moved to Lawrence, Massachusetts. They were both immigrant towns and full of shoe and coat factories. There were different parts of the city and you could identify the neighborhood based on the bakery, church, synagogue, or mosque. It was multicultural and everybody worked together.
My interest in medicine came from my mom, who was an OR nurse. I was able to observe in the OR even though I was only in the 6th grade.
In high school I fell off track a bit. It was the late '60s, early '70s and my interests moved from medicine and science to music. I played bass in a rock band called "Sweetleaf". Despite being in the bottom 20% of my class for the first 3 years of high school I did well my senior year and attended Worcester Polytechnic Institute as a biology major and American literature minor.
In my third year of college I had a summer lab research fellowship at the Harvard Joint Center funded by the American Cancer Society. That was my first introduction to radiation oncology and is how I became interested in the field.
During medical school at the University of Massachusetts I liked oncology. I couldn’t decide between medical, surgical, or radiation oncology. With my prior introduction to rad onc, I moved in that direction because I liked the combination of physics, science, and clinical care. Since there was no radiation oncology residency program I did a rotation at the Joint Center where I became a resident. In 1982 there was no match. You would get a call from the chair and they would tell you’ve got 24 hours to accept.
Naomi Schechter: Who was your chairman?
Bruce Minsky: Sam Hellman was chairman at the time but he had just left to become Physician-in-Chief at Memorial. Jay Harris was the interim chair and Norm Coleman became the chair in my last year. Norm became one of my closest mentors, and one of the four mentors that I’ve had throughout my career.
Applying for jobs in those days was different - it was like an arranged marriage.
I was at ASTRO in 1986 at the Miami Fontainebleau Hotel. Sam Hellman and Zvi Fuks, who was the newly-recruited chair at Memorial met with me and said "we think you should take the job at Memorial." Although I had other opportunities, it was an arranged marriage, and I accepted it. During my residency I developed an interest in colorectal cancer and there was a GI opening at Memorial. That was why I got into the field.
Naomi Schechter: Who were some of your fellow residents?
Bruce Minsky: When I was a resident, the MGH and the Joint Center were separate programs although we were close. The Joint Center residents in my year were Jay Loeffler, Kathy Greem, Ken Leopold, and Tom Goffman. The MGH residents included Paul Okunieff, Paul Busse, and Tom Delaney. Most of us stayed in academics.
Naomi Schechter: What were some of the developments happening at your institution at that time, when you were still in residency?
Bruce Minsky: During my residency the major physics development was CCRT, (computer-controlled radiation therapy) which was the precursor to IMRT. The theory of delivering IMRT existed, however unfortunately neither the technology nor the computational ability was available. In the absence of a multileaf collimator it remained theoretical. However, once available it became a reality at Memorial in the early 1990s.
The other major development on the clinical side was chemoradiation. Historically, radiation therapy alone and either in the adjuvant or the post-op setting. In the late '80s, early '90s, the development of combined modality therapy for solid tumors began.
Naomi Schechter: So you came to Memorial with the intent of being a GI attending.
Bruce Minsky: Yes.
Naomi Schechter: That was consistently your main clinical and research focus?
Bruce Minsky: yes, and I was fortunate that it was available. At Memorial there was one person per organ system and I was responsible for all of GI rad onc.
I developed a collaborative program with one of the colorectal surgeons which allowed the change in the treatment of rectal cancer from postop to preop. Lou Harrison and I started the same day as attendings and helped push the institution towards multimodality therapy. We, along with Jeff Forman, were the first recruits in years that came from outside of the Memorial system.
Naomi Schechter: Well, he mentioned that Memorial was a very surgically driven institution at the time. So, you had to work inroads probably with the surgeons to develop the program.
Bruce Minsky: Absolutely. As a resident at the Joint Center morning conference if we quoted data from Memorial, the attending would ask us not to since most were not interpretable. Memorial needed to develop the concept of cancer treatment beyond surgery. I credit Zvi Fuks with facilitating this.
Naomi Schechter: Well, during your time at Memorial, the attendings you were with and Dr. Fuks changed the picture of Memorial. By the time I was there, everyone believed it was the number one cancer center in the country.
Bruce Minsky: Yes. When first arrived, it was decades behind the times. Both Sam and Zvi modernized it both physically with new equipment and facilities as well as personnel. Prior to Zvi it was a private practice and there was little incentive for multidisciplinary treatment. Physicians competed against one another.
