Joel Tepper, MD, FASTRO
Dr. Montana: Joel, where were you born and where did you grow up?
Dr. Tepper: I was born in Brooklyn, New York. I lived in Flatbush in Brooklyn; lived there till I was seven, or so. I have some memories of the time when I lived there, but not too much. I didn't know New York City very well. I had a grandmother who lived on the other side of Brooklyn, in Williamsburg. When I was about seven years old we moved to Fall River, Massachusetts which is in southeastern Massachusetts, 50 miles from Boston, physically. It’s about 5,000 miles from Boston, socially. I grew up in Fall River. Fall River is not a wealthy community. It was an old mill town. Its heyday was in the 1910-1920s era and the economy was originally based on cotton mills. The mills gradually got abandoned or converted to some other functions, but that was often the case with towns like that. It was a nice place to grow up and you had your own group there that was very nice and pleasant. I started school in Fall River when I was in second grade and went through high school, just public schools. There was, maybe, one high school. Everyone went to the same school but it was a big high school. There were about 750 people in my graduating class.
Dr. Montana: Can you tell us about your family?
Dr. Tepper: When I was growing up in Flatbush, it was a prototypical Jewish family from the 1950s. Three of my grandparents were immigrants, and the fourth was born in the United States. The one that was born here, her parents came over in the 1880s. My mother's side came from Russia, actually from Ukraine. They lived outside Kiev and they came over with a whole group of people. I had one conversation with my grandmother when she was very elderly. She had an easier time coming over than many people, because they had relatives here. She was eight or nine when they immigrated, and they had family who had found a place for them to live, and the community from Kiev lived largely together in Williamsburg.
Dr. Montana: Did any members of your family have a college education?
Dr. Tepper: Well, one grandfather was a pharmacist, and he immigrated when he was about 17 and went to school here. He always talked about being a farmer, but he ended up going to pharmacy school. I had a step-grandfather on my father’s side who became a dentist. So there was a fair amount of academic interest, which was pretty common in the Jewish community at that time. People often were poor, but education was paramount and it was inculcated into all of us. My father went to college and became a certified public accountant. My father always said that he would have loved to have been a physician, but he really couldn't afford it. He went to college, night school and was working at the same time. The idea of being able to manage medical school was something he didn't think was realistic. But he said a number of times that medical school was something he always wanted to do. My mother was the eldest of two daughters and she went to Hunter College, which is now part of CCNY, and then got a masters degree from Columbia. So again, education was important to her family, and it clearly had a bearing on how I lived my life and what was emphasized within the family.
Dr. Montana: You went to Washington University and got a degree in electrical engineering, right?
Dr. Tepper: Not quite right, but we'll get there in a minute. The other thing that was important, in ways that are hard to define, was that when I was very young, between the ages of two and three, I was very sick. I was in the hospital for about nine months, and that had, I think, a major influence in terms of what I could do and how my life developed. It’s hard to define how, because I don’t know what would have happened without that illness. But the illness was important in my life. If you’re in the hospital for nine months that's got to have an impact on a two-year-old.
Dr. Montana: Where was that Joel, in what hospital?
Dr. Tepper: Most of it was in a hospital that I don't think exists anymore. It was mostly at a rehab hospital called Haverstraw a little ways upstate in New York. It was a bit distant, so my parents could visit me only on weekends, but that's about it. It doesn't exist as a standalone hospital anymore.
Dr. Montana: You have memories of that?
Dr. Tepper: Not really, I can't remember. There was a picture or two but it's not a real memory. My parents didn't like to talk about it very much. It wasn't the high point of their life, but those things tend to have an influence in unknown ways. I guess they can strengthen you and they can destroy you. It did have implications for my life.
Dr. Montana: Do you have any siblings, Joel?
Dr. Tepper: Yes, I have two sisters. One sister is two years older than I am, and the other one is eight years younger. Not surprisingly, I had very different interactions with my two sisters. The older one and I were close enough that we got along well, but we also fought like siblings do. The younger one was very much a baby sister. It was a different relationship with each sister. We still keep in pretty close touch. During problem times we always come together.
Dr. Montana: Okay, so now we’re coming up on MIT.
