Question: The date is the 12 of June of 2012, and this is Chris Rose. Dave Larson and I will be interviewing Dave Hussey. For the record, Drs. Rose, Hussey and Larson were ASTRO presidents beginning in 1998, 1999 and 2000, respectively. Are you all set, Dave?
Dr. Hussey: All set.
Question: Well, this is going to be a lot of fun. Why don't you start out? Just tell us about where you were born, your early life and so forth.
Dr. Hussey: Okay. I was born and raised in Savanna, Illinois. It's a small town of 5,000, west of Chicago on the Mississippi River, a blue-collar town. The industries were two railroads -- the Burlington Northern and the Milwaukee, and an Army depot. It was a great place to grow up. We didn't ever lock the doors of our house unless we were going on vacation. We left the keys in the car sitting out in front. So it was just a small town. The opportunities were there to participate in all the activities in school. My father was a small-town family doctor. He delivered almost everybody in town, and then he took care of the kids as they grew up. His practice evolved as he grew older with his patients, first concentrating on obstetrics, then on pediatrics, then internal medicine and geriatrics. I used to ride along when he made house calls in the country. He probably is the reason why I went into medicine, although that's not what I planned to do originally.
Question: How did your father end up in medicine? Do you have any idea?
Dr. Hussey: Good question. I don't know. He grew up in a small town in central Illinois, and his father had a lumber company. He went to Northwestern and went on to medical school there. I have an older brother and a younger sister. My older brother was a better athlete than I was, but I was a better student. My sister was the extrovert in the family. My brother ended up being a transplant surgeon -- kidney transplants -- my sister a librarian.
Question: So, Dave, what do you remember about tagging along with your father when he made his house calls, and did that make an impression on you?
Dr. Hussey: Yes, certainly, although I mainly just sat in the car, so I didn't participate much in that until I got to medical school. I remember when I was in medical school I went along once, when he got called, when he was called on an emergency in which a man had a flail chest because of rib fractures following an auto accident, and I made the suggestion on how to prevent the chest wall from sucking in on inspiration by clamping the ribs with a hemostat and attaching it to weights and pulleys. Later on, when I was being interviewed for an internship, I was asked the same question by a thoracic surgeon. I told him the same story. I guess he was satisfied with my answer, because I was offered an internship. But, no, I don't remember a whole lot. I do remember painting his office building one summer, and somebody was brought into his office with a massive myocardial infarction. He couldn’t be resuscitated. It upset me and I ended up stopping painting for the day. That was when I was in high school.
You asked about my early education. I went to the public schools. They were good as far as learning basics, but didn't offer some of the opportunities you commonly get in the big city schools. But they did offer something that you can’t get in the big city schools, and that was opportunity for most everybody to participate in school activities, whether it is sports, the high school plays, the band, etc. My kids went to excellent schools, but I think they didn’t get some of the opportunities I got by going to a small town school.
Another advantage I had was the opportunity to work in the summer. I had a summer job every year, usually doing labor, of some sort. One time I was laying tracks on the railroad, and another time it was testing for gas leaks in the gas system for the utility company, and another time delivering coal and lumber. Otherwise, I spent the summers on the river, on the Mississippi River, usually water skiing or fishing. It was a good life. Savanna is a very blue-collar town, but a lot of people in my class went on to college and some of them have done very well.
One person in the class a year ahead of me became president of Mazda, and then when he retired there he became president of Hyundai. Another was president of Hitachi. So there were some who excelled. There were a few other physicians and a few college professors. Not everyone has prospered, but some have done very well. There was a strong work ethic, and everyone had a desire to get ahead.
But the town hasn't prospered. The railroads have cut back and the ordinance depot has closed completely. There is one new industry and that is a prison that was built just south of town. That is the one that's scheduled to take the Guantanamo prisoners. When you hear about it on the news, they'll usually refer to it as being the Thomson, Illinois, prison, but that's because the prison is located two miles from Thomson, but it’s four miles from Savanna.
Question: Dave, I'm really struck by the fact that this was a very small town, 5,000 people, and yet you say that there was a lot of accomplishment. Was there something about the community? I mean, you said there was a work ethic and it was blue-collar. Was there something else about a sense of community that caused people like you and your brother and these other folks to really want to do something special, something important, to serve?
Dr. Hussey: Well, I'm sure it was the family tradition for my brother and me, but I’m not sure about the rest of the town. There were some very charismatic teachers there. There was an English teacher who was particularly strong who convinced a lot of people to go to college who probably wouldn't have otherwise. A good friend of mine whose father worked on the railroad section gang all his life was encouraged by that teacher to go on to college and he's done very well. That's part of it. And I think there is a strong work ethic in the Midwest.
Question: Do you maintain contact with some of the kids that you grew up with and went to high school with, for example?
Dr. Hussey: Yes I do. I didn't maintain contact with anybody from college but I have maintained contact with quite a few high school classmates and friends from my medical school and my residency.
Question: How many people were in your high school graduation class?
Dr. Hussey: Sixty-three.
Question: And were you the only physician or were there others?
Dr. Hussey: One other became a physician and he just retired recently. He was in general practice. He worked in Chicago for most of the time he was practicing and then went back to a town just about 15 miles from where I grew up. He retired there and had a small practice.
Question: Who were your role models?
Dr. Hussey: Well, I guess my father and my brother. My father is probably the reason why I went into medicine because that's what he did. My brother was a better athlete than I was and that's probably the reason why I stayed in sports, even though I wasn't very athletic. And then my freshman algebra teacher and my football coach all were role models for me at that time. When I graduated in 1955, I went to Northwestern. My father, as I said, had gone to Northwestern. My brother was at Northwestern at that time. I was planning to become a chemical engineer when I started college, so I entered the engineering school.
Question: Do you recall the reason you wanted to be a chemical engineer?
Dr. Hussey: Oh, I don't know – maybe experiences in high school chemistry. My chemistry teacher had ties with some people from my hometown who had explored for uranium in Wyoming. One time she had them come to the school to test the ore samples to determine how much uranium it contained. They offered me a job that summer going to Wyoming to assay their ore samples on site. I didn’t take that offer, probably because I wasn’t ready to move away from home. I was a junior in high school then. Anyway, I didn't really settle on a career for a long period of time, as you'll learn soon.
Question: Dave, when you went to Northwestern, you went from a small town to the big city life. Was there some sort of recognition that you were going to be spending a lot of your life in big cities from now on, most likely?
Dr. Hussey: I didn't think about that, actually, because I hadn’t decided on a career. When I first went to medical school, I had actually planned to go into pediatrics and come back to a small town practice like my dad did. But you’re right. I did get overwhelmed a bit by Northwestern. I didn't stay there very long. It seemed too big for me. I might mention that one of my brother's best friends at Northwestern was a guy who later became a radiation oncologist. He grew up in a town about 30 miles away from Savanna, and that's Al Schroeder, maybe you know him?
Dr. Hussey: He practiced at Santa Rosa for a long time?
Dr. Hussey: And as it turned out, I kind of followed him. I wouldn't say that he was my role model, but he went to medical school at Iowa and took a general radiology residency there, and then, later on, limited his practice to radiation oncology.
Anyway, after Northwestern, then I transferred to Beloit College in
southern Wisconsin and I changed my major to physics, but I also took all the pre-med requirements just to keep my options open. I initially planned to get a PhD, so I applied to graduate school in physics. I entered graduate school in biophysics at Johns Hopkins the following fall, which would have been 1959. I was at the Homewood Campus there near Pimlico where they just had the Preakness a couple of weeks ago, and it was also very near the Baltimore Colts football stadium. But I changed my mind after a year there and decided to go to medical school. I obviously had not yet settled on a career and I really never did settle on one until I was halfway through my residency. So I started medical school at Washington University in St. Louis in 1960, and I graduated in 1964. My most important role models at Wash U included the Chairman of Surgery, Carl Moyers, who spent a lot of his time teaching (I don't know as he ever did much surgery because he was always teaching medical students or residents) and Tom Brittingham who was head of internal medicine at St. Louis City Hospital. Brittingham was the kind of professor who was both loved and feared by the students -- everybody was worried about getting stuck having to present to him. He raked me over the coals when I was the first one to present a case to him my junior year. I remember after I presented he asked me how long I stayed up the night before. I told him 3:00 in the morning. He seemed satisfied, at least with the effort.
Question: David, take a minute, any observations about how medical school in the '60s might be different from medical school today, 50 years later?
Dr. Hussey: Oh, gee, I’ll have to think about that.
