Question: I am Dr. Gustavo Montana, Chairman of the ASTRO History Committee. Dr. Norm Coleman and I will be interviewing Dr. Eli Glatstein, a very distinguished member of our Society. Today is March 13, 2012. So we shall begin by asking Eli about where you were born, and where did you go to undergraduate, graduate and medical school?
Dr. Glatstein: I was born and raised in a small town right on the Mississippi River called Muscatine, Iowa. If you know the shape of the state of Iowa, there's a nose that protrudes into northern Illinois, and the tip of that nose is sometimes called the tri-city area -- Davenport, Iowa; Rock Island and Moline, Ill. My hometown was located right where the nose would run, a sort of the rhinorrhea of the Midwest. And I went to undergraduate school at the University of Iowa and then left after three years to go to Stanford Medical School.
Question: So from undergraduate you go on to medical school. Why did you go to medical school?
Dr. Glatstein: Well, I was bound and determined to be a doctor.
Question: Family pressure or your own?
Dr. Glatstein: No, that's what I wanted to do. I'd been generously tutored, so to speak, by a family physician who took interest in me, and his son was my best friend, so we got along very well. And it just sort of followed that's what I wanted to do.
Question: So what was your life like in the small town in Iowa?
Dr. Glatstein: Well, you know, when I was growing up in a small town in Iowa, you knew everybody, and everybody knew you and had their own expectations for you. And I remember, later, when I was applying for internship, I wanted to go to New York City, because I hadn't been in New York City. I applied to Columbia, which I think was my first choice at the time, and the form asked you to describe your non-scholastic experience of value. And I thought for a second, and I put down Jewish upbringing in small Midwestern town. I thought it would either get me in or keep me out.
Question: At Columbia it was out.
Dr. Glatstein: It kept me out. But I got into New York Hospital, so it all worked out.
Question: And what were some of the things you did as a kid? Some of the jobs you had?
Dr. Glatstein: Oh, the usual kinds of things.
Question: Did you work in the family's business?
Dr. Glatstein: My father owned a furniture store, and I used to work in the store. I used to sell, and I used to deliver things to people—chairs and sofas and tables, ect. And then I worked as an orderly in a hospital when I was going to college. So I didn't do anything spectacular.
Question: Would anybody mistake you as a football player?
Dr. Glatstein: Well, I did play football. I was a quarterback; actually. I was a terrible quarterback. We won two games every year. And the main reason I think I was the quarterback was that I knew what everyone was supposed to be doing. We had a bunch of guys who weren't sure who they were supposed to block, and so forth, and I would tell them who to go after, and so forth.
Question: Eli, later on you were recognized by your high school and you received an honor from Muscatine because for being the quarterback? That was not because of being the quarterback, right?
Dr. Glatstein: No, it certainly had nothing to do with football.
Question: Had nothing to do with football?
Dr. Glatstein: No, I was a straight-A student, even there when it wasn't very common.
Question: Okay. Now the question about Stanford. Why Stanford? At that time, Stanford hadn't reached the heights that it reached later.
Dr. Glatstein: Well, when I was in my third year of undergraduate at Iowa, I applied to three medical schools. I applied to Harvard, to Stanford and Iowa. And I knew I'd get in at Iowa. I was the top student in my class. Harvard told me to reapply a year later. Stanford took me, and I went out there as quickly as I could.
Question: Why did you pick them? Not that it's not obviously a nice place.
Dr. Glatstein: Well, my brother had gone out there and it is a great place to go. The climate is terrific, and I've always been fascinated by what they call on the West Coast, the “big game” between Stanford and Cal. And I just thought it would be a great place to go to school, and it was. It was a terrific place. I don't know what it's like today out there, but, in those days, they didn't take themselves too seriously, so we had a lot of fun. And the impressive thing, of course, is that no matter how smart you are, you always find people who are smarter and there are a lot of smart people out there.
Question: Eli, let me take you back to something you mentioned. You have a brother. I don't know about your brother who also went to Stanford Medical School?
Dr. Glatstein: Yep, yep, yep.
Question: Okay, what did he end up doing?
Dr. Glatstein: He was a private practicing internist. He's retired now.
Question: Do you have any other siblings in medicine?
Dr. Glatstein: No, I have a sister in New York City, but she's got nothing to do with medicine.
Question: Okay. All right. So the obvious question, you went to Stanford, you at the time you were not thinking of becoming a radiation oncologist, huh?
