Carl von Essen, MD
By Gustavo Montana, MD, FASTRO, and Herman Suit, MD, DPhil, FASTRO
In 2002, ASTRO established the History Committee for the purpose of documenting and recording the history of radiation oncology in the United States. This interview took place at the 44th Annual Meeting of the American Society for Therapeutic Radiology and Oncology in New Orleans on February 16, 2002.
Herman Suit and I are members of the ASTRO History Committee. And over the years we have interviewed people of prominence, people who have made contributions to our specialty and to our Society. We would like to interview you, Carl, because we know that you have been a prominent member of our radiation oncology specialty. And, by the way, today is February 16th, and we would like to proceed with the interview. I'm Gustavo Montana, a member of the Radiation Oncology department at Duke University. And with me is Herman Suit, a former chair of the Massachusetts General Hospital Radiation Medicine Department, and I'll let Herman introduce himself and proceed with the questions.
Question: Good morning. Carl and I are very long-term friends. I'm Herman Suit at the Mass General Hospital, and we'd like to go ahead and start, Carl. Perhaps you could tell us a little bit about how you got into this area of medicine. We would appreciate a biosketch and some of the things about your career that you think we ought to have in writing in our archives.
Question: May I interrupt you for a second? I would like to also add that I had the fortune of being one of Carl’s trainees at Yale University when Carl was on the faculty there. I benefited enormously from his wisdom, his intelligence and his teaching.
Dr. von Essen: Oh, thank you. I remember well our collaboration at Yale and the paper you wrote in 1969 on head and neck cancer, which we coauthored with you. And it was a wonderful time indeed.
Question: OK, so would you like to go ahead and start?
Dr. von Essen: Shall I?
Question: Yes.
Dr. von Essen: How did it all begin? Well, it all began when I was a second-year student at Stanford Medical School. That was about 1948, and a bright young faculty member had just arrived from the East Coast by the name of Henry Kaplan. And as I understand, he was the youngest full professor ever appointed by Stanford, at the age of 29, and chairman of the department of Radiology, to boot, so he made quite an impression. My first meeting with him was with a small group of students, and we listened to his discussions about research and cancer and radiation therapy, and I was impressed. The next day I went to see him and asked if I could work in his lab, and he said yes. He outlined an interesting problem to work on and I worked with him ever since when I was at Stanford and even later. And he is the guiding light for my career choice and for much that I know. A great man.
Question: Very good. I think many of us would support your enthusiasm for the intelligence and productivity of Henry Kaplan. Let us go to the next phase, then.
Dr. von Essen: I began my training, first in Chicago at the University of Chicago, and then started a residency in 1952 at the Michael Reese Tumor Clinic which, in fact, was where Henry learned his radiotherapy. Michael Reese Hospital, a large hospital in south Chicago, had a tumor clinic headed by Erich Uhlmann, a German emigré who had a fascinating background. He had also worked as head of the cancer clinic in Ankara, Turkey before emigrating to the U.S. And Uhlmann was the one who trained Kaplan, although Kaplan wasn't always too happy about Uhlmann. Uhlmann was a flamboyant personality, a real prima donna, but a brilliant teacher. And I worked with him several years as a resident. We did some of the real old-fashioned radiotherapy. We used radium for all kinds of things. There was the first radium bomb in the United States, 10 grams of radium packed into a teletherapy apparatus, sort of like the subsequent cobalt bomb. But, of course, the treatment time took hours, mostly for treating head and neck because the FSD was around 12 centimeters, so those were interesting times. I learned to handle radium andall kinds of applications in the cervix, the head,theneck, the breast and so forth, and became, as a radiotherapist should be, hopefully, a well-trained oncologist.
Question: Could you just comment as to the basis of your selection of Michael Reese rather than Stanford for your residency?
Dr. von Essen: Well, I was, first of all, at the University of Chicago for my internship, and Michael Reese was just up the street, so to speak, it was partly a matter of convenience. Henry had really just started the program at Stanford, and there was no high-voltage equipment, and he did not have any trained assistants, so I thought that the exposure at Michael Reese would give me a lot more experience, and it did.
Question: Michael Reese was a very important medical center, right?
Dr. von Essen: Yes.
Question: Yes, very much so.
Question: There are a number of radiation oncologists that are very well-known, indeed, and pioneers in our specialty that had a connection with Michael Reese at one time or another.
Dr. von Essen: The Chicago Tumor Institute, founded by Max Cutler, was initially at Michael Reese and later moved down to the University of Chicago. And at that time, del Regato came from France, and Cantril was working there. They were all working together, Simeon Cantril and Juan del Regato in the Chicago Tumor Institute just before my time there. And so some of the real pioneers of American radiotherapy began their work in Chicago itself.
Question: Simeon Cantril was the first president of ASTRO, actually.
Dr. von Essen: Yes, that's right. A great man, too, whom I worked with later. Well, then I'll continue.
Question: Please do.
Dr. von Essen: I then was drafted into the Navy during the Korean War and served out my time in San Diego as, believe it or not, a head of diagnostic radiology when I didn't have an ounce of diagnostic radiology training, because I'd set my sights on radiotherapy and oncology, even though at that time it was a very unusual choice. It was a very controversial choice, in fact.
Question: At that time you could be certified in radiation oncology, could you not?
Dr. von Essen: Yes, it was possible to be certified in radiation therapy alone or diagnostic radiology alone but, of course, most people chose general radiology, which was just about the same period of training. I think they needed less than a year of radiotherapy to get to qualify. That was, of course, the problem of American radiotherapy in those days. The training was quite often not enough, not adequate. Then, after the Navy, I had been also impressed by Simeon Cantril and went up and got a fellowship from the NCI and became a fellow and a resident with Cantril at the Swedish Medical Center in Seattle. And that was a very fulfilling time, indeed, with him, Franz Buschke and the other residents, Bob Parker and Jerry Vaeth. That was a very fermenting and fulfilling time. After my year, year and a half, I think, at finishing my clinical requirements, Henry Kaplan, who I kept in touch with, suggested I come down and do a fellowship in radiobiology and work in the lab, which I did. I came back with my young family to San Francisco, and I spent two years then in the lab with Bob Kallman, the great radiobiologist, and worked with him in various aspects of mouse tumor radiobiology, and we published a few things. At the same time, because Kaplan needed help and Mal Bagshaw was his assistant in radiotherapy, they were organizing a new project on the campus, which was the Mark IV electron project. The Mark IV linear accelerator was a 72 MeV linear accelerator at the Hansen Lab on the campus of Stanford, and they wanted to set up a clinical trial using electrons with energies up to 72 [ MV ]. Kaplan and Bagshaw asked me to take over this project, and I did, and we carried out a preliminary sort of Phase I study of treatment of patients, often with advanced disease, metastatic disease, really testing out the RBE, dose distribution. And things like that.
