By Nancy Mendenhall, MD
In 2002, ASTRO established the History Committee for the purpose of documenting and recording the history of radiation oncology in the United States. This conversation with Carl Mansfield, MD, ScD, FASTRO, and Nancy Mendenhall, MD, took place in November 2001 during ASTRO’s 43rd Annual Meeting in San Francisco.
Question: I'm Nancy Mendenhall of the University of Florida, and I have the distinct honor this morning of interviewing Dr. Carl Mansfield as part of the Astro History Committee's project on the oral history of radiation oncology. Dr. Mansfield, it's really quite an honor to talk with you this morning. I was reviewing your CV and I noticed that you began medical school in 1952 [at Howard University in Washington, DC].
Dr. Mansfield: Right.
Question: So you've had a half-century of experience in the field of medicine in this country.
Dr. Mansfield: Exactly.
Question: And you've been many places and done many things and have contributed in so many ways to our field that it'll be wonderful to hear what your thoughts are on some of the developments that have occurred over the last half-century. What attracted you to radiation oncology?
Dr. Mansfield: Well, I started out to be a radiologist. A lot of us older fellows started out in general radiology. As part of my training, I had to spend three months in what was called therapeutic radiology and three months in nuclear medicine. For training in therapeutic radiology, I was told that the best place in Philadelphia was to be with Dr. Simon Kramer. So I did a year with Simon Kramer because he wouldn't take anyone for three months. During that time I had to go find my stethoscope and make rounds on patients. Most importantly, I began seeing cancer patients who were alive and well five and 10 years after treatment. I did not know that radiation could cure a patient with cancer until I started seeing these patients. I saw that I could practice medicine, cure some cancer patients and so I was sold. And of course, working with Dr. Kramer was absolutely fantastic. He was one of the leaders in the field even then.
Question: At that point in time, I guess that would be in the 1960s?
Dr. Mansfield: Yes.
Question: How many centers were there in the country recognized for radiation oncology?
Dr. Mansfield: There were basically The Penrose Cancer Center, MD Anderson, Simon at Jefferson, Brady at Hahnemann, Kaplan at Sanford Memorial in New York and about three to four others. There weren't many. Most of the therapeutic radiology was practiced by radiologists who did it part time, usually in the afternoon. They read film in the morning, and then they got out a radiation therapy text book, looked at the directions and then tried to set up the treatment. And after that the technologist did the actual treatment. They were called technologists back in that time.
Question: Oh, so you had an evolution in terminology, too.
Dr. Mansfield: Yes.
Question: OK. So, it sounds like this was a very clinical aspect of radiology, and it sort of reintroduced you to the care of patients.
Dr. Mansfield: Yes.
Question: I noticed, when I looked through your lengthy list of publications, that you were involved in introducing many of the new technologies into our field. I know you worked with ultrasonography, lymphangiography and later with CT. How has technology developed over the last half-century, and what influence has it had in our specialty?
Dr. Mansfield: I think first there has been an incredible change. When I started, trying to determine the extent of the tumor was mostly by palpation and physical signs and X-rays. We had to sort of work as detectives. And that's a difference I notice even now; many of the residents are totally unaware of many of the physical signs because CT or MRI or PET takes care of all those little clues. We still have to be detectives but not as much. There's a lot more information available. Much of it has been with the increased use of different imaging modalities to determine the extent of the tumor. We now hear things like image-based therapy. Back in those days, it was still all physical examination, physical signs and a little help from radiology or clinical labs. Example: When I started out in radiology, you looked at the shadows, the gas patterns and the shape of the muscles. Now, you can “fly” through the colon with virtual fluoroscopy. So, tremendous changes have occurred. We now have laboratory studies that are extremely helpful. As far as treating patients, we used to use 250 kV therapy. When I started, Cobalt was the new type of treatment machine. Dr. Kramer had a Cobalt unit. So, I trained on the 250kV, the 120kV and the Cobalt unit. Now we have linear accelerators and proton beam machines.