Surgeons would dictate radiation therapy doses. One of the first consults I saw was a patient with a metastasis to their distal humerus. The surgeon drew a circle in ink and wrote in the "3000 R". I was perplexed and phoned the surgeon. I said, "there is a patient in my clinic with an ink circle and dose on their humerus, no pathology or imaging, and could you explain it?" The surgeon said "sure, I want you to give 3000 rads to that area." He truly did not know that the radiation oncologist should decide the dose and field.
Naomi Schechter: So how did you change their minds?
Bruce Minsky: I did not stay in the basement, went to tumor boards, and spoke up.
Arjun Sahgal: From Memorial, your second step was Chicago. Right?
Bruce Minsky: Yes. I was at Memorial for 20 years. To be honest my manuscripts began all sounding the same. So, it was just time for a change. I could just stay there forever, but I felt like I wasn’t doing anything new and challenging. An opportunity came up at the University of Chicago. They were looking for an Associate Dean and chief quality officer. I had some experience because at Memorial I was the chair of the institutional quality committee for 10 years.
It was a newly created position and I moved to Chicago to build their quality program. It also provided me with significant administrative experience. The position was great however there were two reasons why I left after 5 years.
First my percent clinical effort was only 5 percent. I had one afternoon clinic per week and to be honest it was my favorite afternoon of the week. No matter how many meetings I would have with Vice Presidents, Deans and board members I simply missed being a doctor. When I would walk into a patient’s room, close the door and take care of them there - was no greater joy.
Second, the winter weather was dreadful and my Hawaiian wife had enough.....
Then the opportunity at MD Anderson developed. I was at ASTRO 2011 (again in Miami!) sitting in the speaker ready room and Tom Buchholz was having coffee. Tom asked, "hey, Bruce are you interested in moving to Houston?" Having just survived the worst winter of my life I said "sure, what’s going on there?" He said, "We’re recruiting a senior faculty for the newly created position of the Director of Clinical Research. I went and looked at the job. The weather in January was nice. The position was 50% percent clinical and the remainder research and administration. I met the faculty and looked at the city, and said, "okay, I’ll take it."
At MD Anderson, due to unusual circumstances, I've had a number of different positions in the Division. Tom was promoted to physician-in-chief and I became the deputy division head, and then interim division head. Just when I thought being the division head would be a great position I was elected to the ASTRO presidency. After much soul searching, I knew that I could not do both jobs simultaneously and would likely short change one. This I would not do. I had already accepted the ASTRO presidency and therefore removed my name for consideration for the permanent division head position. Steve Hahn was recruited from Penn and when he left Albert Koong was recruited from Stanford and serves as the current division head.
Now I’m just a "civilian" faculty member and am happy to help out the clinic, mentor faculty, and teach.
Arjun Sahgal: I think that gives us a good sense of the trajectory. Maybe I’ll just ask you right now while we’re on topic -- and then we’ll move to the next one. When you’re giving advice to junior faculty on everything that you learned over the years, and it sounds like you made some very smooth transitions, so what advice would you give to a junior faculty who do move their jobs and escalate? It's very tricky. And you’ve gone through the big institutions all in the U.S.
Bruce Minsky: A couple of pearls. Your first job is usually not your last. The first job you take should leave you with the greatest ability to be competitive for the next one. Second, you will need to decide your focus - do you want to be a full-time clinician, a clinical researcher, or a physician scientist. It doesn’t make a difference however, whichever you choose, do it well. Some like academics and others private practice. There’s no right or wrong as long you do it well and contribute. In private practice you carry a larger clinical load and are making a significant contribution to our field.
Third is that if you do become an administrator which some people call the "dark side," you should never give up clinical medicine. Not only because it's fun but administrators can easily be fired or reassigned. By being an active physician you can never be removed and if all else fails you can still practice medicine. Also, being an active clinician also makes you a better administrator.
Another common question is how do you become a good faculty member and have a supportive chair? The secret is the 90 percent/10 percent rule. Ten percent of the faculty take 90 percent of the chair’s time. They are disruptive, demanding, and send long emails at 3:00 AM. It just drives you crazy. The other 90 percent just do their job and are nice to the other faculty and staff. If you are in the 90% you will have a wonderful career.
Naomi Schechter: What do you think about the work with major organizations? Like your work with ASTRO and RTOG.
Bruce Minsky: I miss the original RTOG. RTOG was a stand-alone radiation therapy group. It was mostly radiation oncologists and we had real camaraderie. It also allowed junior members a platform to grow quickly and run trials. It was really a gem. Now, as a component of NRG it has lost some of its personality. NRG is an important and impressive group, but I miss the RTOG family. It was really terrific.