Question: Can I take you back to Seattle for just a moment? I don't want to forget this, but wasn't it at that time when you did the study on skin tumors?
Dr. von Essen: Yes.
Question: Because that's a major contribution you made to the treatment of skin tumors and the understanding of tolerance, field size, if you will.
Dr. von Essen: Yes, thank you for reminding me. I tried to reproduce the work of Magnus Stranqvist by studying the records from the Swedish Medical Center, which were excellent, and follow up was excellent. So I was able to trace the results, including the complications of several hundred patients with skin cancer, and I analyzed the results by the dose, fractions, time and also area, which had not been done before. Strandqvist did not use volume or area as a parameter. And from that, I conceived later on at Yale a three-dimensional model of time-dose-volume relationships and basically for skin time-dose-area relationships. And that, of course, was a very useful as a model.
Question: It really was.
Dr. von Essen: And it's based on actual data. It certainly was fairly accurate for skin cancers. But these time-dose models, of course, have certain limitations, which we didn't quite understand at that time. But that was a very fulfilling work that got me a little bit of attention.
Question: Thank you.
Dr. von Essen: So I then continued on at Stanford and I started the electron therapy. In fact, I was the first doctor to treat patients on the Stanford campus, sort of in advance of the time, when Stanford had really moved down to “the Farm,” with the tremendous influence by Kaplan and the faculty at Stanford University, pushing the whole idea of a Stanford medical school being moved to the campus, which was one of the most important things he has ever done, starting an academic, an elite school which now remains a very prominent school in this country. Well, then, at Stanford in San Francisco. Morton Kligerman was also a fellow at that time in the lab with me, and he and I struck up a friendship. And he was just then appointed chief of a new department at Yale at the Hunter Radiation Therapy Center as well as chairman of the whole department of Radiology. And Klig lured me to Yale and we went there in 1959 with my now growing family, and stayed there for 10 happy and fulfilling years at New Haven. And we did a lot of new innovative things; finished that model of time-dose volume relations, developed several programs in chemotherapy which, combining with radiation therapy, we explored there with the really stellar department of Pharmacology with Arnold Welch, Bob Handschumacher, Bill Prusoff, Paul Calabrese and Joe Bertino, a really collaborative work between the fields of clinical pharmacology, chemotherapy and radiotherapy. None of these things had really made big progress in any single place, but the idea of interacting radiation with drugs we worked out, especially the problems of toxicity. And during that time, I got a sabbatical at this large hospital at Vellore in south India where they had a huge incidence of cervical cancer and head and neck cancer from the various factors that happen in Third World countries.
Question: Carl, could you comment on what motivated you to apply for the fellowship to go to India?
Dr. von Essen: Well, my wife was Indian and I thought I ought to go there and expose the children to Indian culture. But basically the trigger was Bob Chase who later became dean at Stanford. Bob Chase was the young plastic surgeon at Yale, went to this hospital at Vellore, was tremendously impressed with the quality of the work. He studied with a very famous reconstructive surgeon by the name of Paul Brand who addressed the problems of damage of tissues and nerves by leprosy through reconstructive surgery. And Bob told me about the huge incidence of oral cancer and that people were overworked there and they could barely deal with the problems. And I said, well, this is a place I ought to go and do something. So that's what happened.
Question: Very good.
Dr. von Essen: So then we went there and we had worked out, already, with the Pharmacology department, a clinical study of a new drug called IUdR, iododeoxyuridine, a pyrimidine analog, which, believe it or not, we applied to two totally different diseases; oral cancer and smallpox. I became, for a while, sort of an expert in infectious diseases. Smallpox was a big problem in India at that time. This is in 1964. There were 3,000 new cases at this one hospital in Madras per year, the mortality rate around 40%. And the Yale departments of Pharmacology set up a collaboration with the Indian government for a Phase I-II clinical trial of IUdR in smallpox because it is an antiviral drug as well as an anticancer drug. So there I went with a Yale medical student 100 miles away in Madras to help set up this study. Unfortunately, we picked hemorrhagic smallpox patients as the subjects. Later, we found out from the biology of smallpox that this is absolutely doomed to failure because once a patient develops hemorrhagic smallpox, it is too late. The blood vessels have already been destroyed. So that trial failed because of the incorrect selection of patients. So that didn't work, but it was exciting and hopefully later on, IUdR has gone on to be used as an antiviral against herpes simplex viruses. Anyway, at the same time, we did the trial with head and neck cancer using the drugs IUdR, Methotrexate, and 5 Fluorouracil in combination with radiation, so I was really the chemotherapist for this large hospital, the Christian Medical College Hospital, and I was engaged in more or less developing their department of Cancer Chemotherapy. And we set up a trial where we treated several hundred patients, and it's still a landmark as the first controlled trial of single-agent drugs with radiation in head and neck cancer.
Question: Now, was this a Phase III trial, then?
Dr. von Essen: Yes, a randomized trial with all of the aspects and the technical demands.
Question: That is right?
Dr. von Essen: What?
Question: Didn't that study include many patients that chewed tobacco?
Dr. von Essen: Oh, tobacco, yes. That was the immediate cause of the oral cancers.
Question: And there was a high incidence of oral cancers in that patient population.
Dr. von Essen: Yes, that's right.
Question: And what was the outcome? Why don't you just put this on the record?
Dr. von Essen: Well, it is. However, we found no significant advantage of any of the combinations over radiation alone. The problems here, of course, were these Stage III and Stage IV cancers and, again, they were probably too advanced to be able to show a significant effect. Methotrexate had the slight edge in long-term survival, but it never panned out as a real breakthrough of any magnitude.
Question: OK, and so after those two years, what happened?
Dr. von Essen: Well then, of course, that project continued. I kept going back and forth, but then returned to Yale and, at some point, was offered the position of chairman and professor at the new medical school in San Diego, the University of California, San Diego. And here, I thank you, Herman, still deeply, for your input in recommending me. Thanks to you, I did get to San Diego, where I had great expectations and great hopes.
Question: Before you left Yale, you did very interesting work with the radiation of the pituitary gland for patients with advanced carcinoma of the breast using the multiple fields.
Dr. von Essen: Yes, I'm so glad you bring these things up, which I should mention myself, yes, what is now called stereotactic radiosurgery.
Question: And that was very innovative and really a new technique at the time. Can you tell us more about that?