Question: Now, when you first began practicing radiation oncology, were you practicing diagnostic radiology as well?
Dr. Mansfield: No. When I finished, I already had decided that I was going to be a radiation oncologist. I took my boards in general radiology, which covered all three specialties. I then went to England for an additional year of training. I came back to Jefferson for two more years of training in pediatric radiation oncology. So, I spent a lot of time before I started practicing.
Question: But when you practiced, then you focused just on therapeutic radiology?
Dr. Mansfield: Yes, just on therapeutic radiology.
Question: Why did you spend a year specializing in pediatric oncology?
Dr. Mansfield: Well, it was very interesting, and I've always liked it.
Question: That's interesting because that's such a specialized area in radiation oncology.
Dr. Mansfield: Right.
Question: To have it singled out so early in the development of the field is interesting. So, when you started practicing radiation oncology, what was the role that the radiation oncologist played in the overall management of the cancer patient?
Dr. Mansfield: A far bigger role than now. We used to admit our own patients. We had a service and that largely, I think, had to do with Dr. Kramer because he had been trained in England. For instance, when I was in England, we had three wards that were run by the radiotherapy department. And we had interns and residents on the wards. We took care of all the patients, all of the problems. If we needed help, say if there were a cardiac problem, of course we got a consult, but those patients were admitted, worked up, and taken care of and discharged totally in our control. That does not happen now for many reasons. All of the specialties are far more advanced. Now there are many more people who can step in. We very rarely admit a patient now, as compared to when I first started and had a whole service of patients.
Question: In the early years of the field, what kind of interactions did we have with other folks who were interested in the management of cancer, in particular surgeons, for example? What was the relative interaction?
Dr. Mansfield: Well, I think there were two different ways. In Europe or England, it was different than here. There was virtually no oncology program. You had radiologists who did the radiotherapy, and you had surgeons. There was virtually no oncologic surgeon. There were no chemotherapists at all. And so, you had these three entities. A patient might get totally treated by surgery and never see a radiation oncologist or vice-versa. Or the family practitioner might manage the patient. The actual oncology specialty really just hadn't come about at that time.
Question: So, how did patients get to radiation oncology? Were they generally seen by their primary doctor, the family practice doctor and then referred on, or how did it happen?
Dr. Mansfield: Most of them came from the surgeon. In those days, the cancer patient was sent to the surgeon because in almost every instance an attempt was made to excise. We saw some patients before surgery and others after surgery. Some of the patients were inoperable, or they had failed.
Question: What do you think the value is of having the radiation oncologist involved in the overall care of the patient? Have we lost something by expanding the number of specialists who have a role in the patient’s management?
Dr. Mansfield: I think probably not. As I've told medical students and residents, cancer is too complicated to be managed by one specialty. So I'm a very strong believer in a multimodality approach. And so, when you think of the knowledge that we have about cancer, all the way to the molecular biology and the molecular radiation biology, to have the medical oncologist, a surgical oncologist and the radiation oncologist working together, that's a vast amount of knowledge that still wouldn't be available to one individual. So, a multimodality approach now is far better than the way it was.
Question: What do you think are the most significant developments in the field of radiation oncology over the last half-century?
Dr. Mansfield: There are several, I think. I will mention radiation biology and molecular biology. There is a better understanding of cancer now, as compared to when I first started. We know about the cell cycle and about the different genes and about their turning on and off and just how they work. I wouldn't say we totally know how it works, but we have some idea of what is going on. As opposed to, in the past, you treated to so many rads and that was it. You were careful not to cause any burning of the skin. We have moved from treatment by intuition and experience to a more scientific basis. The whole science of cancer now, compared to what it used to be, is absolutely fabulous. Using better science, we can apply surgical, medical or radiation oncology alone, combined or in different combinations. Now we have so many more weapons with which to fight cancer.
Question: And, if you look back over your time in the field, who in our specialty do you think has stood out as making those significant contributions and why?