Dr. Glatstein: No, no. If somebody would have told me while I was a student that I would go into radiation oncology, I would have laughed at him. It was the furthest thing from my mind. But later on, during my internship year, I got drafted and went to South Vietnam, as soon as my internship was over. And while I was over there, I decided I wanted to return to Stanford. Now that was kind of a surprise, because when I left Stanford I swore I'd never go back because I thought the place was overrated. That was before I started my internship in New York Hospital where I found out what overrating was really about. So I wanted to go back to Stanford, and I applied to the department of radiology, because it was the best department in the school and I knew that. And I sort of thought I would be a diagnostic radiologist, actually, and I applied for what they called at that time “general radiology,” which was a four-year program and you would alternate every six months for the first two years between diagnosis and therapy, and then the last two years you would do one or the other but not both. And although I sort of thought I'd start out as a diagnostic radiologist, two days after starting in therapy, I said to myself, “Well, how come I never knew about this?” This is fantastic. This is so interesting. And I marched into Mal Bagshaw's office—he was the director of the therapy division—and I told him I didn't want to continue to alternate back and forth between diagnosis and therapy. I wanted to do just therapy. And he asked, "Why don't you want to alternate in diagnosis?" I said, "I don't want to waste a month of my life doing nothing but barium enemas." And he laughed and said, well, as it turned out, the guy I was paired up with, who was supposed to alternate with me, had decided that he didn't want to do therapy, he wanted to do only diagnosis. So it all worked out, and I completed my three-year training program in therapy only.
Question: Eli, when you met Kaplan you were a medical student...
Dr. Glatstein: Yeah, my first dealings with him, I was a first-year medical student walking down the hall and, as you know, most first-year medical students are trying to keep a low profile. This very large imposing figure was walking in the other direction wearing a white coat, and he said, "Good morning, Dr. Glatstein." And I was flabbergasted that anyone would know who the hell I was. And it turned out that all the faculty had received a small card that had everybody's miniaturized picture on it and the name, so that the faculty would be able to identify who was who in the first year of class. Well he had taken the trouble to memorize it. He knew everybody by face and name in the first year of class. There was no one else like that. I don't think it was particularly hard for him, he had a terrific memory, but he took the time to do it. And that was one of his redeeming qualities. He was just an extraordinary individual, not only truly brilliant but overflowing with charisma.
Question: Did you get to know him during medical school? When did you first really get to know him?
Dr. Glatstein: Oh, really not until I was a resident. I was scared to death of him. He was a very imposing and intimidating figure but also, generally, the most rational human being that I’ve ever known. Now, it turned out, once you got to know him, that he was not that way. But he came across that way. He was one of those people that, when he would walk in the room, people would sit up in their chair. He commanded attention and respect just by his presence. He was very imposing.
Question: So how did your relationship with him really evolve? When did you become one of his team members?
Dr. Glatstein: Well, during my residency, I think. I got to know him well, and then he went on Sabbatical during my first year. He was gone for six months. And during that time, I got interested in the Hodgkin's patients and particularly interested in staging. We had studies that depended on the stage that the patient presented with, and sometimes it was difficult to pigeonhole that. Lymphangiograms were being done and sometimes they were equivocal, I had noticed that -- we had a policy that if the lymphangiogram was equivocal, we would explore the patient to be sure about the nodes. It turned out most of the time in those that were called equivocal, they were actually negative histologically, but, also, we had a policy at the time that if we took the patient to surgery, we would also remove the spleen, because it markedly simplified the radiation treatment enormously. It really reduced the probabilities of having a radiation injury to the kidney and even the heart and lung. The function of the spleen seemed to be, I wouldn't say unimportant, but not necessarily critical. The function of the spleen seemed to be largely taken over by RE cells in bone marrow and other parts of the body. So I had noticed that when we took out the spleens in some of these patients who had equivocal lymphangiograms that they would find a focus of clinically-occult Hodgkin's in them. And so I reviewed all the cases that had splenectomy and then when Dr. Kaplan returned, I gave a seminar on it. Now, Norman will remember that in that era nobody did seminars on Hodgkin's; they were scared to death of going toe-to-toe with Henry Kaplan. Well, I was too dumb to realize that, so I gave this seminar and I remember during the seminar, at the end of it, he said, "Now, let me get this straight. When we thought the spleen was normal there was a roughly 30 percent chance that the spleen would contain Hodgkin's disease at laparotomy in these patients?" I said, "Yes, that's correct." Then afterward he came up to me and said, "That was an excellent seminar. You should write that up and burst forth upon an unsuspecting world." That's when I think I really became part of his team.
Question: Eli, so the spleen was already being included in the field?
Dr. Glatstein: Yeah, that's what we would do.
Question: That's what you would do, right.
Dr. Glatstein: We would treat what I call the South American field, the inverted Y, we would flare out laterally to include the spleen.
Question: Okay, so that was very early that the spleen started to be included in the field...
Dr. Glatstein: Oh, he was doing that from the beginning when he treated the total nodal. We take it so much for granted today, people don't realize that when he proposed to do that, people thought he was crazy, and he was going to kill people left and right. He didn't. But everyone was afraid, because it had not been done before, extensive treatment on both sides of the diaphragm.
Dr. Glatstein: He thought bigger than other people. He liked big decisions -- not little ones. The glass was always half empty.
Question: As a medical student, were you aware of the very strong and controversial relationship between him and Saul Rosenberg? Did that come across?
