by David Hussey, MD, FASTRO, and Gustavo Montana, MD, FASTRO
This conversation with Chu Chang, MD, FASTRO, David Hussey, MD, FASTRO, and Gustavo Montana, MD, FASTRO, took place on September 21, 2008, during ASTRO’s 50th Annual Meeting in Boston.
Question: I am Dave Hussey. I'm chairman of the ASTRO History Committee, and I'm here with Gus Montana, a member of the ASTRO History Committee. It's September 21, 2008. We're here in Boston on the occasion of the 50th anniversary of ASTRO. We have with us today a number of founders who were present at the first ASTRO meeting back in 1958. And one of those who we would now like to interview is Chu Chang, MD, FASTRO. He's here with his son, Eric Chang, and with that I think we can get started. Dr. Chang, this is a very low-pressure interview. We're just interested in your history, where you were born, how you got interested in medicine, how you specifically got interested in radiation oncology and then just your experiences with the field during your career.
Dr. Chang: I was born the son of a physician in China in the province of Fujian on the southeast coast of China. My interest in cancer stems from my strong desire to relieve human suffering and from when I was attending St. John’s University Medical School in Shanghai, an American-sponsored missionary university. The American missionary influence in China was much greater than the influence of the British or other European countries like Germany and France. There were four or five powers, including the Americans, the British, Germany and France. Those missions started in China and in Shanghai they would try to educate the Chinese population by attracting them to different kinds of missions from Europe. But the American mission was always a little bit ahead of them, so we came to American missionary school. Obviously we were thinking about going to the United States for further study in cancer treatment if we decided to go abroad. This is the reason I came to the United States.
Question: Dr. Chang, when did you come to the United States? About what year did you finish medical school?
Dr. Chang: Oh, I finished my medical school studies at St. John’s University in 1944. That was one year before World War II concluded.
Question: Right, the end of the World War. And did you come to the United States directly from China?
Dr. Chang: Yes, I came directly to the United States from Shanghai, China on a fellowship award offered by the Donner Foundation in Philadelphia, which advertised and offered a fellowship to come to the United States for further study of medicine, particularly the missionary type of medicine.
Question: And where did you take your fellowship in the United States?
Dr. Chang: I joined the University of California, San Francisco School of Medicine as a research fellow in September 1947 and was registered as a research fellow in Medicine until June 1948. My training was under the direction of Professor William J. Kerr, who was then the chairman of the department of edicine at the time. I then served as a research fellow in radiology from July 1, 1948 to September 1949 under the direction of professor Robert S. Stone, MD, who was chairman, department of Radiology at that time, served on the Manhattan Project throughout the war years as the physician-in-charge in Los Alamos and directed research funding from the Atomic Energy Commission.
Question: OK, but you went on to New York then. How did you get there?
Dr. Chang: Oh, I see. That's because the people trained in Columbia returned to San Francisco, and they recommended that I go there.
Question: So when did you go then to Columbia? What year?
Dr. Chang: I started at Columbia as an associate professor of radiology in 1962. But that was years later. Before that, I spent one year as a resident in Jersey City Medical Center from 1949-1950. Then I served as a research fellow in the Yale University Anatomy Department from 1950-1951 and became an instructor at Yale from 1951-54 and an assistant professor from 1954-1962.
Question: I'm sorry, your name has always been very familiar to me or was familiar when I went to Yale for training. I believe you had already left Yale. Do remember Dr. Kligerman?
Question: At Yale.
Dr. Chang: Oh, Kligerman was later in my history.
Question: OK. You were at Yale before Kligerman went there?
Dr. Chang: Oh, much before.
Question: Much before, OK.
Dr. Chang: From 1950 to 1951, I had a fellowship from a children’s foundation and another foundation, the Anna Fuller Fund Award.
Question: The fellowships, were they in radiation therapy?
Dr. Chang: This fellowship was for pure virus and anatomical research. So it's a pure basic science research.
Question: So the fellowships were in basic science?
Dr. Chang: Yes, I got a basic science fellowship from 1950-51. And that fellowship year I was stationed in Yale but was funded by another foundation. And that year my work, what I had done, was essentially following the work of Henry Kaplan, who spent one year at this Yale-connected research. So I followed Henry Kaplan's style of doing research in radiation and anatomical study of mice. The mice studies were started there in that year, but Henry Kaplan started it two or three years ahead of me using a small colony of highly inbred mice sensitive to the induction of thymic lymphomas. In that year he returned to California to Stanford. They invited him to Stanford. And prior to Stanford I think he spent two or three years at the NIH.