Dr. Mansfield: There have been many. Those who come to mind are Simon Kramer, Gilbert Fletcher, Kaplan, Bradshaw, Del Regado, Philip Rubin, Luther Brady and many others.
Question: Let's take each one of these just for a second and dwell on them for a minute. Dr. Fletcher—what contributions do you think of his are most important? What do you remember him for?
Dr. Mansfield: Two things: head and neck and cervix. I mean, he set the benchmark for what could be achieved in terms of treating patients by means of radiation. Then, there was the breast cancer for which he argued that post-operative radiotherapy really made a difference.
Question: Conceptually, in addition to the disease processes, do you think he helped us in understanding patterns of spread, the concept of clinical disease and dose response and basic principles like that?
Dr. Mansfield: Yes, yes.
Question: Now, what about Dr. del Regado? What do you remember him for?
Dr. Mansfield: Well, I most remember his text book. He worked with Ackerman, a pathologist. Together they were able to associate patterns of spread with methods of treatment and clinical signs and show where are the areas that you need to direct the radiation therapy. I remember the wonderful diagrams of how disease spread from the head and neck.
Question: Were you able to or did you know these great teachers yourself personally? Did you have interactions with them?
Dr. Mansfield: With del Regado?
Dr. Mansfield: From a distance.
Question: From a distance. How about Dr. Fletcher?
Dr. Mansfield: Yes, I knew Fletcher better because Dr. Kramer and Dr. Fletcher were very close friends.
Question: Did he come to visit your institution of training?
Dr. Mansfield: Occasionally, yes. Yes, all of them and Fletcher came. So, we got to see the giants.
Question: Now, what about Dr. Kaplan? Did you get to meet him?
Dr. Mansfield: Yes. I've met him. But again, I was just an ordinary by stander. But his field, of course, was lymphomas and Hodgkin's disease, to which he made a fantastic contribution showing the radiation dose that's necessary to control the disease. I still remember the Kaplan’s plot of dose versus cure rate.
Question: Do you think he had some special contributions with respect to the idea of clinical trials and randomization and some of the newer concepts that we use to try to make our clinical research scientific today? Do you think he made a contribution there?
Dr. Mansfield: Yes, I think so. But the Princess Margaret and the Royal Marsden had done a lot of the randomizing, using retrospective cases and matching patients.
Question: Statistical tools?
Dr. Mansfield: Right.
Question: And what about Dr. Kaplan's interactions with medical oncology and laboratory science?
Dr. Mansfield: Yes, a lot of that, especially in terms of the use of chemotherapy for the lymphomas. He did a lot of that and wrote about it.
Question: And then, what about Dr. Kramer? Tell us about him.
Dr. Mansfield: Well, Dr. Kramer conceived of and received the funding to start the Radiation Therapy Oncology Group (RTOG). Dr. Kramer's interest was also in pediatrics, brain tumors and head and neck tumors. Pediatrics was one of his main areas. In Philadelphia at that time, he was the man to send the pediatric tumors, especially the brain tumors. So, his contribution was also in the area of brain tumors. He started the methotrexate head and neck trial. He did the phase two study on the methotrexate trial before it went to RTOG as one of its first trials. So a lot of the outstanding individuals would have made their contributions in those areas. But Simon was mostly pediatrics and brain tumors. That was his area of interest.
Question: Did you have any opportunity to visit the Princess Margaret or to know any of the great leaders in that institution?
Dr. Mansfield: No, I never visited the Princess Margaret. I did the European tour. So I went to the Royal Infirmary in Scotland; to the Christie Institute and spent several weeks there; then I went to the Gustaf Rousey and spent several weeks there at Radiumhemmett in Sweden with Kottmeier.
Question: At that point in time, it was considered to be an important part of resident education to travel around and visit other schools of radiotherapy?