Dr. von Essen: All right. Well, at that time we tried to burn out the pituitary in patients with advanced breast cancer, and we wanted to develop it with the new linear accelerator. We had a six MV Varian accelerator, and we knew that there was a Swedish neurosurgeon who was trying to develop a cobalt unit which is now, in fact, marketed and is used in several hospitals, called the CyberKnife. That was developed by Lars Leksell. Well, I said, we can do the same with the linear accelerator, and probably easier, and so I set out a program with the physicists. First of all, we had to get accurate immobilization and localization of what we were treating. So we designed a frame to hold the head, sort of based on the neurosurgical frames, and developed a three-dimensional treatment planning program. And this was, of course, well before computers, before really we had easy ways of calculating three-dimensional volumes and conformation and all those other things. This is in the 1960s and with the physicists there, Bob Benbow, Al Agostinelli and Brian Stedeford. We had a wonderful, creative time developing three-dimensional treatment planning with very tiny beams, small-beam therapy, which we used mostly for pituitary, but we started treating some brain tumors as well. Now, of course, stereotactic radiotherapy, conformational therapy, IMRT and everything else are common, but that was sort of the beginning. The concept was not absolutely new, no. Takahashi, MD, in Japan and Waxman in Germany had thought of this and tried to develop it with orthovoltage in earlier days, so the concept is not new, but we had a new tool, six MV X-rays, which could deliver a much better dose distribution. So that was a fascinating project.
Question: But treating the pituitary for advanced breast cancer with radiation, was it new?
Dr. von Essen: Well, we were trying to ablate pituitary function with very high doses. The neurosurgeons were doing excision of the pituitary, the main alternative.
Question: Right, OK.
Dr. von Essen: And this was an attempt to suppress the pituitary with single doses, by the way, of 2,000 or more rads, which was done safely without complication. And that was unheard of at that time. So, anyway, from there I went to San Diego, which was just beginning its medical school. The innovative thing I started there was the use of the Brachytron. Atomic Energy of Canada Limited donated a remote controlled high-intensity intracavitary radiocobalt after-loading unit to me because I had a lot of experience with that concept working with Ulrich Henschke in New York, who was the founder of remote after-loading and the after-loading techniques that are now in common use. Ulrich Henschke was a brilliant man in technical innovation and had all kinds of wonderful ideas. Unfortunately, he died prematurely in Africa in that plane crash. Anyway, I started this remote after-loading project because we had a huge number of patients from Mexico with cervix cancer and they were not able, because they were not citizens, to be treated in a normal way, that is be hospitalized and to have radioactive implants. So we treated them as outpatients.
Question: Herman also collaborated with Henschke, right?
Question: Yes.
Question: In the development of the after-loading applicators.
Dr. von Essen: Head and neck cancer, you worked with me on several cases, Gustavo, I remember, using after-loading catheters, that's right.
Question: Henschke was a wonderful guy, very warm, open and hospitable.
Dr. von Essen: Yes, he was one of the most remarkable people that I've met. He and Juan del Regato and, of course, Gilbert Fletcher, as well as Kaplan. Buschke and Cantril. These are all great notables in the portrait gallery of radiation oncology in this country, and I had the wonderful chance of knowing and working with some of them. So, anyway, we went on and developed the program, which now is useful in Third World countries because it's a way of treating many patients with absolute radiation safety for the operators, and if the dosimetry and the physics are right, they get equally good results. So I felt that was an advance which I developed later on in Sri Lanka. That's just a little later on. It's hard to recall my whole life in a sequence here. From San Diego on a sabbatical to Switzerland, I worked in the lab in Lausanne at the Swiss Institute for Experimental Cancer Research, and at that time I was contacted regarding the possibility of heading up the medical side of a pi meson therapy program at the Swiss Institute for Nuclear Research (SIN). And eventually I was appointed to head up that program and left San Diego but worked with Klig, who was then radiology chairman at University of New Mexico, and I was temporarily appointed for the pion work at Los Alamos. The Swiss program and the Los Alamos program began more or less at the same time for the study of pi mesons. And an interesting aside, I knew Enrico Fermi, Herbert Anderson and Murray Gell-Mann because my brother-in-law was a physicist in Chicago. I was interning and doing residency in Chicago and met these great men who had told me in 1952, as a budding radiotherapist, that the pi meson may be one of the great possibilities for treating cancer because of its unique properties of the Bragg curve, the high LET component and other things that everybody knows. But at that time, there was no practical beam. Well, they said in 20 years there would be, and they were right. One was developed at Los Alamos, and Stanford developed a toroidal superconducting unit, which unfortunately never treated any patients. And then Switzerland (SIN) developed a similar model using superconducting magnets, and they wanted a person with some experience to head up the medical program, which I did. And that was between 1976 through '84. And this was then really the world's most technically advanced beam therapy project. There were heavy particle studies going on with Joe Castro in Berkeley and then, of course, neutron studies, particularly in England. So all of this high LET study was underway in different places, and we were trying to find out if it really could make headway in cancer control. But these were highly expensive programs, technically difficult, and the worst part is that most of them were remote from a medical facility. So few of us were able to carry out a normal fractionation. There were still questions on what is the ideal fractionation for these particles, and that was never really worked out because we were constrained by the problems of logistics, treating patients and getting them to the right places and treating them often enough. And then there was beam time. The beam went down every few weeks, so these were some of the things that have restrained the use and the appreciation of the advantages of these beams. Now with hospital-based proton accelerators, around the world, they have been able to carry out a reasonable fractionated treatment, which now is really working and panning out. In a nutshell, that's all we did with pi mesons. Finally, the pi meson unit was so complicated, it was almost impossible to continue and, in fact, it crashed. The huge liquid nitrogen leak from the toroidal magnets doomed the thing. So I turned to the WHO.
We had already anticipated protons being the more useful, practical tool and had started a proton therapy at Switzerland for eye treatment, essentially copying the technique at the Harvard cyclotron and MGH. And that project is highly successful. It's treated 5,000 patients since I helped start it with Charles Perret and Swiss ophthalmologists back in 1979. So that's a very fulfilling thing and life goes on. And, of course with the brilliant geniuses of the Swiss and other physicists, like Eros Pedroni, there is a new gantry-mounted proton therapy unit, which carries on with my successor running the medical programs. So I go back every now and then and see with great satisfaction the success of the Swiss programs.
Then, after that, I became interested in low-tech problems of the Third World and went to Sri Lanka as a consultant with the World Health, deciding there would be some use for me in a problem of a country that's in political and economic turmoil. Nearly all the radiation oncologists had left the country. Eventually, 16 million patients were without any real treatment for their cancer. I started training programs in “clinical oncology” for doctors and introduced after-loading techniques in Sri Lanka and the same later on in Zimbabwe, where there was not a single oncologist left. Then I came back to New England where I retired.
Question: Well, you work in some hospitals here in the Boston area.
Dr. von Essen: Yes, I developed a private practice in Southwood Hospital. And, Herman, you gave me a wonderful consulting position at MGH, and that was very fulfilling.