Dr. Glatstein: To some degree. As a student, I was actually much closer to Saul Rosenberg than Henry Kaplan. I took all my student elective time at Stanford with Saul. And although I revered Henry Kaplan and respected him enormously, I actually loved Saul Rosenberg. He was just my idea of the quintessential physician. And there was a peculiar relationship between them. I think in many ways Henry had a very filial affection for Saul but also sometimes frustration when Saul did things that Henry thought should have been done differently.
Question: So the portrayal of their relationship in the book written about Kaplan would you say is very appropriate?
Dr. Glatstein: Well, I think Charlotte Jacobs did a very fine job at presenting Henry Kaplan, works and all. He was a remarkable man with enormous strengths with a few serious flaws, and nobody is perfect in this world, including Henry Kaplan. But, my gosh, he was something very special, and I think that her book does real justice to the unique relationship between the two of them. Saul, too, is a most remarkable man and physician, but he was less “flamboyant” than Dr. Kaplan.
Question: So during your training you had some biology time, too. So you met some interesting people in the radiobiology world. Do you want to sort of comment on at Stanford and ones you met in UK?
Dr. Glatstein: Well, at Stanford the people we dealt with were Kaplan himself in radiobiology, Bob Kalman and a bunch of visitors. The visitors included people like Stan Field and Julie Denekamp and then later Martin Brown. These were top-flight people and they were great teachers and very provocative. They liked a good argument. And to some degree, I think I've inherited some of that from them. I like a good discussion, too. I'm not a “yes” person.
Question: But you spent some time in the laboratories and...
Dr. Glatstein: Yeah, when I finished my residency I went to the Gray Lab. Well, actually I went initially to Hammersmith to join Jack Fowler. And then when he moved out to the Gray Lab the following year, I moved with him. I spent two years in London. And Jack Fowler is also one of these guys who’s bigger than life. He's just an enormous individual. He's full of ideas. He probably has more ideas per unit of time than anyone I've ever known. And some of them are outstanding ideas. He's a very thoughtful individual, and I would have to say I've never worked for anyone who was more solicitous of my welfare than Jack Fowler. He was just an outstanding boss.
Question: Eli, being in the lab, it was sort of a rite of passage -- I don't know how to describe it -- for all of the trainees at Stanford, was it not?
Dr. Glatstein: Well, I'm not sure all of them, but most of them . . .
Question: In Kaplan's day.
Dr. Glatstein: Yes. The model then was the physician scientist, and I think it's hard to live up to that. The sciences move so rapidly today that I think it's hard to keep up and still truly be a good clinician. I think it was possible in another era. I'm not sure it's really possible anymore. I think that equally important are scientific physicians. There is a real need to find people who are scientific physicians, as opposed to physician scientists. And the scientific physician is the physician who understands the science even if he doesn't carry it out himself and able to do translational research well. But his primary job is caring for patients and I believe there’s a huge need for such people. Many people think that any idiot can do translational research. I can tell you that isn't true. It's harder to do good clinical translational work than it is to do good science, good laboratory science. There are two reasons. One, in the clinic, you never have the right controls, which is why randomized controls are the best you can get. But we're only beginning to understand what some of the molecular issues even are today, so you never have the right controls in the clinic. The second thing is in the clinic you have to do it right the first time. If you screw up on laboratory experiment, you repeat it. If you kill your first patient on your study, your study is dead. You'll never get another one. So you have to be able to carry these things out safely, and that kind of pressure is something that most Nobel Laureates would have a hard time dealing with because most of the Nobel Laureates—and I've known several—most of them are control freaks, so that's fine. They get to where they are by setting up all the elaborate system of controls so that they can interpret their data properly. And that's fine. But in the clinic, it works somewhat differently. I guess the third difference between clinic and lab is that the mice are bred to be genetically alike, and most of the tumors are transplanted so they are also genetically alike. This is very different from what we see in clinic.
Question: You know, Eli, this is a very important concept that you are talking about, frankly. Very, very important.
Dr. Glatstein: Well, I think it is, but...
Question: I credit Kaplan with your...
Dr. Glatstein: Well, I have to tell you something else.
Dr. Glatstein: The first time I met Gilbert Fletcher, he looked at me and said, "You're from Stanford. You're a mouse doctor." The worst thing he could say, "You're a mouse doctor." He didn't think very highly of laboratory investigation. I think he changed over time, but when I first met him he couldn't think of anything worse to call you but a mouse doctor.
Question: Eli, Kligerman wouldn't have said that to you. Kligerman would have not said that to you.