Dr. Mansfield: It was particularly important because in America there were just the radiologists, in most instances, doing radiation therapy in the afternoon and reading it out of a text book, whereas when you went to England and Europe it was a specialty, as I said before. And they even had wards in which the radiation oncologist ran the show. They were a specialty. Plus, in England and many of the European countries, they were able to follow all of their patients. England had a socialized medical system, so you could review cases of every patient treated. They were followed regularly so that we knew what happened to them. So, at that time, it was to your advantage to do the European tour.
Question: OK. One of the things that has changed a little bit is the terminology. You said that we began working with technologists; we now have therapists. What do you think about some of the terminology changes that have happened in our field?
Dr. Mansfield: I don't have any problem with it. Every once in a while I still say, “Where is the tech?” But they want to be called therapists. I don't have any problem with the new name. I try very hard to remember the proper name.
Question: OK. You've done so many different things in your field. And one of the things that interests me was your very active role in the American Cancer Society. And you've been honored by them with numerous awards, including one for your work in reaching out to underserved populations. What role has the American Cancer Society (ACS) played in radiation oncology and the treatment of cancer patients?
Dr. Mansfield: I did receive several awards from the ACS. The one that I cherish the most was the Bronze Medal, the highest national award by the ACS for public service. It was in recognition of my efforts in stopping the marketing of a new brand of cigarettes to the African-American community in Philadelphia. I was also president of the Philadelphia Division in 1989. I think the ACS plays a very important role. Part of it, is first making the public aware of cancer. I still believe if we can find it early enough, it is possible to cure patients. There are still many people who have no idea of what cancer is like or what the ACS used to refer to as the “Seven Danger Signs.” These are the early signs of cancer. When we asked people in many communities, they had no idea as to what the signs were. Through the ACS the goal was to try to convince the public, especially in underprivileged neighborhoods, that cancer was something that was very important to be aware of and what to look for. Even though, in many of the underprivileged neighborhoods, families had many other concerns. They're worrying about their child growing up in the neighborhood, getting a job, where are they going to get their next meal, and where can they find a place or better place to stay. Because of these concerns and many other priorities, “cancer” is not high on their agenda. And yet, the death rate for someone who gets cancer in an underprivileged neighborhood is 15 percent higher than in the normal population. There are some diseases that are two or three times higher than the death rate for the general population. Much of this is due to failure to recognize the early signs of cancer and poor access to proper medical care. While working in the underprivileged neighborhood, the effort was to try to make people aware of the problem and not to come in as a missionary or saying "We are here to save you from cancer," but to work with the community to help people to understand the risk of cancer. Because it is a real risk and something to which they needed to pay attention.
Question: Are you still active in the American Cancer Society?
Dr. Mansfield: No. Not since I moved from Philadelphia down to Maryland.
Question: You've been a leader in a number of academic departments, and you've played many leadership roles. Can we just review the different institutions where you've trained and then gone on? You began I think at Jefferson.
Dr. Mansfield: Yes. I began my radiation oncology training at Jefferson. Dr Kramer sent me to the Middlesex Hospital in London, England, on a National Cancer Institute Fellowship. When I returned from England, I went back to Jefferson. That was in 1963. I stayed at Jefferson from 1963 to 1976. During that period I did go back to England as a visiting professor on sabbatical in 1973. In 1976, I went to the University of Kansas as professor and chairman of the Department of Radiation Oncology. Kansas was a fantastic state with wonderful people. I was at the University of Kansas for seven years. At that point, Dr. Kramer decided that he would retire and step down. I was asked to come back to look at the position. This made me feel very proud. I was offered the position of professor and chairman of the department of radiation oncology, which was a great honor to me! We built a whole new facility there, and I stayed until I retired in 1994.
Question: But you didn't retire for long.
Dr. Mansfield: No, I stayed at Jefferson, in the background, until May of 1995. And then I went down to the NCI as a director of the Radiation Research Program. I stayed there two years. While I was there, the University of Maryland was looking for a chairman and asked if I would be interested in the position. I said I would be as long as they recognized that I was not a 20 year old and that my job would be just to bring the department up to a level that they could do a national search for someone really strong. And that's where I am now.