Question: So Henry Kaplan was at Yale? Is that right?
Question: Yes. He was in the department of Radiology at Yale, and from Yale and the National Cancer Institute, he went to Stanford to be the head of the Radiology department, and at a very early age.
Question: So, Dr. Chang, were you in the department of radiology at Yale when Dr. Kaplan was there? Was that the department of radiology?
Dr. Chang: I had an appointment in the department of Anatomy and worked in the department of Radiology.
Question: So it was the department of anatomy but you worked with radiology?
Dr. Chang: Like Henry Kaplan did.
Question: OK, but was Kaplan at Yale at that time?
Dr. Chang: Henry was at Yale for two or three years earlier. When Henry Kaplan left, they had this vacancy for me, so I began doing the mouse irradiation experiments. I followed Henry Kaplan's protocol.
Question: So you stayed at Yale following Henry Kaplan's departure?
Dr. Chang: Yale and this foundation. Yale is in the same location.
Question: So when did you go from Yale to Columbia?
Dr. Chang: Oh, for a long time. I stayed at Yale for 12 years from 1950-1962 as a research fellow, instructor and assistant professor before Kligerman came. I served as chief, section of radiotherapy, Yale-New Haven Hospital, 1954-1962, before I left.
Question: Then you went to Columbia?
Dr. Chang: Yes, I was invited to come down to the Columbia University School of Medicine in 1962 as an associate professor of radiology. I rose to the rank of professor of radiology from 1967-1987. One of my more significant administrative accomplishments was that I lead the effort over many years, with the help of my good friend Eric Hall, towards convincing the dean of the College of Physicians and Surgeons and the Columbia Presbyterian Hospital administration to allow the transformation of the division of radiation oncology, which was previously under the department of Radiology, into a separate independent department in its own right, giving it the stature it deserves. I was the director, department of Radiotherapy, Columbia University Presbyterian Hospital, from 1970-86. And I became Professor Emeritus in 1987 and served as Acting Chairman, department of radiation oncology, Columbia University, 1989-1992 and was chairman, radiotherapy division of the New York Roentgen Society, in 1974.
Question: Your name has always been associated with the treatment of brain tumors.
Dr. Chang: Oh yes, brain tumors. In 1973-1982, I had served as principal investigator for RTOG subgrants. And from 1974-80, I served as chairman, Protocol Design Committee on Brain and Eye, RTOG.My primary research interests were threefold. The first focused on tumor blood supply and the effect of radiation on angiogenesis.It has been postulated that if one can shut down all blood supply to a tumor, it will eventually die due to hypoxia and starvation. In the mid-1950s, my colleagues and I, in the Anatomy department, developed a microangiographic technique for visualization of early blood vessel development in a chemically induced tumor in mice [Yale J of Biology and Medicine, 33:451-59, 1961]. The second focused on tumor cell hypoxia. In the early 1950s, British investigators found that tumor resistance to irradiation is largely due to tumor cell hypoxia secondary to tumor necrosis. To overcome tumor hypoxia, an experimental hyperbaric oxygen chamber was first developed in England for clinical use. We conducted a randomized clinical trial for patients with malignant glioma over a period of six years. This clinical trial was considered the best model for future study [Chang, CH: National Cancer Institute Monograph 46:163-169, 1977]. The third was brain tumor staging. The development of a brain tumor staging system is essential for early clinical diagnosis, treatment and improved survival result, particularly for radioorchemosensitive brain tumors in children. In the early 1960s at the Columbia Presbyterian Medical Center, now known as the New York-Presbyterian Hospital, I pioneered the design of a tumor staging system for medulloblastoma, a pediatric tumor which was sensitive to radiation. As a result of this new staging system, medulloblastoma was diagnosed at an earlier stage, treated more rationally to include potential field of involvement and with adequate doses of radiation, a dramatic improvement of five-year survival from 15 percent to 50 percent was achieved at the time to about 80 percent today. This staging system was subsequently known as Chang’s classification for medulloblastoma [Radiology 93:1351-1359, 1969] and is still in use today.