Dr. Glatstein: No. Actually, it's interesting that you bring Klig up. If you actually look at the chairpeople of the radiation oncology departments in this country and you do their pedigree, about three-fourths of them or maybe four-fifths of them have a pedigree that goes back either to Kaplan or to Kligerman. I mean, they were the two real leaders within the American population in radiation oncology and education. Now, if you do the history, around World War II you had a number of people who came, that immigrated to this country including Fletcher, del Regato, Buschke, Simon Kramer and others. And they were full-time radiation oncologists when they were in Europe. In the immediate post-World War II era, there really wasn't a true radiation oncology movement in the US. Most of the radiation oncology was really a secondary issue for diagnostic people, and most of it was cervix and larynx—I should say glottis. When Fletcher and del Regato and others came to this country, the two people who were most impressed with them, I think, were Kaplan and Kligerman. And those two brought to the table a few things that the Europeans didn't have. First of all, they understood the American patient, who is much less docile than the typical European patient. Secondly, they understood the American trainee, who wasn't cut from the-herr-professor-type mold in Europe. And then, thirdly, Kligerman and Kaplan both had, not only respect for the lab, but a true love for the lab. They liked to putter and do their own experiments. They were big on that. And that's something that the Europeans weren't particularly schooled in. And Kligerman and Kaplan were so impressed by the European radiation oncologists that they basically dropped their diagnostic functions and focused entirely on cancer after that. They both set up training programs in America for Americans that were aimed at the American population and the American trainee. And that's why, I believe, we have this remarkable preponderance of Kaplan and Kligerman influence on the academic radiation oncology that exists even today. Would you agree, Norman?
Question: Oh, absolutely. Yeah. And the first guy I met, Gus, when I was a med student was Kligerman.
Question: Really? Oh, yeah, you went to Yale. Of course.
Question: But I got into radiation oncology because Henry Chessin introduced us to Kligerman, believe it or not.
Dr. Glatstein: I believe it.
Question: And they also brought molecular medicine. If you look at the DNA repair fields, a lot of them came out of Kligerman's department and Kaplan's department.
Dr. Glatstein: And they were both bigger-than-life characters. Both of them. They were tremendously influential and, one could say, dominating on young physicians in training.
Question: And they were charming. They were really very charismatic.
Dr. Glatstein: Very charismatic and extremely knowledgeable on a wide range of topics—not just medicine, but music and art and literature.
Dr. Glatstein: These were basically renaissance people.
Question: Yes, indeed. Norm, shall we move on to talk about the...
Question: The career of Eli's layoffs. He goes from one job to another.
Dr. Glatstein: Well, I've only had a few.
Question: You have a great history. So tell us about maybe -- so you went to NCI and you sort of transformed the National Chemotherapy Institute.
Dr. Glatstein: Well, Vince DeVita wanted a program, a clinical program in cancer care that was strong across the board. And he had good medicine and he had good surgery, and he lacked a really strong radiation oncology component and he set out to get one. And, actually, I don't think I was his first choice. I think he actually wanted Zvi Fuks, but Zvi had just gone back to Israel and wasn't about to come back at that time, and so I think I was his second choice. And for whatever reasons, I was the right guy at the right place at the right time. And we worked out what amounts to a team approach for a variety of different cancers, and I was lucky enough to work with guys like Bob Young and Steve Rosenberg and John Minna and so forth, just to name a few of them. And I think it was good for oncology, it was good for NCI, and it was certainly good for me.
Question: So tell us about your program there. What did you put together?
Dr. Glatstein: Oh, well, the program that we set up was primarily modality oriented in terms of the studies that we carried out. We teamed up with the other departments who already had disease-site orientation, but our studies were primarily looking at radio sensitizers and things of that sort for which weren’t necessarily disease oriented. But it worked, and we were able to team up with the other departments and still do things that I thought were interesting and appropriate. At the same time, I was able to recruit effectively. I was in Bethesda for, I think, 15 years and there are 23 people who switched from medical or pediatric oncology into radiation oncology. And I recruited from the outside Joel Tepper. I recruited him from the Air Force.
Question: Ted Lawrence was...
Dr. Glatstein: Ted Lawrence. Steve Hahn and Andrew Turrisi were recruited from medicine at NCI. And I was able to recruit effectively from the outside, as well, people like Allen Lichter and Tim Kinsella and a variety of others came from the outside. You know, I have recruited a lot of good people. If I had one real talent, it was that I was an effective recruiter. And in those days you almost had to be, because there was a huge rate of turnover. People would spend three or four years at NCI, and they'd use it as a springboard to go someplace else. And I had to keep recruiting. I was never free from the recruiting need. But it worked out and I would say that one of my biggest disappointments was that when I left, I thought the department would be able to stand well without me, and it turned out that the department had troubles. And that was a disappointment because you don't build a department to see it fall.
Question: So you were always oriented as a biologist or a scientist, but you have had probably one of the bigger influences in technology, and that started at NCI—is that right?
Dr. Glatstein: Well, I believe we were the first place to have a dedicated CT scanner for treatment planning. And that's about 1978, I think. So we were able to do three-dimensional treatment planning. Now, we couldn't display it the way you do today, but we had CT scanning and CT planning, but I wouldn't call it 3-D. It was 2.5-D because 3-D is basically based on a stack of planar scans, and we were doing that. In order to understand 3-D in those days, you had to go slice-by-slice, because you could really integrate them only in your head. But I think the technology was important and we tried to do things that would help others who were still grasping at the time for direction. And I have to give a lot of credit to Lichter and Tepper. They were particularly good at that.
Question: Is he one of the first people/groups to talk about radiation dose, more is better?