Question: Well, thank you very much. But why don't you just mention your work in writing books, just as an aside, because you have written several, and you have a new one coming up.
Dr. von Essen: Well, I did. I think one of my major books in radiotherapy was co-written and co-edited for the World Health for use as a manual, a handbook on developing worlds. And I hope that book has been useful. It's called Radiotherapy in Cancer Management, A Practical Manual. And that's published by the World Health Organization. And then, just at the end of retirement, I started writing other books, non-medical books. The first one is on my fishing hobby because every time I went to one of these countries, I brought along my fishing rod. So I've fished in some really strange places. I fished in Sri Lanka, of course, India, Turkey, New Zealand and Africa, and later on in South America, a lot of interesting places. I wrote something about that in the book called “The Revenge of the Fish God.” Then I went on and wrote a book on nature because I'd been concerned about ecology and about our relationship to nature, the human relationship to nature, and that book is called “The Hunter's Trance: Nature, Spirit & Ecology,” about the spiritual contact that we need to develop with nature to help preserve it.
Question: Well, that's a very beautiful effort, I think. But don't you have another book that's just about to come out?
Dr. von Essen: Well, I wrote my memoir, “Memory is a Dwelling Place,” and most of what I have mentioned here is in that book.
Question: Has it come out?
Dr. von Essen: Yeah, I sent you a copy. You should have it in the mail tomorrow.
Question: Oh, great. Did you sign it?
Dr. von Essen: Yes, absolutely.
Question: And why don't you mention briefly your efforts as a sculptor?
Dr. von Essen: The book includes other things, too, some interesting aspects, especially about Henry Kaplan and others.
Question: Yes. But I was saying, why don't you just mention some of your successes in being an artist and a sculptor?
Dr. von Essen: Well, yes, I've shown Herman some of my work. Yes, I sculpt. It's a hobby now, and I got a show a few years ago, and I do small pieces in clay, and now I'm beginning to cast them in bronze.
Question: Very interesting.
Dr. von Essen: Yes, and I'm now just having a revision of “Hunter's Trance” with the publisher, and I'm continuing on with another book, a follow-up on my memoir. So writing and sculpting in my retirement is fulfilling. I'm biking around Cambridge, going to the libraries, the Harvard Library, for which Herman has given me privileges all these years, well over 20 years. I'm deeply grateful. I go there almost every day.
Question: I didn't know you went there that often, but anyway, we're glad to hear it. Was there any other item that you would like to mention?
Dr. von Essen: It's hard to know. I thought I covered everything.
Question: I have a couple of questions or comments to make before we close
Dr. von Essen: Go ahead.
Question: And then we can go back to anything we didn't ask you, Carl.
Dr. von Essen: Sure.
Question: Do you have any words of wisdom for the leaders of our specialty now with regards to the direction, things about training or anything you would like to communicate to the radiation oncology community?
Dr. von Essen: Well, thank you, Gustavo. I don't keep in close touch with radiotherapy. I've more or less left the field to focus on writing and sculpting and so on. So I'm not up to date on current things. But I think, in general, one thing for the radiation oncologist is to be, first and foremost, a great clinician and to develop a comprehensive knowledge of cancer, the biology of cancer and the understanding of its effects on the human being. When I came back from Europe, I was shocked that the medical oncologists had sort of taken over the field and that there were a lot of young, what I would call, “whipper-snappers” who thought they knew an awful lot about cancer, and the patients were being sent to them first for their evaluations, and that somehow the radiation oncologists lost their initial role in judging and deciding on the problems of cancer treatment. And the programs I started in Sri Lanka and Zimbabwe are based on the European model, which is clinical oncology, which includes radiotherapy, but they're called clinical oncologists. But they are not expected to be able to give these complex and toxic programs of chemo. Still, you have to be familiar and be able to work closely. I think maybe the specialties are a little too separated right now.
Question: Well, that's an interesting point, Carl. You have had such a worldwide experience, background and view, really. Could that be also the result of the way medicine is practiced in this country that is more fractionated, isolated, one specialty from the other perhaps for economic and administrative reasons?
Dr. von Essen: Well, it's hard to know. I don't know what happens, but now you have freestanding radiotherapy centers, and that tends to isolate even further the radiotherapist from his colleagues, surgery and chemo. This is the way things are, but I would always encourage that the radiation oncologist be a clinician first and foremost and spend time with the patient. The other is, of course, the importance of evaluating your results, even your personal results, and the follow-up of patients long-term because one of the problems, as you know, of radiation is the late changes, late effects, not just two or three years, but even five or 10 years. And that's important, for a doctor to get experience, to meticulously follow up his own patients and to see them periodically to be able to judge the late effects because one of the great problems of radiation is late changes.
Question: We certainly agree with you on that.
Question: One more question we'd like you to comment on professionally. You know, what are the things, or if there's something that stands out to be, when you look back, the most satisfying thing that you have done, or the thing that has brought you most rewards?
Dr. von Essen: Well, those were the international projects. Of course, my father was a diplomat, and maybe I inherited some of his interest in trying to work with others in international settings and to help improve the standards of medicine in our field in developing countries. That was, to me, the most fulfilling part of my career. I must say, making that three-dimensional time-dose-volume model was wonderful, the development of after-loading using Henschke's ideas, but those are not original. And the isocentric treatment of the brain, the multiplanar approach, which now, of course, is the big thing, I think, in radiotherapy because the technology has come along.
Question: Before we close, I want to convey to you Len Prosnitz's best wishes.
Dr. von Essen: Another resident at Yale. We had, I think, a stellar cast of residents, of trainees who came out of Yale and, thanks to Kligerman's dynamic leadership, I was privileged to work with him and work with you in those years. Those were wonderful times.
Question: Thank you.
Question: Carl, we very much appreciate your time and having our memories refreshed about some of the very fascinating things you've done and also the valuable contributions you've made to our specialty.
Question: So on behalf of the History Committee, again, I join Herman in thanking you for giving us the time for this interview and providing us with this very interesting account of your professional experience and the contributions that you have made to our specialty.
Dr. von Essen: Well, thank you both for your interest and for conducting this interview with me. I'm very flattered, indeed, to be selected and I hope my words might be of use to future generations.
A new biography of Henry Kaplan, “Henry Kaplan and the Story of Hodgkin’s Disease,” by Charlotte Jacobs, Stanford University Press, 2010, gives a comprehensive view of Henry Kaplan. In fact, he was formally offered the professorship and chairmanship of Radiology at Stanford just before his 30th birthday. Whether or not he was the youngest at Stanford to receive such an honor is not stated, but I heard somewhere that that was correct.
Von Essen`, C.F. et al Sequential chemotherapy and radiation therapy of buccal mucosa carcinoma in South India. Am. J. Roentgenology, Radium Therapy and Nuclear Medicine, v 52, March, 1968.