Question: Is it structured about the same?
Dr. Hussey: I think it’s probably somewhat different. We had two people to a cadaver and I don't think that you have only two people per cadaver today. I think it's usually four or maybe even six persons to a cadaver today. So we had plenty of specimens to work with there. Wash U in general, even at that time, was pretty research oriented. And the other medical schools I’ve been involved with – in Houston and Iowa -- I think they are more practice oriented and not so much research oriented. Other than that, I don't know, Dave. I mean, we had the usual pre-clinical years -- two years pre-clinical and then we got involved in clinical medicine in the junior year for the most part, at that time. I think we had the usual rotations, but I haven't thought that one through completely yet.
Question: So what were the fields of medicine that attracted you in different ways?
Dr. Hussey: At that time I was planning to go into pediatrics. That was until I took pediatrics --I rotated on pediatrics in my junior year. And then I learned very quickly that sick kids aren't much fun to be with. And their parents are even less fun to be with. That's when I decided that I didn't want to become a pediatrician.
Question: Dave, do you think that your initial choice of a career in pediatrics somehow went back to what you remembered of your father’s experience as a general practitioner, but that there was some fundamental difference between the children that he saw in the home versus the very sick children in the hospital?
Dr. Hussey: Well, I doubt if there was much difference. He saw most of his patients -- the kids in his office. You know, I went on house calls with him but that was not entirely it. Then I don't know -- it was probably just that I didn't appreciate that sick kids are whiny and they can't give you a history, so I just wasn't that happy with it when I actually got to doing it.
Then I decided that I probably would become a radiologist -- but at that time I thought I would become a diagnostic radiologist. I had rotated, had some contact with radiology in my clinical rotations. I took a rotation in radiology at Wash U in my junior year. Bill Powers was still there and Carlos Perez had just returned from a fellowship at Anderson when I was there. That was in November of 1963, the month that John Kennedy was assassinated. That's why I remember the exact month. They say everyone remembers where they were when John Kennedy was killed.
And so then I decided I would go into radiology, but I took a rotating internship, which is what most people did at that time. Straight internships were just becoming fashionable. I was in the match, and I matched with Iowa and I went and I took my internship there. I might mention at this point that Jerry Hanks was a few years ahead of me at Wash U, John Munzenrider was in my class at Wash U, and Jim Marks was a year behind me. Ron Evans who was chair of radiology at Wash U was the valedictorian of my medical school class, a very bright guy, and a much nicer person than his reputation is today. I later learned that St. Louis played a major role in the development of radiology in the United States back in the early 1900s, but I didn't I know that at that time.
I started a three-year residency at Iowa in 1965 after I finished the internship in '64. The residency involved two years of diagnostic radiology training and one year of radiotherapy. The term radiation oncology hadn't been coined yet. But during the first year of my residency, the Chairman of Radiology, Gene Van Epps had a blowup with the dean, and was relieved of his chairmanship. The rest of my residency was spent with the search committee trying to find a new chairman of radiology. In the meantime, Howard Latourette who was head of radiation oncology became the acting chair of the department.
Iowa is a funny place because at Iowa the policy was to have the residents interview all the candidates for chair. We interviewed the people who were consultants advising the search committee and then all the candidates, and we really raked the candidates over the coals. I'm surprised anybody took that job because of the residents who were all pretty bitter.
Question: How many residents were in the group?
Dr. Hussey: Oh, we must have had, I guess, 14 or 15 residents total -- two-thirds of them were doing diagnosis and one-third were doing therapy.
Question: What were they bitter about?
Dr. Hussey: Bitter is probably not the right word. But, they were bitter because their residency was disrupted and they had the turmoil of a chairman search for their entire residency. It was very much a resident run hospital at that particular time. Now there is a difference, David. The hospital at Iowa at that time was very resident run. The residents ran everything and there was very little supervision from the faculty. This was true in all of the departments but, I guess, particularly in radiology because the chairman had left. There were other faculty, I mean, they were good faculty that stayed, but still -- most of the films were read by residents, often with supervision, but not always. And then in therapy, the residents managed most of the patients. Dr. Latourette would know which resident was seeing this patient with lung cancer or that patient with cervix cancer and offered a few comments, but didn't do a lot of supervising of the actual patient care. This was completely different than it was when I got to Anderson where there was a lot of supervision by multiple faculty members.
Question: So your residency was a combined residency program-- you took rotations in diagnostic radiology and radiation oncology. At what point did you decide which direction you were going?
Dr. Hussey: I made the decision towards the end of the residency. It was a mixed program, of course. You might rotate on radiation oncology probably about two-thirds of the way through, so I went for maybe 15 or 16 months doing diagnostic radiology and then I rotated for 12 months on radiation therapy and then came back and did diagnosis for another 4 to 6 months, something like that.
Question: Were residents expected to do any kind of research work during their residency?
Dr. Hussey: No. Not at Iowa. No, we didn't do any research at that time. We did later when I went back to Iowa, but that was because I required it.
Question: So what tipped you to say, “I want to be a radiation oncologist rather than a diagnostic radiologist?”
Dr. Hussey: A fair number of residents decided to practice straight radiotherapy. I think a lot of it was mainly because the diagnostic radiology training was so disrupted at that time. But it was partly because Dr. Latourette was very charismatic. Everybody liked Howard Latourette. And there were, I guess, five or six people who ended up doing straight radiotherapy out of my group of 14-15 residents.
So anyway, at the end, then, I told Dr. Latourette that I wanted to go into therapy in the spring of 1968, the final year of my general radiology residency. And he said that I should go on for further training at one of three places: Stanford, Anderson or Princess Margaret. This was in March of the final year of my residency. I wanted to start in July.
Question: Further training?
Dr. Hussey: Yes.
Question: This would have been in 1968, I guess.
Dr. Hussey: That's right, yes.
Question: So do you think that Dr. Latourette’s identification of those places in 1968 was a general recognition what those were the places that one went to get a fellowship after taking a mixed residency? What about Michigan? Hopkins? What is your memory of what were the preferred radiotherapy training programs at the time?
Dr. Hussey: I think Penrose and del Regato were highly thought of at that time. But there weren’t a lot of the places that had gained much prominence in radiation oncology in the mid-1960s. But, of course in a very short period of time, all of that would change. There would be a tremendous proliferation of good training programs in radiation oncology that would include all the Boston places and Florida. Maybe I’m biased, but I think Dr. Latourette’s list was probably pretty good for 1968. Of course, a lot of people interested in academic careers in radiation oncology at that time went to Europe for further training (France, England or Sweden).
Question: So really those three places plus Penrose Springs, Colorado were the only places where many of the leaders of radiotherapy were coming from?
Dr. Hussey: I don't know. Remember I was just a resident entering the field. I don’t think Lampe was very active in Michigan at that time. He may have been retired. Michigan is where Latourette trained. Buschke, I guess, had been doing something in Seattle. So I was just going on Dr. Latourette’s opinion these wore the ones he recommended -- and it may be that those were the people that he had contact with.
So anyway, he made arrangements for me to go out to Stanford. So I flew out there. I was very naive, didn't realize that Stanford was not very close to San Francisco. So I took the bus, I remember, from the airport to Palo Alto to interview at Stanford and I got there late. Malcolm Bagshaw was leaving at about the time I got there and he turned me over to Scotte Doggett. Scotte showed me around and had me see Saul Rosenberg. They didn't really have any straight radiotherapy residency openings anyway. So they had me talk to Rosenberg -- they suggested some sort of medical oncology/radiation oncology rotation that I never really quite understood.
Anyway, the following week, then, I went down to Anderson, and I was treated royally there. Norah Tapley who was head of the training program, she took me to lunch, and Herman Suit took me out to dinner at a big expensive high-rise restaurant in Houston. So I signed up at MDAH. And I showed up there the following July to start a residency/fellowship It was a one year fellowship at the time. A year later, they would only accept people if they were willing to stay for two years. I was there for one year, and then I went on the faculty at MD Anderson.
Question: Were you the only fellow, or were there others?
Dr. Hussey: Most of the people were fellows there. There weren't too many that were just residents. But the responsibilities of residents and fellows were the same. We had one resident out of the whole group that year -- we had 18 resident/fellows at Anderson at that time and most of those were fellows who'd had some training somewhere else.
Question: Dave, during your residency before the fellowship, how many of the -- how much time of the three years were spent doing radiation oncology?
Dr. Hussey: A little less than one year in radiation oncology in my general radiology residency at Iowa. I think that was pretty typical. It would be about 11 months.