Dr. Glatstein: Well, I'm not sure we ever went that far. I'm not a big advocate for dose escalation. I think more is better for certain patients but not on a routine basis. I don't think that the founding fathers were off by a lot in terms of their concepts of tolerance. But I think that if you think you can get away with a higher dose, I think it's a good idea for most patients. But you can't do it in everybody. This is why you need to follow patients closely during treatment. Some have lots of trouble and others sat through treatment seemingly without turning a hair.
Question: And what do you think—a little diversion? What do you think of fractionation—hypofractionation?
Dr. Glatstein: Fractionation is the only thing we do that routinely tries to exploit biology differences between normal tissues and tumor cells.
Question: Do you think hypofractionation is a step sideways, backward, unknown?
Dr. Glatstein: Well, I think if you're talking about hypofractionation as part of stereotactic treatment where the volumes are small and particularly for a peripheral lung nodule, I think that's probably pretty safe. I'm not so sure about stereotactic treatment for the brain. I think there's a fair amount of necrosis—brain necrosis. Now, because the volumes are small, I don't think it means necessarily the same things that brain necrosis meant when I was a trainee, but I'm not sure that it's safe. After all, the CNS is truly prime real estate within the body. I think that's a real issue. I think people aren't reporting it. I think they're afraid to report morbidity today; they're afraid they're going to get sued.
Question: They're losing market.
Dr. Glatstein: Well, I think that, too. We have -- we did hypofractionation here on a patient not too long ago with a central lung lesion and the patient suffered a serious injury to her airway and died. And our guys wrote it up to try to educate other people as to the events that took place and sent it off to a major journal where it was rejected. But the reason for the rejection was bizarre. The particular journal said they were afraid that this report would discourage patients from getting necessary treatment, which smacks of a conflict of interest. You know, if you've got a problem, if you recognize a problem, you want to be able to deal with it. But the first thing to do is to recognize the problem. And I think that's a real issue today because of the enormous sums of money that are involved. I think people are reluctant to report morbidity and I think that's very sad.
Question: So you've had -- again, you moved to Dallas and you've...
Dr. Glatstein: That was probably a mistake of mine.
Question: Norm, before we get to that, I just want to go back to one thing that Eli said about the founding fathers. I think that the founding fathers were very right in their view or considerations about tolerance and dose. But what makes the difference now is that we're able to deliver those doses in much more circumscribed or much better tailored to the shape of tumors and sparing the normal tissues. But in terms of dose escalation, I think that they were very right or very close to being right from the beginning.
Dr. Glatstein: Well, if you look at what Coutard reported, I think it's in the 1920s, half a dozen patients with laryngeal cancer, glottic cancers that he cured with radiation. And the surgeons thought he was a charlatan. They didn't think that was possible. And the key to his success was protracted treatment—fractionation. And the basis for that was the desire to get higher total doses into the cancer. Normal tissue wasn't really a major consideration at the time. But over time we've learned that there are limits to what you can get away with in normal tissues. We've learned that those limits sometimes take many years, maybe even decades (in the case of CNS) to declare themselves. But they do declare themselves ultimately if the patient lives long enough. And normal tissues love protraction. Normal tissues have real problems with high-dose per fraction. Now, if the volume is small enough, you'll probably get away with it, particularly in a paired organ like the lung. I think one of the problems with high dose per fraction in the brain is that that's prime real estate and you've only got one.
Question: Well, two things because you not only moved to Dallas to learn with better scientists, which you can tell us about, but also your interest in—again, for a biologist—your interest in particle therapy.
Dr. Glatstein: UT Southwestern was supposed to get protons from the super collider which was being built at the time at Waxahachie, Texas, which is just outside of Dallas. And they had, at the time, a relatively weak radiation therapy department, and they knew they were going to have trouble with that, and so they were anxious to recruit someone they thought could handle that. And also John Minna was there and he was, and is, probably my best friend and I had lots of reasons to want to go there. And everything, actually, was going pretty smoothly, although I had the smallest physical plant in the country. I had 4800 square feet which is pretty darn small for radiation oncology. I've actually surveyed all the major departments in the country at the time, and the closest one to me, I think, was Temple, and they had like 7800. The typical department, medium-sized department, at that time, was something like 15,000-plus square feet. Anyway, when the Republicans took over the Congress in 1995, the first thing they did was kill the super collider. And it was going over budget and there were other reasons for it. But once that happened, then everything started to unravel for me down in Dallas. So I was here in Penn within a year once that really took place. And the people down in Dallas, they were nice enough. It was a good place. But there was a peculiar relationship between the medical school and Parkland Hospital at the time, and I had trouble navigating the system. But as I say, nothing really bad took place until the super collider was dismantled and then everything started to unravel. So I came here. And this has been a good move. The best thing I ever did was give up being the chief.
Question: Isn't that the truth?
Dr. Glatstein: Yeah. Now I get to do things that I like to do and that I do well. And it's Steve Hahn's department. It was Gillies McKenna’s department before Steve. But these are good people, and I'm here to help them. I'm not trying to take anything away from them. I'm not trying to take over the department. That's not what I want to do. I want to help them and help the younger people in the department. And that's what I try to do.