In 2002, ASTRO established the History Committee for the purpose of documenting and recording the history of radiation oncology in the United States. This interview took place at the 44th Annual Meeting of the American Society for Therapeutic Radiology and Oncology in New Orleans on February 16, 2002.
Herman Suit and I are members of the ASTRO History Committee. And over the years we have interviewed people of prominence, people who have made contributions to our specialty and to our Society. We would like to interview you, Carl, because we know that you have been a prominent member of our radiation oncology specialty. And, by the way, today is February 16th, and we would like to proceed with the interview. I'm Gustavo Montana, a member of the Radiation Oncology department at Duke University. And with me is Herman Suit, a former chair of the Massachusetts General Hospital Radiation Medicine Department, and I'll let Herman introduce himself and proceed with the questions.
Question: Good morning. Carl and I are very long-term friends. I'm Herman Suit at the Mass General Hospital, and we'd like to go ahead and start, Carl. Perhaps you could tell us a little bit about how you got into this area of medicine. We would appreciate a biosketch and some of the things about your career that you think we ought to have in writing in our archives.
Question: May I interrupt you for a second? I would like to also add that I had the fortune of being one of Carl’s trainees at Yale University when Carl was on the faculty there. I benefited enormously from his wisdom, his intelligence and his teaching.
Dr. von Essen: Oh, thank you. I remember well our collaboration at Yale and the paper you wrote in 1969 on head and neck cancer, which we coauthored with you. And it was a wonderful time indeed.
Question: OK, so would you like to go ahead and start?
Dr. von Essen: Shall I?
Question: Yes.
Dr. von Essen: How did it all begin? Well, it all began when I was a second-year student at Stanford Medical School. That was about 1948, and a bright young faculty member had just arrived from the East Coast by the name of Henry Kaplan. And as I understand, he was the youngest full professor ever appointed by Stanford, at the age of 29, and chairman of the department of Radiology, to boot, so he made quite an impression. My first meeting with him was with a small group of students, and we listened to his discussions about research and cancer and radiation therapy, and I was impressed. The next day I went to see him and asked if I could work in his lab, and he said yes. He outlined an interesting problem to work on and I worked with him ever since when I was at Stanford and even later. And he is the guiding light for my career choice and for much that I know. A great man.
Question: Very good. I think many of us would support your enthusiasm for the intelligence and productivity of Henry Kaplan. Let us go to the next phase, then.
Dr. von Essen: I began my training, first in Chicago at the University of Chicago, and then started a residency in 1952 at the Michael Reese Tumor Clinic which, in fact, was where Henry learned his radiotherapy. Michael Reese Hospital, a large hospital in south Chicago, had a tumor clinic headed by Erich Uhlmann, a German emigré who had a fascinating background. He had also worked as head of the cancer clinic in Ankara, Turkey before emigrating to the U.S. And Uhlmann was the one who trained Kaplan, although Kaplan wasn't always too happy about Uhlmann. Uhlmann was a flamboyant personality, a real prima donna, but a brilliant teacher. And I worked with him several years as a resident. We did some of the real old-fashioned radiotherapy. We used radium for all kinds of things. There was the first radium bomb in the United States, 10 grams of radium packed into a teletherapy apparatus, sort of like the subsequent cobalt bomb. But, of course, the treatment time took hours, mostly for treating head and neck because the FSD was around 12 centimeters, so those were interesting times. I learned to handle radium andall kinds of applications in the cervix, the head,theneck, the breast and so forth, and became, as a radiotherapist should be, hopefully, a well-trained oncologist.
Question: Could you just comment as to the basis of your selection of Michael Reese rather than Stanford for your residency?
Dr. von Essen: Well, I was, first of all, at the University of Chicago for my internship, and Michael Reese was just up the street, so to speak, it was partly a matter of convenience. Henry had really just started the program at Stanford, and there was no high-voltage equipment, and he did not have any trained assistants, so I thought that the exposure at Michael Reese would give me a lot more experience, and it did.
Question: Michael Reese was a very important medical center, right?
Dr. von Essen: Yes.
Question: Yes, very much so.
Question: There are a number of radiation oncologists that are very well-known, indeed, and pioneers in our specialty that had a connection with Michael Reese at one time or another.
Dr. von Essen: The Chicago Tumor Institute, founded by Max Cutler, was initially at Michael Reese and later moved down to the University of Chicago. And at that time, del Regato came from France, and Cantril was working there. They were all working together, Simeon Cantril and Juan del Regato in the Chicago Tumor Institute just before my time there. And so some of the real pioneers of American radiotherapy began their work in Chicago itself.
Question: Simeon Cantril was the first president of ASTRO, actually.
Dr. von Essen: Yes, that's right. A great man, too, whom I worked with later. Well, then I'll continue.
Question: Please do.
Dr. von Essen: I then was drafted into the Navy during the Korean War and served out my time in San Diego as, believe it or not, a head of diagnostic radiology when I didn't have an ounce of diagnostic radiology training, because I'd set my sights on radiotherapy and oncology, even though at that time it was a very unusual choice. It was a very controversial choice, in fact.
Question: At that time you could be certified in radiation oncology, could you not?
Dr. von Essen: Yes, it was possible to be certified in radiation therapy alone or diagnostic radiology alone but, of course, most people chose general radiology, which was just about the same period of training. I think they needed less than a year of radiotherapy to get to qualify. That was, of course, the problem of American radiotherapy in those days. The training was quite often not enough, not adequate. Then, after the Navy, I had been also impressed by Simeon Cantril and went up and got a fellowship from the NCI and became a fellow and a resident with Cantril at the Swedish Medical Center in Seattle. And that was a very fulfilling time, indeed, with him, Franz Buschke and the other residents, Bob Parker and Jerry Vaeth. That was a very fermenting and fulfilling time. After my year, year and a half, I think, at finishing my clinical requirements, Henry Kaplan, who I kept in touch with, suggested I come down and do a fellowship in radiobiology and work in the lab, which I did. I came back with my young family to San Francisco, and I spent two years then in the lab with Bob Kallman, the great radiobiologist, and worked with him in various aspects of mouse tumor radiobiology, and we published a few things. At the same time, because Kaplan needed help and Mal Bagshaw was his assistant in radiotherapy, they were organizing a new project on the campus, which was the Mark IV electron project. The Mark IV linear accelerator was a 72 MeV linear accelerator at the Hansen Lab on the campus of Stanford, and they wanted to set up a clinical trial using electrons with energies up to 72 [ MV ]. Kaplan and Bagshaw asked me to take over this project, and I did, and we carried out a preliminary sort of Phase I study of treatment of patients, often with advanced disease, metastatic disease, really testing out the RBE, dose distribution. And things like that.