Need I say I have deep feelings for ASTRO. I never thought that I’d be president. When I first attended ASTRO meetings, I remember seeing the president and the past presidents walking in the hallway. I would look at them in awe. Then one day, 30 years later, I realized holy ****, that's me. I didn’t join ASTRO thinking that’s what I want to do. It just sort of happened and I'm honored that it did.
Arjun Sahgal: So maybe, Bruce, we’re going to kind of tie in three of the questions. Your research during your career. In particular, probably the chemorad aspect of things, the controversy that surrounded that. The achievements, and particularly your achievements in that role. The conflict that was happening maybe during that time of radiation alone versus chemoradiotherapy. Because you were instrumental in the GI aspect of concurrent chemorad.
Bruce Minsky: I will speak mostly about the chemoradiotherapy question. When I first started my career in 1986, the standard of care for GI cancers was surgery and if there were positive nodes or close/positive margins then patients received postoperative radiation with or without chemotherapy. I developed close relationships with the medical oncologists and went to their planning meetings, tumor boards, and research meetings to better understand how to deliver both treatments together.
We developed a number of pilot studies for rectal cancer which suggested that the benefits of preoperative therapy were superior but, the hardest part was convincing the surgeons. This was a major challenge in the era when surgeons thought that radiation before surgery would result in an increase in complications and anastomotic leaks.
I had to convince some of the older surgeons. Being young at the time, I was 30 and still had hair, was not easy. It took a lot of persistence. What helped was out robust program in intraoperative radiation.
We would be in the OR giving IORT and I got to speak with them on their own terms. They would show me pelvic anatomy, and I would show them where the external beam pelvic radiation field was so they should use unirradiated bowel from outside the pelvis for their anastomosis. They didn’t know about this so we taught each other. The older surgeons weren’t interested, but the younger surgeons were.
Another way I was successful was by sharing publications, clinical trials and grants with the surgeons and medical oncologists. For example, one of our surgeons at Memorial, Jose Guillem, rather than me, was the PI of our R-01 grant for preoperative therapy for rectal cancer.
Arjun Sahgal: For the randomized studies, was it a real uphill battle?
Bruce Minsky: Yes. There were 3 randomized studies in rectal cancer. These included the German trial, NSABP R-03, and the Intergroup RTOG 94-01. Unfortunately, both the NSABP and the intergroup study failed because of lack of accrual. The reason was there’s a limited window of opportunity that you have to ask a phase III question. That window becomes smaller as Phase II data mature and physicians make their minds up.
We were not able to complete the studies in the U.S. since the pendulum had already swung towards preoperative chemoradiation. Fortunately, in Germany, they were able to complete the German trial with the help of pre-randomization.
Arjun Sahgal: Was there any other reflections in terms of key research areas for yourself in development that you saw?
Bruce Minsky: One is the area of esophageal cancer, the RTOG 94-05 esophageal trial In my obituary there will be a sentence “he didn’t believe in dose-escalation.” Still, to this day, some still believe that giving higher doses of radiation is better for esophagus cancer. It’s probably the most controversial randomized study I ran.
It’s strange when you’re known for a study that didn’t show a benefit, but that’s okay. A negative trial is important, if not more important, than a positive trial.
Naomi Schechter: What ideas might you have envisioning the future of radiation oncology? Like you witnessed the developments of the computerized treatments. Where you do think we’re going?
Bruce Minsky: The field is as robust as ever. I think we will treat more patients with metastatic disease than in the adjuvant setting. For example, if I recommended treating liver metastasis 20 years ago with radiation therapy, it would have been an uphill battle. If I saw a patient with three sites of metastatic disease and I was to treat each one in a curative fashion, my colleagues would question my clinical acumen.
When I trained in the 1980s, we had two checkboxes in the prescription; curative or palliative. Palliative meant the patient had metastatic disease and we only treat only if the patient was symptomatic. That’s a major transition in the field and has been due to the improvement in our radiation technology and the improvement in systemic therapy.
Moving forward we will treat more patients with metastatic disease as an ablative modality with the goal of converting a rapidly progressive disease to more of a chronic disease. We can take advantage of better systemic therapy and focus radiation to deliver high doses in a way that was unheard of 20 years ago.
Naomi Schechter: What do you think about combinations with immunotherapy or the high dose like SBRT?
Bruce Minsky: These are concepts which were out of our realm of thinking 10-15 years ago. In my opinion this is the future role of radiation. Another potential advance is MR-guided radiation. Although, we’re using a modality (radiation therapy) which is well over a hundred years old, it’s our ability to design and deliver it in combination with other therapies that are really going to continue to make progress.