Question: Do you want to just tell us a little bit about training? What do you try to inculcate in trainees, and when they go into academics or practice, how do you advise them?
Dr. Glatstein: Well, there's some people who think that we should take only people who want to do academics. I had a guy, a trainee early in my career who used to say, “Eli, I'm traveling light. I'm only carrying one suitcase. You've got to fill it with things I really need to know. Don't tell me anything I don't need to know.” And I laughed at that, but then I got to thinking, you know, he's got a point. And it's been useful to consider that point of view, to decide what is really important for people and not get too carried away with what I consider pseudo science, which is another topic entirely. But you can try to make too much out of things. This is as clinical a field as anything I know in medicine. I try to get everybody to sharpen up their physical examination. And I must say that that's becoming progressively more difficult, because there's more of an interest in depending upon imaging than on physical exam. And I don't want to put down imaging—it's very important—however, imaging is far from foolproof. There are times that the imaging doesn't reveal stuff that's there. The images may say that there's a single pulmonary nodule, and you take them to surgery and you find there's two or three. You don't see the others. I don't know why, but you don't. I don't think you can trust the imaging 100 percent, but the images are so concrete that you're almost mesmerized by them to thinking that you know where all the cancer is, and I don't believe we do. I believe glioblastoma, for example, is just terribly infiltrative. And, while we may get an image of it that shows the mass, the old study by Walker-Dandy years ago where he resected the entire cerebral hemisphere, the glioblastoma, and the damn thing came up on the other side in every case. He didn't cure anybody. I think imaging has limitations, at least in any one moment in time. And while it's important, I don't believe we should depend on it entirely, and I think it's something that the younger people, I think, have a tendency to do, and I think it's a mistake. I also believe that the computer is here to stay, but I think that we're not as good a group of observers as we used to be. We look but we don't necessarily see, and I think we have to train ourselves to become better observers. Because there's still plenty of mysteries that can be resolved by good clinical observation.
Question: Do you think a belief in imaging being true is going to hurt us in some of the technology we're doing now?
Dr. Glatstein: Well, what do the vendors do? They see what we're doing and they try to come up with a better way of doing it. But the better way is basically about doing things faster and perhaps more accurately -- I say perhaps, because I'm not sure that's really been shown. But we do that, and what it's good for is better through-put. But the vendors are not coming up with new breakthrough technology, so they're going to change the way we do things. They're effectively making us do things faster, not necessarily better. Now, I know there are plenty of people who would argue with that, but it remains to be seen. When I was young, if the vendors had a new development, they would come to a department or two, and they'd install their piece of equipment and people would try it out for a year or two. Now they come up with a piece of equipment and they go out to marketing directly. I don't think that's necessarily a change for the better.
Question: So do you think the balance of our research in our field, you say we're mostly a clinical field, but we have a lot of people now doing science. Do you think we have a pretty reasonable balance now?
Dr. Glatstein: No. I think the problem is that the technology all has a billing code with it for which you can bill. And biology doesn't have a code. I think we do a poor job relating to targeted treatments, for example. I suspect some of those targeted treatments would have influence on radiation sensitivity, but who the hell is doing that kind of work? Not many. And I think the key to our future is the ability to manipulate the cells—tumor or normal tissue or both—to alter the sensitivity. That's the key. And if we don't do that, I believe we'll ultimately fade out. If we had a truly effective radiosensitizer with a decent (but not great) sensitizing enhancement ratio of 1.5, it would be far more important than all dose escalation done in the past fifteen years (of course, that presumes that normal tissues are not significantly sensitized).
Question: I just want to go back to what I understand, the two points that you made seem to me extremely as reasonable, indeed, Eli.
Dr. Glatstein: Well, thank you, thank you. You're not going to send me the hate mail that I get from some of my editorials?
Question: No. Absolutely not. One is that having good people well trained, smart and going into private practice, going to take care of patients is not a loss.
Dr. Glatstein: I personally don't feel it's a loss. I think the academic centers can't possibly take care of everybody. We need good people out there in practice. We need good people who know what they're doing and who know when they're over their head so we can send those people to the centers.
Question: You send them with a small bag. Don't travel too heavy. Right?
Dr. Glatstein: Absolutely. And I've told a number of residents, I don't care if they go into practice or not. If they go into practice, I want them to be able to tell me that everybody says they're the best around for a 100-mile radius. If they're doing that, then I'm happy that they're going into practice. Now I've lost some very good people that I think could have been great academicians, but they went into practice. I don't feel bad about it. In today's world, many of these guys have got ridiculous debts that they have to pay off and many of them are married with a wife and two kids or more, and they have to go into practice. I understand that. And that's not the end of the world. I want them to do a great job out there.
Question: Okay, I agree entirely with you. The other point that I'd like to make that I think that if I understand you very correctly is that we're leaving behind or sort of ignoring the value of a good history and a good physical exam. No technology substitutes for that.