Question: Can I take you back to Seattle for just a moment? I don't want to forget this, but wasn't it at that time when you did the study on skin tumors?
Dr. von Essen: Yes.
Question: Because that's a major contribution you made to the treatment of skin tumors and the understanding of tolerance, field size, if you will.
Dr. von Essen: Yes, thank you for reminding me. I tried to reproduce the work of Magnus Stranqvist by studying the records from the Swedish Medical Center, which were excellent, and follow up was excellent. So I was able to trace the results, including the complications of several hundred patients with skin cancer, and I analyzed the results by the dose, fractions, time and also area, which had not been done before. Strandqvist did not use volume or area as a parameter. And from that, I conceived later on at Yale a three-dimensional model of time-dose-volume relationships and basically for skin time-dose-area relationships. And that, of course, was a very useful as a model.
Question: It really was.
Dr. von Essen: And it's based on actual data. It certainly was fairly accurate for skin cancers. But these time-dose models, of course, have certain limitations, which we didn't quite understand at that time. But that was a very fulfilling work that got me a little bit of attention.
Question: Thank you.
Dr. von Essen: So I then continued on at Stanford and I started the electron therapy. In fact, I was the first doctor to treat patients on the Stanford campus, sort of in advance of the time, when Stanford had really moved down to “the Farm,” with the tremendous influence by Kaplan and the faculty at Stanford University, pushing the whole idea of a Stanford medical school being moved to the campus, which was one of the most important things he has ever done, starting an academic, an elite school which now remains a very prominent school in this country. Well, then, at Stanford in San Francisco. Morton Kligerman was also a fellow at that time in the lab with me, and he and I struck up a friendship. And he was just then appointed chief of a new department at Yale at the Hunter Radiation Therapy Center as well as chairman of the whole department of Radiology. And Klig lured me to Yale and we went there in 1959 with my now growing family, and stayed there for 10 happy and fulfilling years at New Haven. And we did a lot of new innovative things; finished that model of time-dose volume relations, developed several programs in chemotherapy which, combining with radiation therapy, we explored there with the really stellar department of Pharmacology with Arnold Welch, Bob Handschumacher, Bill Prusoff, Paul Calabrese and Joe Bertino, a really collaborative work between the fields of clinical pharmacology, chemotherapy and radiotherapy. None of these things had really made big progress in any single place, but the idea of interacting radiation with drugs we worked out, especially the problems of toxicity. And during that time, I got a sabbatical at this large hospital at Vellore in south India where they had a huge incidence of cervical cancer and head and neck cancer from the various factors that happen in Third World countries.
Question: Carl, could you comment on what motivated you to apply for the fellowship to go to India?
Dr. von Essen: Well, my wife was Indian and I thought I ought to go there and expose the children to Indian culture. But basically the trigger was Bob Chase who later became dean at Stanford. Bob Chase was the young plastic surgeon at Yale, went to this hospital at Vellore, was tremendously impressed with the quality of the work. He studied with a very famous reconstructive surgeon by the name of Paul Brand who addressed the problems of damage of tissues and nerves by leprosy through reconstructive surgery. And Bob told me about the huge incidence of oral cancer and that people were overworked there and they could barely deal with the problems. And I said, well, this is a place I ought to go and do something. So that's what happened.
Question: Very good.
Dr. von Essen: So then we went there and we had worked out, already, with the Pharmacology department, a clinical study of a new drug called IUdR, iododeoxyuridine, a pyrimidine analog, which, believe it or not, we applied to two totally different diseases; oral cancer and smallpox. I became, for a while, sort of an expert in infectious diseases. Smallpox was a big problem in India at that time. This is in 1964. There were 3,000 new cases at this one hospital in Madras per year, the mortality rate around 40%. And the Yale departments of Pharmacology set up a collaboration with the Indian government for a Phase I-II clinical trial of IUdR in smallpox because it is an antiviral drug as well as an anticancer drug. So there I went with a Yale medical student 100 miles away in Madras to help set up this study. Unfortunately, we picked hemorrhagic smallpox patients as the subjects. Later, we found out from the biology of smallpox that this is absolutely doomed to failure because once a patient develops hemorrhagic smallpox, it is too late. The blood vessels have already been destroyed. So that trial failed because of the incorrect selection of patients. So that didn't work, but it was exciting and hopefully later on, IUdR has gone on to be used as an antiviral against herpes simplex viruses. Anyway, at the same time, we did the trial with head and neck cancer using the drugs IUdR, Methotrexate, and 5 Fluorouracil in combination with radiation, so I was really the chemotherapist for this large hospital, the Christian Medical College Hospital, and I was engaged in more or less developing their department of Cancer Chemotherapy. And we set up a trial where we treated several hundred patients, and it's still a landmark as the first controlled trial of single-agent drugs with radiation in head and neck cancer.
Question: Now, was this a Phase III trial, then?
Dr. von Essen: Yes, a randomized trial with all of the aspects and the technical demands.
Question: That is right?
Dr. von Essen: What?
Question: Didn't that study include many patients that chewed tobacco?
Dr. von Essen: Oh, tobacco, yes. That was the immediate cause of the oral cancers.
Question: And there was a high incidence of oral cancers in that patient population.
Dr. von Essen: Yes, that's right.
Question: And what was the outcome? Why don't you just put this on the record?
Dr. von Essen: Well, it is. However, we found no significant advantage of any of the combinations over radiation alone. The problems here, of course, were these Stage III and Stage IV cancers and, again, they were probably too advanced to be able to show a significant effect. Methotrexate had the slight edge in long-term survival, but it never panned out as a real breakthrough of any magnitude.
Question: OK, and so after those two years, what happened?
Dr. von Essen: Well then, of course, that project continued. I kept going back and forth, but then returned to Yale and, at some point, was offered the position of chairman and professor at the new medical school in San Diego, the University of California, San Diego. And here, I thank you, Herman, still deeply, for your input in recommending me. Thanks to you, I did get to San Diego, where I had great expectations and great hopes.
Question: Before you left Yale, you did very interesting work with the radiation of the pituitary gland for patients with advanced carcinoma of the breast using the multiple fields.
Dr. von Essen: Yes, I'm so glad you bring these things up, which I should mention myself, yes, what is now called stereotactic radiosurgery.
Question: And that was very innovative and really a new technique at the time. Can you tell us more about that?