Question: And then 12 months at the Anderson? I'm thinking about that you would have had approximately two years of exposure to oncologic situations and then went on the faculty at the Anderson, it must have been tremendously difficult and challenging.
Dr. Hussey: Yes, it was about two years, but remember, at Anderson, there was a lot of supervision -- we'll get on to that in a minute -- and so you were not out there hanging in the breeze by yourself. There was a lot of support from other faculty, and a lot of review of patients I was actually treating.
Question: So at MD Anderson -- when you went there as a fellow, and most of the people were fellows and not residents -- does that mean they didn't have a residency? Were they mainly training people in radiation oncology who had been previously general radiologists as you had been trained when you went there as a fellow?
Dr. Hussey: Most of the people that were there at Anderson at that time had been trained as general radiologists and then wanted to go back and do therapy. So my situation was similar to most of the other people that were there. George Brown came from the Mayo Clinic where he had a general radiology residency. I happened to meet him the first time when we both took the written boards in Chicago before either of us went to Anderson. Jim Slater was also someone who was in my group of fellows who had a full radiology residency before coming to MD Anderson for a fellowship. This was about the time when radiology was changing from combined diagnostic and therapy to straight residencies in either therapy or diagnosis. Most people at my time and before my time trained in general radiology and then devoted their practice to just therapy. Some of those went abroad for further training. For example, Al Schroeder, whom we've talked about, trained in general radiology and I think he stayed on the staff for maybe six months or something like that. Then he got drafted in the war and went off to Vietnam. And that disrupted his practice. Then he came back and ended up in California. A lot of others did that same sort of thing at that time. And so of the 18 resident/fellows that we had at that time -- and they were kind of considered interchangeable at that time -- there was only one who was a straight radiotherapy resident at that time. Jimmy King was the only resident in straight radiation oncology. The rest were -- had some sort of a mixture in diagnosis and therapy.
Five years later it was just the reverse. Everybody was trained as a straight radiation oncologist or a diagnostic radiologist, and very few were trained in general radiology with mixtures of therapy and diagnosis. I remember at that particular time they said that the people who trained in mixed programs actually did better on the boards than those who trained in either straight therapy or straight diagnosis. Of course, that's also reversed now. Most of the people are trained in straight residencies -- either diagnosis or therapy.
Question: Tell us about the faculty.
Dr. Hussey: Okay. We had 18 residents and fellows at that time, only one of which was straight radiotherapy. The faculty included Fletcher; Herman Suit who was head of experimental radiotherapy; Eleanor Montague was there when I arrived but she left during that first year that I was at Anderson to go to Methodist Hospital which is just across the street, in the Texas Medical Center. That was because it gave her more time to raise her children, she came back four or five years later. Others included Bob Lindberg; Max Boone who had ankylosing spondylitis; Norah Tapley; Joe Castro; Fred Durance, but he left to go on to private practice in Houston within a year or two; Lowell Miller; Rod Withers; Luis Delclos but he left for a few years in Spain; Augusto Gutierrez; Lillian Fuller; and Ed Quinlan. Those were the faculty at that time. There were two satellites. Herman Hospital was run by Lowell Miller, and St. Joseph's Hospital, which was run by Augusto Gutierrez.
At Anderson we had six cobalt units, two betatrons, one homemade simulator. We had actually had a better simulator at Iowa, a Siemens simulator at Iowa when I was there. They had just this homemade simulator at Anderson at that time. There was a 300 kVp X-ray machine and a couple hyperbaric oxygen tanks. And then a year later we got the Saggitaire 35 MeV linear accelerator at Anderson. At Iowa we had treated about 80 to 100 patients each day, and when I came to Anderson they were treating -- at Anderson itself -- they were treating 150 to 175 patients each day, which is much less than is being treated there now. They're up in the 300s now, I think. I guess they treated about 30 patients each at Herman and St. Joe's. But that was just a courtesy coverage thing. There wasn't a whole lot of training at the satellites. One resident went to each of those sites, but not a whole lot of time was spent in training at those satellites.
And this is where we get to why I was not out hanging in the breeze with too much responsibility myself. That is because they had an interesting faculty rotation pattern that resulted in a lot of oversight. The entire faculty had double system of rotations with the exception of Fletcher and Norah Tapley who was an amputee and had a leg prosthesis. The entire remaining faculty rotated on all the machines for six-month assignments, and it was their responsibility to actually treat the patients that were being treated on those machines. But the entire faculty also had a research area of interest where they would establish treatment policy and oversee patient treatments (in their area of expertise). The research areas were: Fletcher was mainly interested in head and neck, breast and GYN; Montague was interested in breast; Lowell Miller's was bladder; Bob Lindberg's was head and neck; Herman Suit was sarcomas; Rod Withers GI; Luis Delclos gynecology, brachytherapy implants and various gadgets; Joe Castro was GU other than bladder and he also was involved in pediatric tumors; Lillian Fuller's was lymphomas, Ed Quinlan's was lung and thoracic tumors.
The patients on a machine were usually seen by two faculty members on their weekly evaluation clinic and by the resident assigned to their treatment machine. So a patient with breast cancer might be seen each week by Luis Delclos, if Dr. Delclos happened to be rotating on the cobalt machine that treated breast cancers, Delclos' resident, and Eleanor Montague who was in charge of the breast cancer program. In that situation, Dr. Montague would direct the treatment and decide on any treatment changes, but Delclos and Delclos’ resident would carry them out. Next day a patient with cervix cancer might be seen by Lillian Fuller if she were rotating on the betatron and her resident along with Luis Delclos who was in charge of GYN tumors. So there was a lot of oversight at Anderson.
Question: So each patient each week would be seen by two attendings as I understand it. Would that be on the same day or on different days?
Dr. Hussey: Same day. They would be there together seeing the patient. Together. Now, on other days when something came up with a patient or when the patient actually started and when you planned the treatment and drew the lines on the patients, that would be managed by the person who was in charge of that machine and that person’s resident. So Eleanor Montague wouldn't be in there setting up the breast patient, wouldn't have to be there every day when a new breast case was started. The person in charge of the machine would start it. They would do the initial planning and then she would make modifications when she saw the patient the following Tuesday or whatever day of the week was her clinic day. So there was a lot of oversight and the residents and junior staff didn't feel they were being left out on a limb. I think that the bigger drop-off, when you start feeling alone, is when you go out in practice away from your training program. The time I was given the most responsibility was when I came on the faculty, which occurred for me the following year. I started on the faculty in 1969, and George Brown started at the same time as I did.
When I went on the faculty, I was put in charge of lung and thoracic tumors because Ed Quinlan, who was previously managing those patients, left to go into private practice in Hawaii. And Eleanor Montague left to go to Methodist Hospital and so George Brown then took over the breast area. And then when Delclos left for Spain for a few years, Joe Castro took care of those for a while. So over the years there was some turnover in the staff like you see in many large institutions. Some went into private practice, and some went into other academic programs. Delclos went to Spain for a couple years; Montague to Methodist; Suit to chair the department at Mass General; Max Boone left to chair the department at Wisconsin; Ed Quinlan went into private practice in Hawaii; and George Brown went into private practice in Austin.
At that time a whole bunch of others came on the faculty. These included John Stryker, Bruce Borgelt; Al Nelson; Jess Cadero; Carlos Fernandez; Mario Gonzalez; Len Shukovsky; Bob Langren; Art Hamburger; and Jerry Barker all were people who came on the staff for a while at Anderson. Some of them stayed for many years and some of them left after a few years. The best learning experience, when I learned the most radiotherapy, I think, was during my first few years on the faculty at Anderson. I learned more radiation oncology during those years on the faculty than I did in any of the time I spent as a resident either at Iowa or M D Anderson.
Even when I was a junior faculty member, there was a fair amount of oversight. There was also a lot of interaction with the referring physicians; I spent a lot of time with the head and neck surgeons, the gynecologists, urologists, and a few medical oncologists at that time. Because we had that rotation system, everybody rotated on a different machine every six months; we stayed up on most areas of practice of radiotherapy. Those were some of the best years of my life, those first few years on the faculty at Anderson.
Question: What was a typical Anderson day like? Just take us quickly through a typical day from start to finish.