Question: And I think you've brought in a fair amount of new technology, in contrast to what equipment you began with when you started your career in radiation oncology. Tell us a little bit about what technology is in your department now.
Dr. Mansfield: As I said before, the technology when we first started was mostly manual and experience of how to angle the beams to target the tumor was by physical examination, palpation, intuition experience and X-rays. And I remember that Dr. Kramer and Dr. Suntha did a lot of the original work on developing the simulator. I was able to offer a little help because of my diagnostic radiology training. The prototype simulator was used to help decide how to set the fields in terms of the angle, size and shape. This, for us, was wonderful progress! So we've come now to the Accu-Sim. We have refined the simulator and combined it with the CT. Now you can actually put the patient through this machine in a matter of minutes. Then go to another room to virtually simulate the patient and generate the treatment plan. You can put on the fields and change positions of the beams while watching the dose distribution curves being displayed as the fields are being altered. At the University of Maryland, our physicist, Dr. Cedric Yu, has developed rapid and ingenious methods to calculate the dose distributions and program the treatment machine. He has been working on 3-D conformal therapy and IMRT. And Dr. Yu is now working on IMAT, which is the Intensity-Modulated Arc Therapy. It is faster and doesn't take as much time.
Question: Pretty amazing.
Dr. Mansfield: Yes, right.
Question: OK. You've had an enormous impact on many people in our field: physicists, therapists and many radiation oncology physicians. You're regarded as a wonderful teacher and mentor. Tell me a little bit about what makes you such a good teacher? What do you try to do when you work with residents? What are your goals?
Dr. Mansfield: Part of it is I like doing it, and I like being able to pass on information, especially when they appear appreciative or surprised by the information. Also, to see the results of my efforts and see how well the individual does over time—that is very rewarding.
Question: You've worked very closely with physics, I think, in the past.
Dr. Mansfield: Yes, With Dr. Suntha for many years and recently with Dr. Yu.
Question: And that seems to have been just an extremely fruitful collaboration for you. Any comments on the relationship between the radiation oncologists and the physicists and what that type of interaction needs to be?
Dr. Mansfield: Yes. Many times the radiation oncologist tends to take the physicist for granted. I've found that they are incredibly valuable in terms of helping you to understand what you're doing, what is happening when you direct a beam towards a tumor, what are the risks, what is the dose distribution or what are the possible techniques available. I have enjoyed working with the physicists, especially with Dr. Suntha, with whom I worked for years. I consider myself fortunate to have had him as a physicist and friend. It was from those early days with Dr. Suntha that I was able to get a better understanding of physics. And once I did, I could really see its use. So it has always been something that I've enjoyed doing and certainly have enjoyed working with the physicists.
Question: Do you think that our discipline has missed any steps or made any mistakes? Do you feel comfortable with where we are in our contributions to the understanding of cancer at a molecular level? Do you feel comfortable with where we are with medical oncology and advocating for government policy? Have we done our job as a discipline in furthering the science behind cancer therapy or not?
Dr. Mansfield: I believe as far as the general care of cancer patients, this specialty has a good concept of how cancer works, spreads and should be managed. However, I believe strongly that we must work with the clinical, laboratory and research specialists in cancer in order to eventually conquer this disease. All of the disciplines, through their research, are closer to solving the riddle of cancer. They are learning more about the molecular and genetic components of cancer. The radiation biologists have made important contributions to our knowledge of this disease. I am comfortable with where we are in our relationship with surgical and medical oncology and the government’s policies.
Question: I've heard some concerns expressed about the relative aging of our radiation biologists and concern about whether or not we are inspiring young people to study tumor biology and radiation biology in particular. Any thoughts?
Dr. Mansfield: Well, there's one other aspect. We have the traditional biologists, radiation biologists and then of course the molecular biologist and the molecular radiation biologists. It has been difficult for many radiation biologists to change from one to the other. This is reflected in the grants. Many are basically mechanisms and molecular biology based. As some of the radiation biologists become older, they will be moving out of the field anyhow. I am a strong believer in the molecular biology aspect of cancer.