Dr. Tepper: Yes. In high school, I was always good in the sciences, which I guess is true of a lot of people in medical school. I was always much more oriented towards the physical sciences. The biological sciences, in many ways, were a challenge. It was more memorization in high school than it was in really understanding biology. To me, memorization was terrible. I could never memorize anything. I still can't, but I can remember concepts. It’s mathematics and physics that can challenge you in a very discreet way. So I applied to colleges and ended up going to MIT. Originally I thought I'd be a physics major, which of course is the true love of probably a third of people entering MIT. A lot of people have the same type of experience, math and physics is what they can relate to in high school. I did reasonably well at MIT. The curriculum at that time had a lot of requirements, and the requirements were very heavily related to the physical sciences. So we were required to take four semesters of math and four semesters of physics, and this is MIT math and physics. In the second year I entered an honors physics class. Everyone was taking physics and there were 30 people taking the honors physics class. I tell you, this was the smartest group of people I've ever been around, and there’s no question that I was the dumbest person in that class. I decided that I could be a physicist, but I wasn't going to be a really outstanding physicist. So I needed to think of other approaches for my life, so I left the physics major and went into electrical engineering. This wasn’t because I had any intention of being an electrical engineer, but it was, in many ways, close to physics and I was in the honors electrical engineering program. It was a much more theoretically oriented electrical engineering class. It was not very practical, but MIT was a terrific experience because it does a phenomenally good job in terms of making one think in ways that I think many undergraduate educations do not do. You would have problem sets for homework, but the problem sets would not just be practicing how to solve problems you learned in class, but they were developing new course material. So you would actually develop the course material doing the problem sets, and you would develop the things that you needed to know. Tests were almost always open book. It was not so important that you memorized an equation, but it was important that you understood how to use it. Often, when you had a problem set, you would “set it up.” You would write out the way to solve the problem, and then go on to the next problem. I wouldn't solve it because you received mostly full credit if you set it up right. They didn't really care about the right answer. You knew how to get to the right answer, but if you made a technical mistake in solving it, that didn't hurt you very much in terms of grades. So it was a wonderful experience in terms of how to think and how to analyze, and I've always used that. It's been one of my strengths, and I give MIT a fair amount of credit for that. I get to learn how to think. As I said, I didn't want to be an electrical engineer because I didn't think I would enjoy doing that, but medicine had always been in the background. My father talked about it and I was a nice Jewish boy growing up, so medicine was there. I always thought that medicine might be a good profession, but I was afraid that I would hate medical school. But I decided, what the heck, even if I hated medical school, that's okay. I ended up taking a biology course, because you have to take a biology course to get into medical school. I took one that was the forerunner of a molecular biology course. Molecular biology did not exist, but that was its orientation.. It was not comparative anatomy or zoology or any of those things.
I took one semester of a biology lab which was taught by an amazing professor whose name was Jerry Letvin. He was an MD who taught electrical engineering and biology and, I think, psychology. He tended to think most MDs were stupid. So we would make our own devices for measuring electrical signals from the frog optic tectum, and things like that, but we had to construct the electronics in order to do it. It was as much electrical engineering as it was biology. I took organic chemistry at Harvard over the summer. That was basically eight weeks where you went to class three hours a day, and then you had the rest of the day as lab. On Friday afternoons there was a test, and so that was a pretty intensive organic chemistry course. Then I applied to medical school and a couple of places turned me down instantly, probably because they thought I didn't have their prerequisites. But I got into Washington University.
What happened with getting into Wash U was a bit strange, because I applied and I thought I should have heard something about interviews. So I called them up and they looked and said, “Oh yeah, do you want to come for an interview?” I said, “Okay, is it going to be worth my while to come for an interview?” They basically said yes and so I got down there. It wasn’t much of an interview. I met with this guy, and he said, “Well you’re pretty minimal on your premedical studies and all, but I guess it's okay.” He accepted me on the spot, so it was rather bizarre – they clearly had decided before the interview that I was going to be accepted as long as I could speak the language, or that I didn't look like a total MIT nerd, or something like that.
But it was pretty bizarre for an interview, because I walked out of the interview and I called my mother and I said, “Hey, they accepted me.”