Question: When and where did you train in clinical radiotherapy?
Dr. Chang: That was at Yale.
Question: At Yale, OK.
Dr. Chang: At Yale I stayed for 12 years. The first year I was a research fellow and was completely dedicated to doing mouse work. The second year I started as a clinical instructor in radiology. At that time I started the brain tumor studies.
Question: Was your clinical training in general radiology or only radiation oncology?
Dr. Chang: I didn't have any training in general radiology. Just following that one year of animal work; irradiating mice to produce different kinds of tumors—breast tumors, brain tumors and pituitary tumors—all these things.
Question: But did you have training in general radiology?
Question: Reading X-rays?
Dr. Chang: No, the whole year was animal work.
Question: But later on?
Dr. Chang: The second year they gave me some clinical work in human diseases.
Question: Treatment of patients with radiation?
Dr. Chang: Yes. And my title changed to instructor in Radiology at Yale.
Question: You were ahead of your time, because at that time I think many people trained in general radiology. I did, for example, but you trained specially in radiation oncology … .
Dr. Chang: I had training in human brain tumors and human tumors of many other kinds. Yeah.
Question: Did you take the boards? The board examinations?
Dr. Chang: No, not until two years later. I was still in the department of Radiology and I followed the procedures of the department of Radiology, and I waited to take the Boards as they considered me as if I were still a radiation oncology resident, so I waited until I could take the examination for therapeutic radiology at that time.
Question: And what year was that?
Dr. Chang: I successfully passed the American Board of Radiology examinations in 1953. It was a mix-up, a little bit. Not a pure radiology residency. It was part being an instructor and part residency.
Question: So you were a member of the faculty in the radiology department, but you were doing radiation oncology residency?
Dr. Chang: I was considered an instructor. On the other hand, I was not formally put on the residency program, but I got to look like a resident.
Question: There are actually quite a few people who have had that same history of being on a faculty and a university situation and also get in dual training at boards. For example, I think Rodney Withers, that happened fairly recently, and others. So that wasn't that unusual. Can you recall anything about the practice of radiotherapy in the early years that would be of interest to us on the History Committee?
Dr. Chang: I worked for a few years in the department of Radiology at the University of California, San Francisco, where Robert Stone, MD, who was in charge of radiation safety aspects of the Manhattan Project, was chair of the department. When he retired from the Project and came back to California, he took me on and said, “You now belong to the radiology department and not to the Medicine department anymore.” So he took me into radiology, and at the time we had no divisions of diagnostic or therapeutic radiology.
Question: Do you remember what type of equipment you worked with in your earlier years?
Dr. Chang: In 30 years, at that time it was the 200kV X-ray machine, and then another one was, you remember, the California special so-called high-voltage radiotherapy machine. We have two machines. One is the regular orthovoltage X-ray machine; I think it was 200kV, Westinghouse, something like that. The other one was the University of California, so-called Berkeley; they developed their own supervoltage 600kV machine, which was the first such supervoltage machine in the United States.
Question: Must have been a resonance transformer.
Question: Did you yourself have to give the treatments when you started in radiotherapy, or did you have people that were trained to do that?
Dr. Chang: In treatment?
Dr. Chang: Well, once you get into the residency, you could do treatment.
Question: But did you administer the radiation or did the technician?
Dr. Chang: Technician. I gave or wrote the order.
Question: You mentioned the name Robert Stone earlier. Did you have any contact at all with neutron therapy that he was known for?
Dr. Chang: Oh, no. With Dr. Stone I did not have any neutron experience like that. At that time, Dr. Stone had another associate who came from Europe, B.V.A Low-Beer, MD, a Czech radiologist. He was a very good radiation oncologist. He was in charge of day-to-day therapy operations. Stone was in charge of administration. He was the dead chairman of a department, so he oversees diagnosis and therapy.
Dr. Chang: And Dr. Low-Beer was very good in radioisotopes, particularly good in P32, phosphorous 32. So he popularized P32 treatment, to give superficial radiation.
Question: Oh, with the P32? Was that an applied solution? Let me ask you a question. Did you use a lot of radium interstitial intracavitary?
Dr. Chang: Oh, not too much. No, I used radioisotopes, P32 mostly. Phosphorous 32, which could be made into many points to treat superficial skin cancers.