Question: Well, what should be the role of academic programs in trying to foster the right kind of research to move the field forward and in trying to train our residents and fellows to either do that kind of work themselves or to create an environment where biologists want to work with us? What should we be doing?
Dr. Mansfield: I think advocating for better salaries and better resources for radiation biology research because right now a person who is trained in biology or who has a PhD can find jobs in industry that pay very well. Also, the PhDs have to get grants. If you don't get a grant, then you're in trouble. Therefore, the PhD has to spend a lot of his time worrying about where the next grant is coming from. Therefore, there should be a constant source of income so that he can spend more time worrying about the research, not spending time writing grants. I know the grant is somewhat of an indication of the researcher’s progress in his field. But it shouldn't be up or down. So many of the PhDs will say, "Why should I bother with this when I can go into industry and have a regular income and security." So that's something that we need to review. We must advocate for some kind of a base amount so that they never have to worry so much about their job disappearing or their salaries going down
Question: So you would be an advocate then for the continuance of tenure at academic institutions? Many academic places are contemplating whether or not tenure should be kept.
Dr. Mansfield: Yes, tenure might be the answer. For the PhD it means a lot. But you have the institution that has to come up with the money. That is only one of the mechanisms for what I'm saying in terms of coming up with the money. Whether the institution does it or there are more lifetime grants from the government.
Question: Do you see any danger for our specialty in working more closely with industry for research? There has been a move in our discipline over the past years to try to tap into the resources of industry for the very reasons that you're talking about: the difficulty in coming up with funding to support biology and physics research. Are there any dangers that we need to be watching for?
Dr. Mansfield: I believe so. I still think the purest way is through a long term or “career” government grant. The researcher presents his or her proposal to a group of peers. It is reviewed, and in theory, the best of the proposals would be funded.
Question: Peer reviewed for the merit of the professor’s research.
Dr. Mansfield: Right.
Question: OK. You've been quite a role model for minorities. And I don't know whether this is something you feel comfortable talking about or not. You've opened doors, I think, for many of us who are women and for women and men of color and different races. Are you conscious of how much of an impact you've had?
Dr. Mansfield: I'm not conscious of the impact, but I have always judged each individual by their potential and qualifications. As a result, my department always looked like the United Nations. I, being in a minority and having grown up in this country, was treated pretty badly many times. I did not give up because of my strong belief in God. However, many people did treat me fairly. At Jefferson I was always treated fairly.
Question: Do you mind sharing with us some of the barriers that you ran into in your career path?
Dr. Mansfield: Well, one that comes quickly to mind is a letter written to me in response to my application to an advertised position, "I see you are very well qualified, but my patients would not want to have, in most cases, a Negro seeing them. So, I'm sorry I can't offer you the job." I ran into a lot of that.
Question: Approximately what year was that?
Dr. Mansfield: This was back in 1962-1963.
Dr. Mansfield: And that trend has always been there in many places. But then, there's one thing we haven't talked about, and that's my religious belief and my trust in God. So, I never gave up or accepted the fact that I was not qualified. I can understand why in the minority community, especially the African American community, a lot of people give up. Because some of the things that happened to me, if I hadn't believed that there was a God who treated us all equally, I would have given up. I would have been convinced by everything that was done to me, that I was nothing.
Question: OK. Now, I noticed that you were asked to participate, I think in 1996, in the Centennial Celebration of Radiology. And I noticed that you had written a history of African-Americans in radiation oncology and radiology.
Dr. Mansfield: Right.
Question: Can you tell me a little bit about your findings?
Dr. Mansfield: Well, it surprised me. Until I would say maybe 20 years ago, the African-American was invisible in this country in terms of accomplishments. No one wrote about their accomplishments. In fact, one of the things I found was an article written by a white person about African-Americans in radiology. He said, "Because these people are invisible, I want you to know what they have done." Their accomplishments in the field of radiology have been amazing. But yet I knew nothing, absolutely nothing about it. So, it was very helpful to me as well to know that from the beginning of the use of X-rays, there were African-Americans who had been radiologists, had written articles and had contributed to the field.