Dr. Hussey: We started with what was called Planning Clinic at 8 o’clock in the morning every day. All of the new cases other than the gynecology cases and the palliative cases were presented to Dr. Fletcher at that conference. That went for about an hour. And everyone in the whole department was there in what was pretty much a small amphitheater, I mean, everybody was sitting around and Dr. Fletcher was down in front with an examining room chair and equipment for him to examine the patients and there would be a presentation by a resident/fellow, a discussion by faculty members, and a disposition would be made on those patients. They would make an appointment on a machine for each of the patients and decide who would be in charge of their treatment. The gynecology cases were handled in a separate clinic two days a week on Tuesdays and Thursdays. They did the same thing but the gynecological oncologists were also present on those days. But the head and neck surgeons weren't present for the morning planning clinics. This was just the people in the radiotherapy department.
Question: Did residents present cases at that time?
Dr. Hussey: That's right. The residents presented those cases.
Question: And they were grilled?
Dr. Hussey: They were grilled to some extent -- but it was more of a disposition clinic than an educational clinic, which is a little bit different than the way I ran it when I had similar responsibilities at Iowa. There I had it as more of an educational thing where I grilled the residents for education, not to decide how those patients were going to be treated.
Then after Planning Clinic broke up at around 9 o’clock, everyone went off to their various machines where they had patients coming. There would be a certain number of patients that were scheduled to be seen on that machine and then one day a week they would see those patients or maybe there would be two or three categories of patients being treated on a machine, and they would have weekly clinics for each category where the faculty members assigned to that machine, his/her resident, and the faculty member who had special interest in that category would see all of those patients. That effort was called Clinic Day. It wasn’t very efficient, but there was a lot of oversight, and careful records were made which facilitated research efforts.
Then there was usually a teaching conference at noon or later in the afternoon. This is when the residents were grilled more aggressively. There were also various tumor boards, which were attended by radiotherapy faculty members, their residents and the physicians from other departments. Here I'm talking about Anderson. It was a little bit different at Iowa, but very similar otherwise.
Question: Dave, I'm struck by the comment that you made about those first two years being some of the best years of your life in terms of the acquisition of knowledge. At that time, there was Fletcher's textbook and there was very little else. There was no “cookbook” like there was for Dave and me. How did you acquire knowledge? How did you know the ways to treat patients?
Dr. Hussey: It was mainly in hands-on clinics with oversight by several radiation oncology faculty, a clinical conferences with input from surgical oncologists, gynecologists, and medical oncologists, and input input from visiting oncologists from anywhere in the world. (There were always 10-15 visitors in the department). And we also learned a lot from the research projects that were ongoing in the department. Of course we also went to the library to research patients we had under treatment.
There were three books at that time that people looked to. I looked at them for different types of information. There was Moss' book that had a lot of the history of radiation therapy, normal tissue effects of radiation, and some discussion of the literature and different approaches to treatment without much detail. Then there was Fletcher’s book that discussed Anderson techniques in detail. Everyone at Anderson followed it pretty closely. And then there was del Regato’s book that had more epidemiological information and some pathology, but not much else. Those were the three books that were available and radiation therapists of that era used them for different purposes. They kind of complemented one another and that was it -- but, you're right -- there weren't many books.
And there weren’t many journals that dealt with radiation therapy issues -- there was Radiology (the grey journal) and the American Journal of Roentgenology (the yellow journal) and Cancer. And the only two scientific societies were the Radium Society and the RSNA. And I guess the Radiation Research Society. And then, ASTRO started holding independent meetings in the early 1970s and the Red Journal (International Journal of Radiation Oncology•Biology•Physics) came in a year or two later. I have every issue of the Red Journal from the very beginning because I was there at the very beginning.
Question: But when a patient would come in and was a little bit different, how did you and your colleagues figure out what to do? The knowledge base was so much smaller.
Dr. Hussey: But don’t you think the same thing occurs today? Radiation oncology wasn’t settled science then, and it isn’t settled science now. It’s an evolving field that changes every year because the knowledge base changes and new technology becomes available.
I actually think we had a lot more resources available to us at MD Anderson than radiation oncologists elsewhere did. We had a lot of people we could consult. We had 10 to 15 faculty members with a lot of experience, and there was a lot of experience available in other departments. If it were a head and neck case, there was a lot of input from Dick Jesse or Bill McComb, or the other head and neck surgeons as well as Fletcher and Lindberg. So, there was a lot of support there. MD Anderson probably had the largest group of radiation oncologists in the U.S., maybe in the world, at that time. There were similar staff levels in other departments. Remember, I was coming from a much smaller department at Iowa. When I got to Anderson, I felt that I had many more resources that I could draw from than I did when I was at Iowa.
If I were to criticize it, it was probably that it was too inbred -- maybe they looked at things too much as doing it the Anderson way, but a lot of the advances that were made that came out of Anderson at that particular time were not based on randomized studies -- they were based on treating patients in a consistent manner and a frequent analysis of results. The whole concept of subclinical disease came out of those kinds of observations. They would treat patients in a consistent manner and then analyze the results and modify the policy accordingly. They didn't change policy very often -- but they would change it for a reason. They saw recurrences here or there, or they had complications of this sort and they would modify the treatment a little bit. It was done in a very cookbook-ish fashion.
There were relatively few randomized trials. This was about the time that the NSABP study was going on. Fletcher and Montague had criticized previous breast studies for the radiotherapy being inadequate, too low a dose or treating the wrong area or whatever. So when the NSABP trial started up, Bernie Fisher had Eleanor design the radiotherapy technique that was to be used in that study. That was about the time that Eleanor was leaving to go to Methodist Hospital, and so it was left to George Brown. George Brown visited all the participants in the NSABP trial to make sure that they conformed to the protocol, and he went back periodically to oversee that. It's interesting, though, that Anderson didn't really contribute any patients itself to that first study. I think that was because the MDAH surgeons refused to participate. It was about that same time that Fletcher had a big falling out with the surgeons and he complained to Lee Clark, the head of the hospital, that he might as well resign if they're not going to do anything scientific. They threatened to take him up on that.
We also had a random study on the hyperbaric oxygen trial that was going on at that time. The Anderson did participate on the hyperbaric oxygen trial. That was how the Sagittaire linear accelerator got funded. That was bought in order to treat patients in hyperbaric oxygen tanks to see whether irradiating patients under hyper-oxygenated conditions improved the control of locally advanced cancers over the results achieved when just breathing air.
And then a third trial that might be worth mentioning is one initiated by Herman Suit. Dr. Suit carried out a clinical trial to see if giving radiotherapy to extremity sarcomas, either bone sarcomas, osteosarcomas or soft-tissue sarcomas could be improved if you put a tourniquet on and then cranked the dose up high. They randomized patients to receive either with 14,000 rads in 14 fractions over seven weeks with the tourniquet (treating with 1000 rads per day on two consecutive days per week) or 7,000 rads in 35 fractions over seven weeks without the tourniquet. The reason why it was given in only 14 fractions was that they wanted to give it in 2,000 rad fractions but they couldn't get the cobalt machines to stay on for 2,000 rads so they had to give it in two consecutive days. So they gave two doses per week of 1,000 rads each. It turned out to be a negative study because the control group did just as well as the experimental group. However, it did lead to Herman getting the General Motors Prize, the Kettering Prize a number of years later. And it established the role of radiotherapy in the treatment of soft-tissue sarcomas.
Question: So what was the theory behind the tourniquet?
Dr. Hussey: It was to get rid of the differential between the hypoxic cancer cells and the well-oxygenated normal tissue cells by making everything hypoxic. They had to increase the radiation dose by a factor of 2.5 to 3.0, the OER.
Question: So the hope was to make normal tissue as hypoxic as presumably the tumor tissue was.
Dr. Hussey: That’s right. There is one other study that I was involved in that might be worth mentioning. That was the prostate study that was designed by Dr. del Regato for Stage C prostate cancer. The purpose of this randomized trial was to determine whether radiotherapy or hormones was better in the management of stage C prostate cancer. Participants were given a choice of three randomizations. We chose a.) randomizing patients to receive treatment with radiotherapy alone to a dose of 70 Gy in 7 weeks or radiotherapy plus hormones which was 5 milligrams of stilbestrol per day. And we gave the stilbestrol after the completion of radiotherapy so we gave 7000 rads to the prostate and then started stilbestrol or 7000 rads without hormones. Other possible randomization choices were b.) hormones alone versus hormones plus radiotherapy and c.) radiotherapy alone versus hormones alone. And I don't think this study ever showed much, but I was told once that a later analysis showed that the group that got hormones plus radiotherapy did a little better.
Question: Had you transitioned from thoracic to GU.
Dr. Hussey: Yes, I did change my areas of interest.
Question: To GU?