Dr. Glatstein: I believe that's true. I also believe in the era of the computer, the initial history gets repeated over and over again. They may be asking the right questions, but they're not necessarily recording them. You see a patient three years later and you look at the latest history and it's the same history that was recorded before the guy was ever treated.
Question: Copy and paste.
Dr. Glatstein: Yes, yes, yes. And the computer almost begs for that. It's so easy to do. And I think it's a bad habit to get into. In some ways it’s like quoting the abstract of a paper without actually reading; you miss a tremendous amount.
Question: So, Eli, do you think the Society is doing what it should be doing, anything regarding the actual cost of treating patients with radiation oncology in terms of the perhaps misutilization/overutilization of some of the resources, techniques that we use now?
Dr. Glatstein: Well, I know that happens. I don't have a good feel for how common it is. But I think it's more common than I want to believe. But I saw somewhere there was a paper on doing complex treatment planning to spare the hair in the whole-brain treatment for brain metastases. Somebody who is doing that doesn't have enough to keep them busy.
Question: The hair professor.
Dr. Glatstein: The use of stereotactic treatment for 12 or 13 different metastatic nodules in the brain, you know, there are many instances where the revenue issues seem to be trumping common sense. And I'm not against the technology per se, but I think the technology is seriously over touted and it's hard to find data that actually show we have better outcomes.
Question: Yes. I'll give you a brief example and see if you would agree with me. Patients that have been treated for advanced carcinoma of the lung with combination therapy and are being followed frequently with CT scans of the chest and when you review—as I have—the reports of the CT scans they provide no useful information. The patients are beyond the scope of cure they cannot be salvaged. An old simple chest X-ray will give you an idea—eh, so-so, about the same, worse, cannot tell what is going on—at much more reduced cost.
Dr. Glatstein: I think that that's true. I would dispute there is no value at all. I think when you've radiated someone's chest like that, sometimes you learn about radiation injury, but the fact is that that's a relatively small benefit. There’s certainly no survival gain that can be shown. But, yeah, I think that that's absolutely true. I'm relatively comfortable following people with a simple chest X-ray because I've done it for a long time. But the fact of the matter is that's not what most people are doing today. I’m very partial to the statement attributed to Einstein that not everything that counts can be counted, and not everything that can be counted counts.
Question: Okay. So, Eli, you had some experience at the Red Journal? Is that correct?
Question: Written a few editorials?
Question: A little bit about that and editorial and why you write those things.
Dr. Glatstein: What? The editorials?
Question: How you view what the journal is supposed to do and what your intention is with your editorials, because I know they're often misunderstood.
Question: Well, not entirely.
Dr. Glatstein: There are things that I think need to be said to make people think, to provoke them. People are very trusting and very assuming today in many, many ways. And I think part of our job, I believe, is to provoke them and make them aware, to make them think, think about things that they haven't given a lot of thought to. Sometimes it's an academic issue. Sometimes it's just an awareness of what's going on. I mean, I wrote one, I think it's called "The Return of the Snake Oil Salesman." And the point of that was simply to make people aware that we're subject to all kinds of market forces today that in another era we weren't subject to at all, or virtually none anyway. But now the market forces are almost the dominant force. And certainly people are doing things, buying equipment, for example, where the benefits of the new equipment are marginal at best, but that's what's happening. I think that there's an obligation, I think, on the part of people who want to consider themselves leaders in the field to lead. They've got to make other people aware. Other people don't have to agree, but they've got to be thinking about these issues and if they want to disagree, they have to think it through. I don't believe this is about popularity. This is about real leadership where there are complicated issues that we're not all going to agree to, but it's a question of whether you're thinking about the patient, the doctor, society as a whole, the government—these are not easy issues. The science in our field, I think, is actually reasonably good. But the exploitation of the science I'm not sure is there. We're exploiting other things, and I don't think it's science. And in that regard I think the journal has an opportunity to fill a need for the field as a whole. And I think that sometimes they do. Sometimes the journal does fulfill that function and other times it doesn't. I think the Red Journal is a good journal. It could be better and I think Jim Cox did a good job of building it up and I think Anthony Zietman will do a good job at building it even further. I think some of his ideas are very good. I think that the quality of the articles is the most important thing. The quality of the editorials are important. And quality is a hell of a lot different than quantity. And it's not always easy to know when something is good quality, at least early in the game. And the people who lead our field need to be able to take a position that such-and-such is a meritorious article or editorial, even if they don't agree with it. If it just provokes them to think, I think that's good. I don't know, does that answer your question?
Question: Yes. Eli, let me just say, should the journal have more space for opinions?
Dr. Glatstein: Well, I think it depends on what you mean by opinions. I think the opinions have to have reasonable documentation and reasonable thought. I wrote one not too long ago about alpha/beta for normal tissue.
Question: Oh, “The Omega on Alpha and Beta.” I loved it.