Dr. von Essen: All right. Well, at that time we tried to burn out the pituitary in patients with advanced breast cancer, and we wanted to develop it with the new linear accelerator. We had a six MV Varian accelerator, and we knew that there was a Swedish neurosurgeon who was trying to develop a cobalt unit which is now, in fact, marketed and is used in several hospitals, called the CyberKnife. That was developed by Lars Leksell. Well, I said, we can do the same with the linear accelerator, and probably easier, and so I set out a program with the physicists. First of all, we had to get accurate immobilization and localization of what we were treating. So we designed a frame to hold the head, sort of based on the neurosurgical frames, and developed a three-dimensional treatment planning program. And this was, of course, well before computers, before really we had easy ways of calculating three-dimensional volumes and conformation and all those other things. This is in the 1960s and with the physicists there, Bob Benbow, Al Agostinelli and Brian Stedeford. We had a wonderful, creative time developing three-dimensional treatment planning with very tiny beams, small-beam therapy, which we used mostly for pituitary, but we started treating some brain tumors as well. Now, of course, stereotactic radiotherapy, conformational therapy, IMRT and everything else are common, but that was sort of the beginning. The concept was not absolutely new, no. Takahashi, MD, in Japan and Waxman in Germany had thought of this and tried to develop it with orthovoltage in earlier days, so the concept is not new, but we had a new tool, six MV X-rays, which could deliver a much better dose distribution. So that was a fascinating project.
Question: But treating the pituitary for advanced breast cancer with radiation, was it new?
Dr. von Essen: Well, we were trying to ablate pituitary function with very high doses. The neurosurgeons were doing excision of the pituitary, the main alternative.
Question: Right, OK.
Dr. von Essen: And this was an attempt to suppress the pituitary with single doses, by the way, of 2,000 or more rads, which was done safely without complication. And that was unheard of at that time. So, anyway, from there I went to San Diego, which was just beginning its medical school. The innovative thing I started there was the use of the Brachytron. Atomic Energy of Canada Limited donated a remote controlled high-intensity intracavitary radiocobalt after-loading unit to me because I had a lot of experience with that concept working with Ulrich Henschke in New York, who was the founder of remote after-loading and the after-loading techniques that are now in common use. Ulrich Henschke was a brilliant man in technical innovation and had all kinds of wonderful ideas. Unfortunately, he died prematurely in Africa in that plane crash. Anyway, I started this remote after-loading project because we had a huge number of patients from Mexico with cervix cancer and they were not able, because they were not citizens, to be treated in a normal way, that is be hospitalized and to have radioactive implants. So we treated them as outpatients.
Question: Herman also collaborated with Henschke, right?
Question: Yes.
Question: In the development of the after-loading applicators.
Dr. von Essen: Head and neck cancer, you worked with me on several cases, Gustavo, I remember, using after-loading catheters, that's right.
Question: Henschke was a wonderful guy, very warm, open and hospitable.
Dr. von Essen: Yes, he was one of the most remarkable people that I've met. He and Juan del Regato and, of course, Gilbert Fletcher, as well as Kaplan. Buschke and Cantril. These are all great notables in the portrait gallery of radiation oncology in this country, and I had the wonderful chance of knowing and working with some of them. So, anyway, we went on and developed the program, which now is useful in Third World countries because it's a way of treating many patients with absolute radiation safety for the operators, and if the dosimetry and the physics are right, they get equally good results. So I felt that was an advance which I developed later on in Sri Lanka. That's just a little later on. It's hard to recall my whole life in a sequence here. From San Diego on a sabbatical to Switzerland, I worked in the lab in Lausanne at the Swiss Institute for Experimental Cancer Research, and at that time I was contacted regarding the possibility of heading up the medical side of a pi meson therapy program at the Swiss Institute for Nuclear Research (SIN). And eventually I was appointed to head up that program and left San Diego but worked with Klig, who was then radiology chairman at University of New Mexico, and I was temporarily appointed for the pion work at Los Alamos. The Swiss program and the Los Alamos program began more or less at the same time for the study of pi mesons. And an interesting aside, I knew Enrico Fermi, Herbert Anderson and Murray Gell-Mann because my brother-in-law was a physicist in Chicago. I was interning and doing residency in Chicago and met these great men who had told me in 1952, as a budding radiotherapist, that the pi meson may be one of the great possibilities for treating cancer because of its unique properties of the Bragg curve, the high LET component and other things that everybody knows. But at that time, there was no practical beam. Well, they said in 20 years there would be, and they were right. One was developed at Los Alamos, and Stanford developed a toroidal superconducting unit, which unfortunately never treated any patients. And then Switzerland (SIN) developed a similar model using superconducting magnets, and they wanted a person with some experience to head up the medical program, which I did. And that was between 1976 through '84. And this was then really the world's most technically advanced beam therapy project. There were heavy particle studies going on with Joe Castro in Berkeley and then, of course, neutron studies, particularly in England. So all of this high LET study was underway in different places, and we were trying to find out if it really could make headway in cancer control. But these were highly expensive programs, technically difficult, and the worst part is that most of them were remote from a medical facility. So few of us were able to carry out a normal fractionation. There were still questions on what is the ideal fractionation for these particles, and that was never really worked out because we were constrained by the problems of logistics, treating patients and getting them to the right places and treating them often enough. And then there was beam time. The beam went down every few weeks, so these were some of the things that have restrained the use and the appreciation of the advantages of these beams. Now with hospital-based proton accelerators, around the world, they have been able to carry out a reasonable fractionated treatment, which now is really working and panning out. In a nutshell, that's all we did with pi mesons. Finally, the pi meson unit was so complicated, it was almost impossible to continue and, in fact, it crashed. The huge liquid nitrogen leak from the toroidal magnets doomed the thing. So I turned to the WHO.
We had already anticipated protons being the more useful, practical tool and had started a proton therapy at Switzerland for eye treatment, essentially copying the technique at the Harvard cyclotron and MGH. And that project is highly successful. It's treated 5,000 patients since I helped start it with Charles Perret and Swiss ophthalmologists back in 1979. So that's a very fulfilling thing and life goes on. And, of course with the brilliant geniuses of the Swiss and other physicists, like Eros Pedroni, there is a new gantry-mounted proton therapy unit, which carries on with my successor running the medical programs. So I go back every now and then and see with great satisfaction the success of the Swiss programs.
Then, after that, I became interested in low-tech problems of the Third World and went to Sri Lanka as a consultant with the World Health, deciding there would be some use for me in a problem of a country that's in political and economic turmoil. Nearly all the radiation oncologists had left the country. Eventually, 16 million patients were without any real treatment for their cancer. I started training programs in “clinical oncology” for doctors and introduced after-loading techniques in Sri Lanka and the same later on in Zimbabwe, where there was not a single oncologist left. Then I came back to New England where I retired.
Question: Well, you work in some hospitals here in the Boston area.
Dr. von Essen: Yes, I developed a private practice in Southwood Hospital. And, Herman, you gave me a wonderful consulting position at MGH, and that was very fulfilling.
Question: Well, thank you very much. But why don't you just mention your work in writing books, just as an aside, because you have written several, and you have a new one coming up.