Dr. Hussey: Yes, when Joe Castro left, Fletcher asked me to take on prostate and testis. And when Tom Barkley came on the staff there was another change. Tom Barkley was a thoracic surgeon who went on to train in radiotherapy at Anderson. When he completed his residency and came on the faculty, he took over the lung and thoracic tumor area of interest. And about that time, Max Boone left, and I got involved in neutrons. And that's another story -- I guess the next chapter. Do you want me to go on to that?
Question: Yes, tell us about the neutrons.
Dr. Hussey: Okay. Well, the neutron project at Anderson started about 1970. I came to Anderson in '68, and I was a resident then. Max Boone was there at the time (Ed Quinlan told me once that there were three geniuses in the department. One was Gilbert Fletcher, the second was Herman Suit, and the third was Max Boone). Max was a very bright guy and a very innovative thinker. He had all sorts of ideas. Max was very interested in neutrons at that time, and he had approached Texas A and M about the possibility of using their cyclotron, TAMVEC (Texas A and M Variable Energy Cyclotron), to treat patients with fast neutrons. He asked me to work with him on that project. So he had me come down to visit him when he was on vacation out at the coast with his family in Palacios, Texas, to begin talking about writing a grant for a fast neutron project. That's how I got involved. But like many bright guys, he was going off in all sorts of directions. And he just up and decided he was going to go to the University of Wisconsin as chair of the department. So he left to do that. And soon after he left, Dr. Fletcher approached me about pursuing the neutron therapy project. So I went down to the beach again, but this time to Fletcher's beach house in Surfside, Texas, to write the neutron grant. But we also had to get a commitment from Texas A and M. So then I continued to deal with the Texas A and M people. As it turned out, Texas A and M jumped at the chance to participate. It was a source of support for their cyclotron.
The first time I went to meet with the A and M representatives at College Station, Jim Smathers was there. This was kind of interesting because Jim was two years ahead of me in high school back in Savanna, Illinois. I hadn't seen him in years. I hadn’t realized that he had gone on to become a nuclear engineer, and he didn't realize what I'd done with my life when we met at that particular time. Jim became the main Texas A and M physicist on the neutron project. And he later went on to become head of physics at UCLA. You must know him, Chris?
Question: Yes. I guess he must have he must have been recruited by Bob Parker to start the UCLA neutron project.
Dr. Hussey: Bob asked me about approaching him as a possible candidate for that position. I told him he'd be a great choice. Jim is a great guy.
Question: He was the one who built the UCLA cyclotron. But I can hardly wait to hear this whole story of the MD Anderson cyclotron because I know that you were a commuter -- right? TAMVEC (the Texas A and M Variable Energy Cyclotron) is far away from Houston isn’t it? It’s in College Station, right?
Dr. Hussey: That's right. It’s 100 miles away. And so we would go and take patients up there twice a week. Actually, we had a period where we actually stayed overnight and treated patients for four days a week. But the problem was in getting the access to the cyclotron. The scientists ran the cyclotron. When I say scientists, I don't mean Jim. I meant all the physicists who actually built the cyclotron at Texas A and M and had control over it. We had a few people in the administration of Texas A and M who were our backers, but the other people who actually conducted research with the cyclotron, they weren't all that excited about us being there. That was probably because we didn’t want to play by the same rules they did. We were sharing the machine with them. But we needed to keep a regular treatment schedule, and when the machine broke down we needed to be able displace the next person on the cyclotron schedule.
Question: But did we get too far ahead of the game? I mean, nobody knew what the RBE was going to be and what was the right way to do it, so tell us how you figured all that stuff out.
Dr. Hussey: Well, there was an experience at Hammersmith and there were tremendous reports coming from Mary Catterall at Hammersmith Hospital. Although some of those results were a bit fishy. I mean, I remember one time she was giving a talk and showed this tremendous tumor that had shrunk away but she didn't really give the details on that particular patient. So after she finished her talk, I asked her what the histology was on that patient. And she kind of hesitated and then she admitted that it was Hodgkin’s Disease. So you might have expected that it would have shrunk very well. But she didn't tell us that in her formal talk.
So Mary Catterall was reporting wonderful results, at Hammersmith, and the reports from Hammersmith were the whole reason why everyone got interested in fast neutron therapy in the 1970s.
Hammersmith was treating patients with fairly low energy neutrons. They were produced by bombarding beryllium with 16 MeV deuterons. I think they were treating with 12 fractions, three days a week over four weeks. When we got to start treating at TAMVEC, we initially used 16 MeV deuterons on beryllium and a four-week schedule to try to make our treatments as similar to Hammersmith as we could. However, we moved to a beam using neutrons produced by bombarding beryllium with 50 MeV deuterons very soon because the dosimetric properties of the 50 MeV beam were much better. The 50 MeV deuterons on beryllium neutron beam was dosimetrically like cobalt 60 (with 0.5cm skin sparing and attenuation to 50% at 11 cm depth); whereas the 16 MeV deuterons on beryllium produced a beam with dosimetric properties like 250 kV X-rays (no skin sparing and rapid attenuation).
When we started, we used the 16 MeV deuterons on beryllium, the lower energy beam, for the first six months, because Hammersmith had had considerable experience with this energy beam and a four-week treatment schedule. So we had an idea about an acceptable dosage schedule. We had some idea about the RBE of the 16 MeV beam and these fraction sizes. But the RBE of a neutron beam is very dependent upon the beam energy and the fraction size. So we did a lot of pre-clinical studies to evaluate our beam. These included pre-clinical studies with Chinese hamster ovary cells, bean roots, and all sorts of in vitro studies like that. We also treated spontaneous canine tumors, normal canine oral mucosa and pigskin. Rod Withers took a bunch of pigs up to College Station and irradiated the pigskin and compared the skin reactions on the pigs.
When we got into the clinical studies, we started by irradiating far advanced head and neck patients in a phase one study. We tried to match acute mucosal reactions with what we would expect if we were treating with photons. That is the way Fletcher designed the dosage schedules when he started treating patients with the betatron (22 mV photons) by matching acute skin and mucosal reactions. So we were using acute reactions to make judgments about late effects, those that would be responsible for complications. That turned out to be a mistake because we later found out that there is a disassociation between acute and late effects with neutrons. But we had no idea about that, at that time.
We did the pre-clinical studies in 1971 and '72. That was necessary because the RBE is dependent on beam energy. The higher beam energy, the lower the RBE. And the beam energy differed for all the cyclotrons in the cooperative clinical trial. Therefore the dose schedules had to differ a little bit at each institution. The difference wasn't great. It was only about 10 percent or so, but there was a difference. The RBE also varies with fraction size and also the biological end point.
The patient treatments started in October 1972. We initially treated patients with very far-advanced cancers in the pilot study. But it soon became apparent that we were dealing with a beam that produced significant long-term late effects in normal tissues. We weren't able to duplicate the excellent results that were being reported from Hammersmith.
So the question was, “Was this due to the energy of our beam?” The beam characteristics for our 50 MeV beam should have been better than Hammersmith's. “Was it because we had only a horizontal beam?” That's a problem because when you treat patients when they're standing up, they're thicker and the tumors are deeper. At that time in my apartment complex, there was a guy who sold women's lingerie and he commented that women are thinner when they lay down -- when women can't get their girdles on, he tells them to lay down to put their girdles on, because they're thinner when they lay down than when they stand up. It's the same sort of thing with patients. They are quite a bit thicker when they stand up. Later on when we treated patients with a combination of photons and neutrons, supine with photons and standing with neutrons, we saw that there was up to 8 centimeters difference in thickness in those patients. “Was it due to the fact that we were treating only twice a week?” I think Hammersmith was treating three times a week. Texas A and M would give us access to the machine only twice a week.
So we launched a lot of intercomparison studies with all the cyclotrons that were being used clinically. We went to Hammersmith; to Edinburgh; to Texas A and M; the Naval Research Lab in Washington, DC; the Cleveland Clinic; FermiLab and the University of Washington -- all those places had ongoing neutron projects at that time and eventually there were new cyclotrons at UCLA and at MD Anderson. Intercomparison studies were performed at all of these institutions to try to find comparable dose schedules.
Dr. Fletcher gave the first MDAH/TAMVEC report at the Gray Lab meeting in England in 1973. I think that was in the fall of ‘73. His report was met with a lot of criticism from the Hammersmith group because we didn't report good results like Mary Catterall had. But other neutron facilities were coming online, and they weren't seeing anything different than we were. No one was able to duplicate the results that Hammersmith was reporting.