Question: Put it on like a paste?
Dr. Chang: Yeah, tape on for 48 hours, for 52 hours. A book was published on that.
Question: This is for skin cancers then.
Dr. Chang: Yes, by Dr. Low-Beer.
Question: You have seen a lot of changes in the field. What are the things that you think have been the most important changes in our field?
Dr. Chang: Oh, yeah. I did see a lot of changes.
Question: What do you feel is the most important change in the field?
Dr. Chang: The most important change probably is our concept about radiation protection, personal exposure to all the superficial radioisotopes to a 600kV X-ray. Those are the changes. Other time the cobalt has now been used. At MD Anderson in 1952, they started using radio cobalt treatment patients. At the time, California had not yet started.
Question: I guess the one remaining question that I would like to ask you, probably you have some other questions, but what do you recall of the early years of ASTRO? When did you first get involved in either the club that Juan del Regato, MD, had assembled in 1955 or the early years that you can remember of ASTRO?
Question: What do you remember of the early years of ASTRO? When did you join the club formed by Dr. del Regato?
Dr. Chang: In 1950 … 1949 or 1950, del Regato came to many radiology departments to talk with the residents, residents of radiology, they could do both diagnostic and therapeutic, and a resident can take both diagnostic radiology and therapeutic radiology. And in 1949, I was allowed to take the therapeutic radiology, and I passed it.
Question: The field has changed a lot since the days when you began. Is there something that you would like to say to us, to the Society or to the young people in radiotherapy that you would like for us to keep in mind as a lesson or something that we ought to sort of think about as the years … as we face the future?
Dr. Chang: I think, in my time, the treatment in diagnostic and therapeutic was less separated, almost they could do both, and if a resident finished in three years, they could take complete Boards, diagnostic and therapeutic, but therapeutic was much easier for that. So I think the . . . from that year on, 1949 or 1950, they're more strict, on diagnosis and therapy, they have put more weight on the therapeutic radiology. In previous years it was easier to pass the therapeutic radiology. The emphasis was on diagnostic. So I still was a stepchild in a sense, as the world regarded, and nobody hired a therapeutic radiologist for people to run the therapy. There was no separate department outside the University of California.
Question: I have one more question. Let's see if there's something that you remember that gave you the most satisfaction in your professional life that you enjoyed the most or that you … .
Question: I think, Dr. Chang, this has been a wonderful interview, and we've learned a lot. I think those are all the questions that Dr. Montana and I have. Is there anything that you want to tell us?
Dr. Chang: Well, I think the Board of Radiology talk was a very correct one. They had to be very strict on diagnosis and therapy for three years, and that improved in training. So they have diagnostic; at that time there was a professor of radiology of diagnosis, two or three associate professors, and one assistant professor of diagnostic radiology. And they had only one Dr. Low-Beer, it was a proper structure of therapeutic radiology. They still spent more money on the department of diagnostic than therapeutic radiology. Also, primarily, I was trained as a clinician, and I love patient care. I found that compassion, competence and easy accessibility are the qualities most patients expect in a good doctor.
Question: OK, well, I think that concludes it. Don't you?
Question: Wonderful interview. Great. Thank you.
Dr. Chang: You're welcome.
Question: It's nice to hear your history. It's very important for the Society.
Dr. Chang: It's been an interesting journey.
Question: On behalf of the committee, the History Committee of the Society and on behalf of the Society, I want to thank you very much for taking the time to come to this meeting, for being available to sign the book and for giving us the time to interview you.
Dr. Chang: Another thought, I requested my son to come today. My son Eric Chang.
Question: I'm glad he did.
Dr. Chang: He is now an associate professor of radiation oncology at MD Anderson.
Dr. Chang: And he is the second generation of radiation oncologists from a straight line of mine.
Question: I think that's wonderful.
Dr. Chang: He is doing well at MD Anderson in therapeutic radiology, and he has published over 50 articles on his recent CNS research, mostly in therapeutic radiology.
Question: We're going to be interviewing him for the 100-year anniversary.
Question: You have made the most important and lasting contribution to the field by giving our specialty your son. Thank you.
Dr. Chang: Thank you very much for this opportunity to present myself and my son. Thank you.
Question: Thank you very much.