Question: Can you, off the cuff, remember any names that you'd like to mention?
Dr. Mansfield: No, my memory's not good for names. I can never remember names.
Question: No, it's a wonderful thing and there's no question about how much you've meant to many people in our specialty. OK. Now, another thing that I wanted to ask is whether or not you have any advice for our training programs? What should our focus be in them?
Dr. Mansfield: Well, the first thing I always stress is the care of the patients and that all our research is to better treat the patient. And all the training that we're giving them is so they can better take care of the patient.
Question: OK. Now, thinking just a little bit back over some of the things that you've done, you've made some major contributions in several areas – breast cancer for one. Your work in the cooperative groups in your research in Hodgkin's disease is another area. What do you regard as your most significant contributions to the field?
Dr. Mansfield: I think it has been in breast cancer treatment. And one of the techniques I pioneered was doing the intra-operative radioactive implant, that is, doing the implant at the time of the surgery. What made me think of intra-operative implants was my concern about the accuracy of post-operative implants. We used to treat the post-op breast with external beam first, and then give a local boost to the tumor excision site with electrons or an implant. Many times when we did that we had no idea of the exact site where the tumor had been. You felt where the induration was under the surgical scar. We tried to direct the beam or place the implant in that area. The placement of clips gave a rough idea of the location but not the total volume. I decided that it might be better if I were right there in the operating room at the time that they took the tumor out, then the surgeon and I together could actually decide where to place the implant. I started doing this in 1978 at the University of Kansas with the surgeon Dr. William Jewell. I presented my first paper on the subject in 1983 at the Radiology Society meeting in Chicago. The other advantages were that the patient did not have to be readmitted to the hospital to have the implant, and the radiation started three to six hours after the tumor was removed, not 10 or 14 days later.
Question: I'd like to say something. I think you recognized the problems with identifying the high-risk area before we had clips and the tumor activity showed what we were actually missing with our boost fields. And your work was certainly in advance to the recent ERDC trial, proving the benefits of the boost and needing extra dose in that high-risk area. So, I think history will regard you as a pioneer in understanding the dose response concept in breast cancer and the problems with identifying a sub-clinical disease area that's at risk. So, there is no question about that contribution at all. And I remember when you presented your paper having personal experience with over a thousand patients, everyone wanted to hear your experience and it was wonderful.
Question: Let's talk just a little bit more about those breast cancer patients that you have taken care of for so many years. You've seen us go from an era of radical mastectomy for the most part, to mostly breast-conserving therapy. Tell us about what had to happen to make that possible, what changes had to happen with respect to other surgeons' attitude toward the disease and the patients' concerns.
Dr. Mansfield: I, in my early days of practice, also tried to convince patients to have the radical mastectomy and post-operative radiation therapy as the proper treatment for their early breast cancer. However, over time, as I reviewed the results of different treatments in different countries, I began to realize that the local control and survival results with less radical surgeries were as good as the radical mastectomy. A few examples were McWhirter in Scotland, Pierquin in France and Mustakallio in Finland, in addition to many others in Europe and Canada. Also, I found that using more aggressive and extensive surgery such as the “extended radical” or the “supra-radical” mastectomy resulted in the same local control and survival results. In 1976, I published a monogram on the subject. In America, it was difficult to convince the surgeon just to take the lump out and let us treat the breast with whole breast irradiation and a local boost of irradiation to the tumor site with external beam or an implant. At the University of Kansas, Dr. William Jewell was willing to do conservative surgery (lumpectomy). Over time our numbers grew. This began to happen in many parts of the country as the ladies’ magazines began to write about the results from many centers in America. A group of my patients petitioned the Kansas legislature and eventually was able to get a law passed that required the surgeon to tell the patient all of the options, including conservative surgery, for the treatment of early stage breast cancer.
Question: So you've seen a lot of changes it sounds like.