“Was it due to the hypo-fractionated treatment schedule?” So the next thing we did was move to a mixed beam thinking that it might be due to the fact that we were treating just two days a week. We then treated three days a week with photons with a vertical beam and the patients supine, and two days a week with neutrons, which was delivered with the patients standing because the beam was horizontal.
And we also started looking into getting our own cyclotron. We went out for bids, and the Cyclotron Corporation won the bid to build a cyclotron for MD Anderson. That was to be a beam that produced neutrons by bombarding beryllium with protons -- 42 MeV protons -- which would give a beam almost as good as 50 MeV deuterons on beryllium neutron beam. Because the cyclotron would be at MD Anderson, we would avoid the long trip to College Station, it would give us to more flexibility in the selection of treatment schedules, and free up TAMVEC for the Texas A and M scientists.
Unfortunately, there were many delays in the delivery of the new machine. I didn’t arrive until 1983 -- which was about the time that I left Anderson. By that time I had decided that neutrons were probably not the answer to locally advanced cancer.
In my opinion, the problem with neutron therapy is that the repair of tissues responsible for late effects does not occur as well with neutrons as it does with photons. This is because much of the damage from low-LET sparsely ionizing photon irradiation is sublethal and it can be repaired in the slowly proliferating tissue before the cells try to divide (Late effects occur in slowly proliferating tissues). However, much of the injury from densely ionizing high-LET neutron irradiation is permanent and can't be repaired. So a course of neutron therapy, even when it's well fractionated, is like a course of hypofractionated radiotherapy and carries a significant risk of normal tissue damage. And because there's the difference in the way slowly proliferating tissues are responsible for late effects and rapidly proliferating tissues like mucosa or skin are responsible for acute reactions, there is a disassociation between acute and late effects. Cancers are usually somewhat rapidly proliferating. This makes it hard to use acute reactions to monitor dosage schedules. That's my opinion.
Question: What happened to the Anderson cyclotron?
Dr. Hussey: They built it and it was used. That was about the time I left, so I never ever used it clinically. They did use it for neutron therapy for a while and then it was used for a while to make isotopes. But it's not being used clinically now to treat patients.
Question: Dave, given the current enthusiasm -- and certainly Dr. Larson is one of the early proponents of this -- for hypofractionated treatments, were one to take neutrons as a unique source of DNA damage and pair it with more modern methods of localization, collimation, and treatment planning, do you think that there would be any unique advantages to that particle in tissues that are hydrogen-rich? Prostate cancer, parotid tumors?
Dr. Hussey: I think if you could get a high LET beam with dosimetric properties that would allow us to deliver a very isolated beam – maybe something like heavy charged particles or maybe even pions that might accomplish what you are saying. The problem with neutrons with that regard is that you get a lot of scattered radiation and a lot of normal tissue irradiation with that beam.
Question: So, we'll have to wait for carbon to see whether or not RBE is important.
Dr. Hussey: I guess so. That's right.
Question: Dave, did you ever get involved with boron neutron capture therapy?
Dr. Hussey: Only as a site visitor. I site visited in Boston and also in Idaho when they were thinking of doing it there.
I site visited it originally when Dr. Sweet, the neurosurgeon Dr. Sweet, was proposing it at Mass General. That was just after Herman Suit had arrived there. The site visitors asked why Herman wasn't involved. That was in the morning of the site visit. They dug up Herman by the early afternoon and brought him out to talk to about it. It was obvious that they hadn't involved him originally, but he spoke strongly for them.
Question: Why do you think -- why have neutrons pretty much gone away? Is it because of the observation of the toxicity or is it because there were competitive things like 3-D planning with photons where everybody could dose escalate without need for an expensive cyclotron?
Dr. Hussey: I think it was pretty clearly the toxicity. I think that neutrons died before those competitive things became popular. The neutron beam is a noxious beam. In a lot of ways, it wasn’t fun to deal with. It wasn’t fun to handle those cases. It got so that I would hate to see those cases come into the clinic.
I left Anderson in 1983 for several reasons. 1.) One reason is because Fletcher had retired and it was time for me to leave. It was a good turning point in my career. And 2.) I had decided that neutrons weren't going to be the answer, and there were a lot of side effects with neutrons.
I look back on my time in Houston as the best years of my life. Anything that I accomplished later on stems from the time that I was at MD Anderson. Later when I got involved in lots of other things, it was because of what I did when I was at MD Anderson. I also met my wife there, and my three kids were all born there. It was a great place.
But the neutron project had a lot of heartaches associated with it, too, and it was not pleasant dealing with those complications. Of course there were other places that were doing neutron therapy -- Lionel Cohen and Frank Hendrickson at FermiLab, for example, and Tom Griffin and George Laramore at the University of Washington, and there were several places in Europe. They continued neutron trials for a while, but I think that all of the trials have closed by now. Apparently Hammersmith has given it up, too. So I think it probably was the toxicity. Who knows, maybe it will be resurrected again 20 or 30 years from now.
Question: What was your next move after that?
Dr. Hussey: Well, next I went to Dallas with Dale Fuller’s group. Dale was a couple years ahead of me at Iowa. He was one of those who also decided to go into radiotherapy, probably because the radiology department (specifically diagnostic radiology) at Iowa was in turmoil. He was head of the group in Dallas. It was a relatively large group. They had, I think, seven radiation oncologists at that time. I think it was one of the largest radiotherapy groups in the country at that time. So I went there thinking that I could do the same sort of thing that I had done at Anderson, and I would be able to participate in multidisciplinary care and sub-specialize in one or two areas.
The problem was that the group was spread too thin to do that. We had seven radiation oncologists and six radiation oncology facilities. So it would be solo practice for the most part and that wasn't why I had gone there. So I decided to leave after about a year and go back into academic medicine. So I went on to Iowa. I never ever looked at Dallas as home. I did feel that way about Houston, and I did feel that way about Iowa, but not Dallas. I wasn't there long enough.
So anyway, I returned to Iowa in 1985. Tony Franken recruited me there. It was still a general radiology program – with diagnostic and radiotherapy divisions. The chair, Tony Franken, had trained in a general radiology program at Indiana University. So he'd had some radiotherapy experience in his training. He also let me alone so I could develop the program pretty much as I wanted. Tony Franken is a good guy. So I was happy. I probably made a mistake in not asking for a separate department at that time because I think he would have given it to me.
I just wanted to develop a strong academic program, and that was it. I tried to develop a program like what I was used to at MD Anderson. We had a planning clinic conference every morning at 8:00 a.m., where we discussed all new patients and any problem cases. And we had a teaching conference every day at 4:00 p.m. One day it would be a head and neck conference with the head and neck surgeons, the next day it would be a conference with the general surgeons where they mainly talked about breast cases. The next day we would have a rad onc/medical oncology conference where we had case presentations and discussions with the medical oncologists. And we had gynecology tumor boards two days a week. We also had lectures on physics and biology a couple days a week. Obviously, not all of these conferences were at 4:00 p.m.
I required a research project and a paper from every resident, and the faculty all subspecialized in the major areas. I also wanted to extend the residency from three years to four years. This was during the time when the ABR only required three years. Unfortunately, I wasn’t able to do that because the residents refused to stay the extra year. The problem became apparent with my first resident -- she was one of my favorite residents -- and she came along to finishing the residency in that fourth year and I told her that I expected her to stay the fourth year. But she had fallen in love with a surgeon from Norway who was at Iowa to get a PhD in radiation biology. She was planning to marry this surgeon and move to Norway. And so I gave in and let her leave after three years. From then on it was difficult to enforce the rule that this was going to be a four-year residency. It didn’t matter though, because the ABR moved to require that all radiotherapy residencies be four years long a couple years later.
I mainly wanted it to be a successful teaching program, and in general, we were successful in that effort. We never had anybody at Iowa who failed the boards. So it worked out well from that standpoint. And we did have some interesting research projects. At that time, we had one cobalt unit, and a small and a large linear accelerator. One of them was 18 MeV. We had another cobalt unit that we had modified for total body irradiation because we had a big bone marrow transplantation program. We had hyperthermia, intraoperative radiation therapy, a conventional simulator, and then we got one of the very first CT simulators. And we got IMRT in about 1996 or 1997, but we had some difficulty putting it in our department because our department is located above the ground so shielding was difficult. But we did get IMRT before I left.
It wasn’t a big department. We had five radiation oncologists on the staff and two physicists. We also had a well-established radiation biology lab that dated back to the 1950s. Titus Evans started it. There were four PhD radiobiologists there and three to four graduate students. Because of that lab, we were the only clinical department that could offer a PhD.