Naomi Schechter: You mentioned earlier about the importance of networking, being sociable, how you had been into music as a hobby. Your wife is an outstanding well-known singer. Do you want to talk a little bit more about your family?
Bruce Minsky: Sure. I had a rock-and-roll band in high school and have always continued playing bass up to recently when we had to put our current band on hold because of the pandemic. We perform yearly at our MD Anderson holiday party, which is always fun.
My wife, Connie, was a professional singer based in Hawaii. We met in Lanai. She was performing every other month for weekend and I was attending a Bristol Myers meeting. I first was with her at the airport and I had just got on the plane for an interisland flight. I didn’t see her performing and she didn’t hear my lecture. It was open seating so I sat next to her and said hello.
She said, "gee, what are you doing here?" I mentioned that I was giving a lecture. Her next question was "what were you lecturing about?" Usually that’s the point where the conversation stops because it was about rectal cancer. To my surprise she was interested so I told her what I do. We met for lunch at the Honolulu airport. We had a long-distance relationship between New York City and Hawaii. She even wrote a song "Island to Island" on one of her albums. We got married in year 2000 and have been together ever since.
Connie will sing in our band, but she tells me I can’t keep time. She’s right. She’s professional and I’m the amateur!
Naomi Schechter: Well, what recommendations would you have for people about balancing their active career and their family life?
Bruce Minsky: It’s really important. I put a lot into my career at the beginning. In retrospect I wish I had more of a balance. What I’ve learned is that if you’re not happy in your personal life, you will not do well in your professional life. They truly are tied together yet compete with one another.
Naomi Schechter: I think you had dogs that you really loved. Is that correct?
Bruce Minsky: Yes, we had two labs. Now we have a cat whose name is Popoki - which is Hawaiian for cat. We really like animals. I also enjoy cooking. We built a house a few years ago and enjoy Houston very much.
Naomi Schechter: So, it all came together for you.
Arjun Sahgal: Maybe we’ll get a little bit back into like a little bit of controversy in the field because you’re in the place now. You've got MR guidance. You've got particle therapy. I think a lot of younger radiation oncologists and just the field in general are struggling. How do we deal with the emergence of technologies that are not necessarily evidence-based in terms of benefits but are present? I think with the lens of what you’ve learned and where we’re at now, how do you approach it? What do you think the future is in particular in these two avenues of MR-guided radiotherapy and particle radiotherapy? I think those are the two branch points now.
Bruce Minsky: They both have value, but they aren’t necessarily competitors. They will both find their role. I think MRI-guided radiotherapy is more feasible and is financially more affordable. It can be delivered in a smaller radiation oncology department; whereas, particle therapy requires a larger physical infrastructure as well as significant physics expertise.
I’m particularly hopeful for the future of MRI-guided therapy. As the need for high doses ablative therapy in conjunction with systemic therapies in patients with metastatic disease increases, we will need better imaging to help deliver our treatments. The technology is in its infancy - similar to where IMRT was in the early 1990s.
Building infrastructure is always a challenge. For example, when IMRT was first developed at Memorial, we treated two patients an hour since multileaf collimators did not exist. With time and technology development it has become a routine and efficient procedure.
Arjun Sahgal: What about particles? I mean you’d been there. didnt You had the MGH center doing a lot in the country. Then now you got two per state almost. Is this a mistake in the direction or do you think that eventually it will be still dominant for a therapy? Going 50 years, there has been no real evidence.
Bruce Minsky: Having been involved with our proton P01 I have learned how much we don’t understand. It has become clear how much uncertainty exists with high energy particles. We have a long way to go to truly understand the details.
Arjun Sahgal: Okay. Wonderful. Is there anything that you wanted to add, Bruce, in terms of your perspectives over time in the future?
Bruce Minsky: I always had trepidation about this interview. When you hear from the History Committee, that means you are near the end of your career! On the positive side, radiation oncology is a terrific specialty and I am proud to see a new generation of residents and faculty continuing the mission.
The daughter of a resident who worked with me in 1988 did a rotation with us last September. Who ever thought I would be mentoring 2 generations. Now, I truly feel old....
My final parting thought a plea to our senior radiation oncologists. They should mentor then step aside and allow the next generation to become our leaders. We’re not the future - the next generation is. I was fortunate to have mentors who did that for me and it is my turn to do the same. The future is not me - the future is you.
Arjun Sahgal: Thank you so much Bruce.
Bruce Minsky: I can’t thank you enough. Nothing makes me prouder than to see all of you do well.
Naomi Schechter: Thank you.