Dr. Mansfield: Yes.
Question: And participated in them. What can you say about your observations of the quality of life of the patients that have had breast-conserving therapy?
Dr. Mansfield: Right. I remember that some women would lose their husbands once they lost their breast, because Americans were then, and I believe still are, breast-oriented. In addition, it appeared to me that the patient had a better self-image after conservative surgery.
Question: You've had a lot of experience also in working with cooperative groups, and you've been involved in very important studies in Hodgkin's disease. Those studies have attempted, I think, to define the role of radiation in advanced Hodgkin's disease, but they've shed light on issues of quality assurance. I wonder if you could tell us a little bit about your experience working in cooperative groups and your experience in working with quality assurance issues.
Dr. Mansfield: I believe that cooperative groups have contributed a tremendous amount to the treatment of cancer in terms of surgery, chemotherapy and radiotherapy. Especially in terms of the multimodality approach. That is why, in advanced Hodgkin's disease, I believed that the multimodality approach got the best results. And so, Dr. Carol Fabian and I gave a low dose of radiation with chemotherapy to show that it's still possible to get good responses and survivals in advanced cases of lymphomas. We are still not sure of the results, since the statistician used the concept of “intent to treat.” If we counted only the patients who were or were not treated, the results were positive.
Question: And what about the medical oncologists who you worked with?
Dr. Mansfield: I worked very well with the medical oncologists. We determine where each of us is heading and sit down and try to work out a treatment approach. I've just gone through that a couple of weeks ago and it's turned out very well. We have come to some agreement as to how the approach should be.
Question: What about quality assurance in radiotherapy? Have we as radiation oncologists done our job conscientiously enough with quality assurance?
Dr. Mansfield: Yes, I think we've always been good at that because we keep records of everything that is done. Part of it was because we had the physicists as well who would check the charts, have regular checking of the machines, the dosages and so forth. I think that quality assurance has always been well done. Now with computers we can keep records of what the machine output was for each patient. Also, the machine can tell you if you have set an incorrect dose.
Question: We're moving, as you alluded to in our earlier discussion, from standard field design based on an understanding of patterns of disease spread and clinical intuition and physical exam, to image-based therapy in a lot of areas. Do you think that we are good enough with our diagnostic radiology to make this move? And what are the pitfalls?
Dr. Mansfield: I think we are better, but we haven't totally gotten there. One of the problems is we still cannot tell where that last cell is located.
Question: Your institution has led the way in intensity modulated radiotherapy and very, very tightly conforming the dose distribution to images that can be seen. Do you worry at all about missing the sub-clinical disease?
Dr. Mansfield: Yes. The whole issue—that we get so precise, that we may actually not get all the tumor—that is why knowing exactly where the tumor is is going to be important.
Question: So you feel like we still need a fair amount of clinical judgment?
Dr. Mansfield: Oh, yes.
Question: We're not ready to make a full circle to go all the way back to diagnostic radiology yet. We still have to be clinicians.
Dr. Mansfield: Right, with a clear understanding of the disease.
Question: OK. Are there any other areas that you'd like to discuss? Any other important developments and changes that you think are important in our field?
Dr. Mansfield: I think that it is important to note what is happening in terms of the molecular biology of cancer, the treatment and imaging equipment, and the advances in medical and surgical oncology. These will get better and better. Finally, that we work together in a combined modality approach to the treatment of cancer.
Question: Have you ever had any second thoughts about choosing radiation oncology?
Dr. Mansfield: No. That is why I'm still doing it. Maybe I should stop.
Question: Oh, I don't think so.
Dr. Mansfield: But I enjoy it. I think it's a wonderful field. And I like looking at the results compared to what things used to be years ago. It gets better and better every year.
Question: And what gives you the most satisfaction? Is it seeing some of the patients that you've cured?
Dr. Mansfield: Right. Patients coming back in are very pleased with their results, very happy. Or they bring their families. They've been able to go back to a normal life. And I think that's tremendous.