Dr. Glatstein: Well, I didn't say that what’s going on is wrong. I said that it's not an alpha/beta ratio for normal tissue, because when you've got a problem with normal tissue after radiation treatment, it's not about the cells that you've killed, it's about the cells that have survived. It's about sub-lethal injury, sub-lethal damage. What they're doing may have value. I don't want to question that. But it's not an alpha/beta ratio. That's my point. Don't call it that if you can't demonstrate it's a ratio of two different types of radiation killing. And I don't think that can be done. I want to see people use stronger logic. We live in an era where people put great emphasis on evidence-based decisions. I don't want to say that we should casually dismiss evidence. I don't believe in that. But I do believe that the logic is actually more important than the evidence, because evidence has to be interpreted. Logic should flow. And I believe in the logic. Logic is the heart of the scientific method; it is the basis for hypothesis upon which scientific progress is based.
Question: Sure. So an opinion should be logical.
Dr. Glatstein: Absolutely. It can't be emotional or shouldn't be emotional.
Question: Okay. Eli, what are you most proud of professionally?
Dr. Glatstein: I'm most proud of the people that I've been able to influence. I'm proud of the fact that I have 27 individuals who either trained with me or were junior faculty with me that have gone on to become academic chairs. Actually, a couple of them are dead now, but I'm still proud of them. I'm proud of people who went in academics and made it work when it was not easy. I'm thinking specifically of at least one individual who had major language problems and overcame it. God, I think so much of that guy. He's made a name for himself when it was not easy, and done a beautiful job. So I'm proud of the people more than anything else. I wish that we were able to intersect better with our colleagues in other fields. I think that we tend to be seriously marginalized because of the perception that we are there to fulfill some technological function at their request. And I think it's a real problem we have to convince our surgical, medical colleagues and pediatric colleagues that we are real doctors and we are doctors first. Norman is a great physician. So is Steve Hahn and many others. So are a lot of the people who transferred into this field after having board certification in internal medicine. Our field is so technical that, you know, if you try to explain IMRT to an audience of internists or surgeons, then you can see their eyes glaze over. We have to convince them that we're doctors before anything else. We have technological expertise, absolutely. But we're doctors first. And I think we've not done a great job as a field in making that obvious. And we have to make it obvious. I had a guy ask me one time, a surgical trainee, "Did you have to go to medical school to become a radiation oncologist?"
Question: What did you tell him?
Dr. Glatstein: Yes. Yes, it's essential. You have to know anatomy, physiology and pathology. You know, a simple thing that bugs me—DVHs. The DVH—everybody nods approvingly—you've got to have a DVH of such-and-such. The DVH presumes that every cubic centimeter of Organ X is the same as every other cubic centimeter of Organ X. It doesn't make a distinction between the renal cortex and the renal medulla. Well, you know, that's why you took histology, to learn the anatomic subtlety. And now we're using DVHs to smear that out. I don't think that's necessarily good. If you have a hot spot when you're treating lung cancer and that hot spot happens to coincide with the AV node, what's going to happen? Well, I don't know, but I worry about those kinds of things. I don't think I want to look at the DVH and say I'm comfortable with it. It's a security blanket that people use and I'm not convinced it's a good one. I understand where they're coming from, I understand that that's what's being done. I do it myself, but I'm not happy with it.
Question: Okay. One last question for me is is there something that we haven't asked you that you are dying to tell us, Eli, whether Norm wants to hear it or not?
Dr. Glatstein: No. I don't have any secrets. I'm pretty transparent.
Question: Let me ask you a couple of questions, Eli. There was one statement when they interviewed Henry Kaplan. So how do you want to be remembered in the long term in the history of our field?
Dr. Glatstein: Well, I'd like to be remembered as a terrific physician, as a compassionate physician, as an innovative physician, someone who thought about things before he did them. I'd like to make PDT into a standard treatment. I've got some things I want to do yet -- actually in lymphoma with radioimmunotherapy. I've got some ideas on how to improve that. I've got some ideas about what to do with small cell that I'd like to put into effect. And I think we'll be able to do them over the next few years here. I'd like to be remembered as someone who was a good teacher, who could make people think, who could make them see some of the nuance, some of the subtlety in whatever we're talking about, whatever we're doing. Those are the things I'd like to be remembered for. And I'm getting there.
Question: Yeah, I would add the example of truth and integrity to you.
Dr. Glatstein: Well, thank you. I'd like to be thought of as someone who says what he thinks and says it honestly. I think I've tried to do that.
Question: Yeah, you have.
Question: Indeed, you really tell it like you see it and, you know, a lot of us think that you see it right very, very, very often if not nearly always.
Dr. Glatstein: Well, nobody is perfect and that certainly includes me. But I think there are things that need to be said and I'm perfectly willing to say them.
Question: Well, we are close to perfect, Eli.
Dr. Glatstein: Well, I don't have any illusions about perfection. I have feet of clay like everyone else.
Question: All right. So, Eli, on behalf of the ASTRO History Committee and particularly Norm and myself, we thank you very much for giving us this interview again. And, again, we could do it another time and it would be even better. This has been a wonderful interview. Thanks.