Question: How many patients were you treating per year?
Dr. Hussey: We were treating around 80 to 100 patients a day-- usually closer to 80. The problem I had at Iowa was that it's located in a small town and all the patients wanted to go closer to home to be treated. I thought that this was unique to Iowa at first, but then when I got to San Antonio the same sort of thing happened there. And that was in a large city. So I think it's just that there are so many radiotherapists and so many radiotherapy facilities that they tend to impinge on one another. Dale Fuller gave me a bit of philosophy when I was in Dallas. He said, “You know, patients don't know what good radiotherapy is, and neither do the doctors in the community. But there's one thing that they're experts at and that's service. They've been standing in lines at supermarkets all their life, and they know what good service is.” So the patients want to be treated closer to home.
We tried to encourage them into staying by developing multidisciplinary clinics where they could get seen by two or three oncology specialists at one time and hopefully get better treatment. But I don’t think that did much as far as encouraging them to stay at the University for treatment.
I think I mentioned that at Anderson we were treating 175 patients or so and that's probably up to 250 patients there now. But at Iowa it was around 80 to 100 a day and when I got to San Antonio later it was 70 to 90 patients a day for the most part. And I guess if you multiply those numbers by 10, that's about the number of new patients per year.
Question: Please tell us about your involvement in professional societies.
Dr. Hussey: I also got more involved in national organizations during that period. I went on the American Board of Radiology Board of Trustees in '93 and got more involved with the Radium Society. I became president of the Radium Society in 1999. I also got, more involved with ASTRO and the RSNA and I'll get on to discuss that more later on.
Anyway, in 1997, Tony Franken decided to step down as chairman of radiology, and he was replaced by Mike Vannier who came from Mallinkrodt (Washington University St Louis), which is where I went to medical school. Mallinkrodt was still a combined program -- They did not have separate departments of diagnostic radiology and therapy. And Dr. Vannier had no interest in separating the departments at Iowa. Dr. Vannier had never had any training in radiation oncology. In spite of this, he wanted to directly manage the radiotherapy division. He was also concerned about me being involved in too many national organizations.
About that time, in 1998, I got a call from Rich Hoppe asking me to run for the presidency of ASTRO and within 15 minutes got another call, this one from Sy Levitt asking me to go on the RSNA board. I knew that would lead to the presidency of the RSNA. I then went to Vannier to inform him of these opportunities. At the time, I had in my mind that I would probably accept the request to run for the presidency of ASTRO but that I would not accept the RSNA invitation because I was getting stretched pretty thin. But he told me to not accept either invitation. So I accepted both. When I did that, he decided that he would replace me as director of the radiation therapy division as of the following July. That was when I decided I would probably leave Iowa.
I was still on the ABR board of trustees. And so I took a sabbatical in Tucson working for the Board of Radiology in 1999. The primary purpose for my taking the sabbatical, other than getting away from Iowa, was to develop a computerized exam to replace the oral exam. We accomplished that and we actually even tried it at Louisville once, but it hasn't come into common usage. I think that actually they've developed a computerized exam now for diagnosis but not for therapy.
The rationale for a computerized exam is this: the ABR thinks the written exam is good for assessing cognitive knowledge, but it's not good for assessing deductive reasoning or testing for certain skills that are important to a radiation oncologist – things like portal placement. For that you need an oral exam to do so that you can have candidates actually draw the fields they would use, so on and so forth. That's difficult to do on paper. The problem with the oral exam is that you introduce a potential for bias on the part of the examiner. I was trying to develop a computerized exam that would allow us to test deductive reasoning by asking questions that are pertinent to a case and then modifying subsequent questions a bit on the basis of the response of the examinee to the first question. It could also be used to test for portal placement by asking the examinee to draw his/her portals on the computer screen and scoring their answers by having an acceptable range of fields stored on the computer. One can score it all by computer, eliminating the chance for bias on the part of the examiner.
I was there for almost a year -- about 11 months in Tucson -- and I enjoyed it. It was a good time.
After that, I went to San Antonio in 2000, to the University of Texas at San Antonio. Terry Herman was the chair of the department of radiation oncology there at the time.
Question: I think you had family in San Antonio.
Dr. Hussey: Yes, my wife's sister lived in San Antonio, yes. And her mother lived in Waco, which is a little bit north of where I am now. So we did have family there. So anyway, that was a good time. I enjoyed my time in San Antonio. Remember, I mentioned that all the people I trained in Iowa did well -- they all passed the boards. That wasn't true for the ones that we trained in San Antonio. About two-thirds of the residents in San Antonio passed the boards but not all of them. And I think it was probably because we didn't have a well-structured training program there. Terry Herman is very bright. The problem was that he was bright in knowledge that wasn't radiotherapy, so he did a lot of teaching of residents in internal medicine and medical oncology but they didn't get a lot of radiotherapy training. I think that may have been the problem.
Question: If you look back at your various places starting with MD Anderson up through San Antonio, you would have had direct teaching contact with a huge number of residents.
Dr. Hussey: Yes, quite a few.
Question: Any idea what that number is, the number of people you've taught over the years and who were residents under you?
Dr. Hussey: Never thought about that. I would guess up around maybe 400 or so, maybe more --something like that. San Antonio may be close to 60- 70. At Iowa it may be close to 100-130. I was at Anderson for a longer time and we had a bigger department, so there were probably 250-300 or so at Anderson. But then you get all the people who were there for very short periods of time. Anderson always had visitors in the department. We didn't have that many in Iowa, but there were a few.
Question: And I have a totally unrelated question, and that is when you took your orals in the '60s or whenever it was, do you recall whom your examiners were?
Dr. Hussey: Yes, one was Bob Sagerman -- he always hates to hear me say that he examined me, because it sounds like he’s that much older than me. Luther Brady was the other radiation oncologist. And I was examined in general radiology, so there were 4 or 5 diagnostic examiners and a physics examiner. I didn't certify in straight therapy until I took the recertification exam in 2000. And I actually took the recertification exam twice because I took it once just trying out the test as it was being developed.
Question: As I recall, you were the one who twisted all of our arms to take the first recertification exam.
Dr. Hussey: Probably. Yes, probably. I remember you taking it.
Question: When somebody called you and asked you if you would be willing to run for ASTRO president, who was it that made that phone call and what was your reaction?
Dr. Hussey: It was Rich, Rich Hoppe. And for the RSNA it was Sy Levitt. And the calls came within 15 minutes of each other.
Question: Did you say yes about the ASTRO immediately, or did you say I need to think it over? How did that work?
Dr. Hussey: I said I need to think it over for both of them. And then I went to Vannier and he said no. So then I decided that there is such a thing as academic freedom and I should be able to do what I want. So I said yes to both. And he said, well, fine. But you've got to take the lumps. But it worked out okay.
Later on I was talking to Bob Sagerman about it, and he said that it’s the chairman's prerogative. The exact words were “that I served at the chairman’s pleasure.” It kind of irked me when he said that. But he's right. I mean it was at the chair’s prerogative. I went to the dean about it, but that’s another story. Mike Vannier had more problems after I left. Many of the faculty in the diagnostic division left. So he was thrown out about two years later. By the way, the departments split a couple years later, so they now have a separate department of radiation oncology.
I don't have a whole lot left to discuss -- I retired from practice completely in 2008. I had planned to actually go back periodically to teach the residents. I like teaching the residents. I didn't think that I wanted to be responsible for patients, but I thought that teaching residents would be a nice way to stay involved. Initially I planned to go back every week or two. I did go a few times, but it didn’t work out. It was too hard to round the residents up when I got there, and so I thought, well, it's 100 miles away, and it's a big hassle. So I just stopped going completely. So I don't go back now except maybe to say hello to people every few months, that's it. And otherwise I'm completely retired.
Question: In 2000 Dave Hussey was president of ASTRO and I was chair. It was a very tumultuous year. I think that Dave was particularly judicious in how he dealt with a number of conflicts that he faced.
Dr. Hussey: Well, I've blocked out a lot of the memory of that. I don't think I handled it all that well, myself. Instead we brought in McGladrey and Associates as a management consultant. But it was obvious that the Society was going through a lot of turmoil, and something had to be done. It's interesting that the same sort of thing happened in the RSNA three or four years later, and the RSNA board went through the same steps as we did at ASTRO.
I think we handled it pretty well at ASTRO, probably better than it was handled at the RSNA. That may have been because we had an executive committee at ASTRO, and three people shared all of the difficult decisions. We also had a superb interim Executive Director. Again, I think we handled it pretty well at ASTRO.