Dr. von Essen: Well, I did. I think one of my major books in radiotherapy was co-written and co-edited for the World Health for use as a manual, a handbook on developing worlds. And I hope that book has been useful. It's called Radiotherapy in Cancer Management, A Practical Manual. And that's published by the World Health Organization. And then, just at the end of retirement, I started writing other books, non-medical books. The first one is on my fishing hobby because every time I went to one of these countries, I brought along my fishing rod. So I've fished in some really strange places. I fished in Sri Lanka, of course, India, Turkey, New Zealand and Africa, and later on in South America, a lot of interesting places. I wrote something about that in the book called “The Revenge of the Fish God.” Then I went on and wrote a book on nature because I'd been concerned about ecology and about our relationship to nature, the human relationship to nature, and that book is called “The Hunter's Trance: Nature, Spirit & Ecology,” about the spiritual contact that we need to develop with nature to help preserve it.
Question: Well, that's a very beautiful effort, I think. But don't you have another book that's just about to come out?
Dr. von Essen: Well, I wrote my memoir, “Memory is a Dwelling Place,” and most of what I have mentioned here is in that book.
Question: Has it come out?
Dr. von Essen: Yeah, I sent you a copy. You should have it in the mail tomorrow.
Question: Oh, great. Did you sign it?
Dr. von Essen: Yes, absolutely.
Question: And why don't you mention briefly your efforts as a sculptor?
Dr. von Essen: The book includes other things, too, some interesting aspects, especially about Henry Kaplan and others.
Question: Yes. But I was saying, why don't you just mention some of your successes in being an artist and a sculptor?
Dr. von Essen: Well, yes, I've shown Herman some of my work. Yes, I sculpt. It's a hobby now, and I got a show a few years ago, and I do small pieces in clay, and now I'm beginning to cast them in bronze.
Question: Very interesting.
Dr. von Essen: Yes, and I'm now just having a revision of “Hunter's Trance” with the publisher, and I'm continuing on with another book, a follow-up on my memoir. So writing and sculpting in my retirement is fulfilling. I'm biking around Cambridge, going to the libraries, the Harvard Library, for which Herman has given me privileges all these years, well over 20 years. I'm deeply grateful. I go there almost every day.
Question: I didn't know you went there that often, but anyway, we're glad to hear it. Was there any other item that you would like to mention?
Dr. von Essen: It's hard to know. I thought I covered everything.
Question: I have a couple of questions or comments to make before we close
Dr. von Essen: Go ahead.
Question: And then we can go back to anything we didn't ask you, Carl.
Dr. von Essen: Sure.
Question: Do you have any words of wisdom for the leaders of our specialty now with regards to the direction, things about training or anything you would like to communicate to the radiation oncology community?
Dr. von Essen: Well, thank you, Gustavo. I don't keep in close touch with radiotherapy. I've more or less left the field to focus on writing and sculpting and so on. So I'm not up to date on current things. But I think, in general, one thing for the radiation oncologist is to be, first and foremost, a great clinician and to develop a comprehensive knowledge of cancer, the biology of cancer and the understanding of its effects on the human being. When I came back from Europe, I was shocked that the medical oncologists had sort of taken over the field and that there were a lot of young, what I would call, “whipper-snappers” who thought they knew an awful lot about cancer, and the patients were being sent to them first for their evaluations, and that somehow the radiation oncologists lost their initial role in judging and deciding on the problems of cancer treatment. And the programs I started in Sri Lanka and Zimbabwe are based on the European model, which is clinical oncology, which includes radiotherapy, but they're called clinical oncologists. But they are not expected to be able to give these complex and toxic programs of chemo. Still, you have to be familiar and be able to work closely. I think maybe the specialties are a little too separated right now.
Question: Well, that's an interesting point, Carl. You have had such a worldwide experience, background and view, really. Could that be also the result of the way medicine is practiced in this country that is more fractionated, isolated, one specialty from the other perhaps for economic and administrative reasons?
Dr. von Essen: Well, it's hard to know. I don't know what happens, but now you have freestanding radiotherapy centers, and that tends to isolate even further the radiotherapist from his colleagues, surgery and chemo. This is the way things are, but I would always encourage that the radiation oncologist be a clinician first and foremost and spend time with the patient. The other is, of course, the importance of evaluating your results, even your personal results, and the follow-up of patients long-term because one of the problems, as you know, of radiation is the late changes, late effects, not just two or three years, but even five or 10 years. And that's important, for a doctor to get experience, to meticulously follow up his own patients and to see them periodically to be able to judge the late effects because one of the great problems of radiation is late changes.
Question: We certainly agree with you on that.
Question: One more question we'd like you to comment on professionally. You know, what are the things, or if there's something that stands out to be, when you look back, the most satisfying thing that you have done, or the thing that has brought you most rewards?
Dr. von Essen: Well, those were the international projects. Of course, my father was a diplomat, and maybe I inherited some of his interest in trying to work with others in international settings and to help improve the standards of medicine in our field in developing countries. That was, to me, the most fulfilling part of my career. I must say, making that three-dimensional time-dose-volume model was wonderful, the development of after-loading using Henschke's ideas, but those are not original. And the isocentric treatment of the brain, the multiplanar approach, which now, of course, is the big thing, I think, in radiotherapy because the technology has come along.
Question: Before we close, I want to convey to you Len Prosnitz's best wishes.
Dr. von Essen: Another resident at Yale. We had, I think, a stellar cast of residents, of trainees who came out of Yale and, thanks to Kligerman's dynamic leadership, I was privileged to work with him and work with you in those years. Those were wonderful times.
Question: Thank you.
Question: Carl, we very much appreciate your time and having our memories refreshed about some of the very fascinating things you've done and also the valuable contributions you've made to our specialty.
Question: So on behalf of the History Committee, again, I join Herman in thanking you for giving us the time for this interview and providing us with this very interesting account of your professional experience and the contributions that you have made to our specialty.
Dr. von Essen: Well, thank you both for your interest and for conducting this interview with me. I'm very flattered, indeed, to be selected and I hope my words might be of use to future generations.
A new biography of Henry Kaplan, “Henry Kaplan and the Story of Hodgkin’s Disease,” by Charlotte Jacobs, Stanford University Press, 2010, gives a comprehensive view of Henry Kaplan. In fact, he was formally offered the professorship and chairmanship of Radiology at Stanford just before his 30th birthday. Whether or not he was the youngest at Stanford to receive such an honor is not stated, but I heard somewhere that that was correct.
Von Essen`, C.F. et al Sequential chemotherapy and radiation therapy of buccal mucosa carcinoma in South India. Am. J. Roentgenology, Radium Therapy and Nuclear Medicine, v 52, March, 1968.