I always thought that my experiences at ASTRO and, to a lesser extent the Radium Society, would be useful to the RSNA board when I was on that board. There were many times when issues came up on the RSNA board that were the same as, or very similar to, those that we had dealt with at ASTRO. However, when I told them how we had dealt with an issue at ASTRO, it wasn’t all that well received. The audience response system for the educational sessions is an example. We started using them at ASTRO when I was on the ASTRO board. And I proposed them for the RSNA, but they weren’t interested. Another one of the ASTRO advances that I mentioned to them was the high profile educational session of practice changing papers, the Plenary Session. I think you were the one who started that Chris. Again, they weren’t interested. However, that one might not have been feasible for the RSNA because it has a broad range of subspecialties.
Question: Dave, your management style was particularly collaborative and inclusive. When faced with a new problem or situation when you were the ASTRO chair, it seems to me that your instinct was to ask what past leaders or other medical societies did under similar circumstances.
Dr. Hussey: Well, that was the reason why I pushed the past-presidents breakfast that I thought was a great idea was before I was a past president but when I became a past president I decided, may be more of a nuisance to do and maybe the past-presidents don't want to have a breakfast. But the past-presidents always seemed to be sticking their nose in and wanting to offer advice to the current board. So I thought we ought to at least give them an opportunity to tell us how they handled things. So I thought, well, why don't we have a past-presidents breakfast where we can formally get their advice without them having to complain that we weren't doing things right. I guess it worked out pretty well.
Anyway, I think that we did pretty well, the three of us, as well as Larry Kun and Rich Hoppe. Don't you? I mean, I think that ASTRO has turned out pretty well. The only criticism that I have now is that the people in the ASTRO office don't seem to return calls very well. That's the only area I have trouble with.
As I look back on my career, I've held many positions in ASTRO over the years. Excluding the time I was on the ASTRO board (I was actually on the ASTRO board twice, once in the early 1990s when I was treasurer, and then in 1999 when I ran for president.) the two assignments I enjoyed the most were 1.) being editor of the newsletter and 2.) chairing the history committee while the 50-year history was being prepared. I had an opportunity to work with Fran Glica when I was editor of the newsletter, and she was a delight work with. And working on the 50-year history of the Society was a wonderful opportunity. I enjoyed both of those jobs a lot.
Question: Tell us about your role in developing an ASTRO foundation.
Dr. Hussey: My interest in having a foundation comes from my time on the RSNA board. I saw how successful the RSNA foundation was. There were also a number of ASTRO members over the years that encouraged me to develop a mechanism for radiation oncologists in private practice to support research and education in our specialty. Todd Wasserman was one of those who discussed this with me. And so I appointed a committee chaired by Sarah Donaldson to look into the feasibility of developing an ASTRO foundation. I think that was in the year 2000. Unfortunately the tech bubble burst and the economy went into a tailspin – exactly the wrong time to start a funding drive. So we had to put the foundation on hold.
Question: One of the things you did that was very important was to develop ASTRO’s 50-year history book. Tell us about that.
Dr. Hussey: Well, I happened to be the head of the History Committee when the 50th anniversary history book came up -- I don't know whether there was a reason for that or not. The ASTRO board conceived it, and the board asked the History Committee to put it together. The ASTRO board also hired a professional writer to help us with it.
So we, the History Committee, set up several subcommittees to do most of the work. There was a working subcommittee to gather information and write the various drafts of the document. That had to be a group of people who were willing to put in the time and get the facts right. We had deadlines, so they had to work in a timely fashion. And there was a second subcommittee, the reviewing subcommittee who would review the various chapters as they became available. They were asked to check the chapters for accuracy and completeness. For this subcommittee we selected senior members of ASTRO who had lived through much of the history we were reporting on.
I felt that there were a number of critical elements. First and foremost, it had to be accurate. Secondly, it had to be comprehensive, no major omissions. Third, we needed to make sure all of the major elements of the society were included and fairly represented. Fourth, we had to have a lot of pictures to help keep the readers’ interest. And lastly, we had to stay on time, because the book had to be completed in time to be distributed to the membership at the annual meeting on our 50th anniversary.
Question: Well, it was quite an accomplishment because there was certainly a deadline for finishing it and a lot of people were working on it. But it turned out to be very successful overall.
Dr. Hussey: Yes, I'm happy with the book. Several other societies are going to have centennial celebrations in the next few years. The RSNA is one of those organizations. In fact, my only continued responsibility for the RSNA is as a member of their history committee. The centennial year for the RSNA is coming up in 2015. I recommended that they publish a history of the RSNA for their centennial year. I told them how successful our 50th year history book had been, but again they weren’t interested in our experience. They may come up with a book of pictures, but they aren’t interested in documenting the history of the society like we did for ASTRO. I think it’s a mistake because the RSNA would have a rich history. Needless to say, I think we did it right. But we had the backing of the ASTRO board. We couldn’t have done it without the backing of the board.
Question: Let’s move on to your thoughts about radiation oncology and the direction it's going.
Dr. Hussey: Okay. I jotted down four or five topics about this. My first thought relates to the relationship between diagnostic radiology and radiation oncology. I think that it's interesting that diagnostic radiology and radiation oncology are now moving closer together after almost completely separating in the 1970s. That was the subject of my RSNA presidential address four or five years ago. I don't think it's to a point where we will be consolidating training programs or anything like that, but it is interesting that both specialties -- both diagnostic radiology and radiation oncology are becoming stronger because the two are moving closer together. It's because each branch benefits from new capabilities in the other branch. Diagnostic radiologists are now better able to define the extent of the cancer, and radiation oncologists are better to deliver the treatment to a localized area.
I think it’s likely that the specialty societies will also move closer together. And this brings up a second thought. I personally think that radiation oncology would benefit from more involvement in the multidisciplinary societies, like the Radium Society and the RSNA. The Radium Society is the oldest multidisciplinary cancer society in the country. It’s a place where you can exchange ideas with head & neck surgeons, gynecologists, and medical oncologists. And participation in the RSNA would help radiation oncologists gain knowledge in imaging, which is a necessary and important part of our practice.
Question: Well, their meetings are amongst the best there are, I think.
Dr. Hussey: I do, too. And I think that sometimes ASTRO pressures them and that makes it difficult for them to maintain the participation of radiation oncologists. I wouldn't want to see radiation oncology forced out of these societies, and that’s possible if we aren’t able to keep up the participation of radiation oncologists.
Another thought -- I'm a little worried about the recertification process. I took the recertification exam in 2000 so I should be recertifying again. (The certificates are good for only 10 years.), but I'm not practicing anymore, so it may be difficult for me to make effort. I’m sure others feel the same way. Although it’s a noble effort in general, it might be so difficult to implement that it will water-down the effectiveness of the examination process overall. I feel strongly that the board process in general has strengthened all the specialties considerably. And I think the fact that people are forced to take an exam to get into the field and then take a recertification exam to keep up on it to some extent -- all that's very good. I think it is going to help the specialty considerably. But it may be that if it becomes such a hassle that nobody will continue to recertify, then it's going to be a problem.
Another thought relates to medicine in general. I really worry about the status of health care in this country. It bothers me that medicine, the profession I chose to pursue, might put our country and our way of life in jeopardy. And radiation oncology isn’t completely innocent in this. Radiotherapy is expensive treatment these days. And expensive modalities such as protons might not be worth the risk to our economy. I personally think that these unproven modalities ought to be tested in a few well-chosen centers before they are disseminated to the community. In fact, Gilbert Fletcher used to refer to the “medical-industrial complex.”
Question: So let me ask you one last question and that is that you've practiced for years and you've seen lots of technical changes and changes in machines and knowledge about response rates and complications and so on that have changed over the years. So if you could go into the future, in say, 20 years, what do you think radiation oncology is going to be like then?
Dr. Hussey: I don't know. There is some uncertainty because of the cost. Now, I don't know what's going to happen in general to research. I think it's going to go one of two ways. Either we're going to continue to flourish as we develop new techniques such as protons or carbon ions, or perhaps even pi mesons or things we haven’t even considered today. But I think it's more likely that there won't be the money available everything we want to do -- and that the heyday of medicine in general will be over. Of course, I guess it’s possible that there will be a whole new field that takes over cancer treatment. But I haven’t thought about it, and I’m not very good at reading crystal balls.
Question: All right, David. This has been extremely informative and fun for Chris and me.
Dr. Hussey: Well I enjoyed it. Thanks for interviewing me.