The first year I really despised it, but I had hesitated to go to medical school because I thought I would despise the first year, so it lived up to my expectations. It seemed to be all memorization, with very little understanding. During the first year I did okay, though I certainly didn't set a record for my grades. I came back the first day of the second year, and I walked into class and a number of people came up to me and said, “You came back!” I said, “Did you think I wasn't?” They said, “Well, we heard that there was one person who had not flunked out but had just decided not to come back. We figured it must be you.” After that it got better. I got a little more into the swing of things, understood a little more of the style of medical school and decided I would just put up with the memorization. As it went on it got more interesting. I can’t say that I enjoyed the first two years of medical school. Everything was new during the first years of medical school. I told you what my one biology course was like and the other students had taken comparative anatomy, zoology, and other premed courses, so they already knew much of the information. Everything I heard was totally new to me. I didn't know any of this stuff. Then I started to think of what I wanted to do for a career. I considered doing internal medicine and I thought about doing radiology. I took a radiology elective and I spoke to a pulmonary radiologist, Jack Forest, about careers. I didn’t want to be a radiologist and sit in the dark and read films all day. I told him what I liked, and he said, “You know, you should look at radiation oncology. It sounds like more of the kind of thing you'd like. It has a lot of technical pieces to it, but you see patients and do different types of things.” So I explored that a little bit, not nearly as much as you might think, certainly not by today's standards. I went to speak to one of the radiation oncologists, and the person I spoke to was Carlos Perez. I just chatted with Carlos generally. He was in the middle of a lab experiment with mice. We talked about radiation oncology and it sounded interesting, but I don't think I spoke to anyone else within the radiation oncology division at that time. I certainly never took an elective in radiation oncology. Later, I was taking a pathology rotation and I was interacting with Lauren Ackerman who was one of the preeminent surgical pathologists of his era. I ended up having a long chat with. I'm sure Carlos would have been furious if he knew this at the time but Ackerman said, “If you're going into radiation oncology, you should do a residency with Herman Suit. He just moved to the MGH in Boston. You should train with him.”
Dr. Montana: That would have been around 1968, or so?
Dr. Tepper: This would've been around 1971. I think Herman Suit was just moving from MD Anderson, right about then. This sounded kind of nice to me because I like Boston. Before I went to Boston for a senior elective, I called up Dr. Suit and said, “I am a medical student and I am interested in going into radiation oncology. Can I meet with you?” He said sure, and I came over and we talked for probably two hours. We had a long chat, so I guess he kind of liked me. I never actually submitted an application for residency, but at one point, I just called Herman and said that I would like to do a residency. He basically said okay and I didn't meet with anyone else. I never had an interview process, he just accepted me. It was a pretty new program at Mass General. It had been a division of radiology before that, so it wasn't starting from scratch. I ended up doing an internal medicine internship at Presbyterian St. Luke's Hospital in Chicago, which I had applied to and got in before I met with Herman. I was there for a year and got a good intensive clinical experience.
I then moved back to Boston and started my residency. It was new as a department, having recently separated from radiology, but it was interesting because they did have two very senior people who were there already. The most senior person was Milford Shultz, an individual who is not now remembered by many people in our field, but he was the first full-time radiation oncologist in New England. He was the only radiation oncologist for a while. He's the person who initially set up radiation oncology at Mass General. He was very much an old-fashioned individual in a number of different ways. He was heading towards retirement when I got there, but I did a rotation with him. His notes would be two to three sentences long, such as, “Fifty-four year old man with a T-1 vocal cord tumor on his right cord. Will treat it with radiation.” That was basically the note. He used to tell stories about what things were like when he was young. Initially, the way patients would pay for radiation oncology treatment was that the patient would go down to an office and they would buy a ticket for 10 treatments. After each treatment you would get the ticket punched until you used up the 10 punches on the ticket, and then you would buy another ticket for the next 10 treatments. That was well before my time. Milford was one of the original founders of the club that became ASTRO. There's a picture that I've seen a number of times with about 12 founding members of the radiation oncology club, the predecessor of ASTRO, sitting around a table in Chicago. Milford was one of those at the table and was one of the early pioneers in the field.
The other person who was already at the MGH was CC Wang. CC was very much Milford’s junior partner and Milford trained him. CC already had a substantial reputation and he was certainly a very knowledgeable person about cancer. CC understood how cancer was supposed to behave and understood the natural history of the disease extremely well. He knew what was going on and treated a lot of patients with some pretty lousy equipment. When I got there we had three machines. The first year in the old department, they were building a new physical department at the time, and we had a 55 cm isocentric cobalt unit, a 2 MEV Van de Graaff generator and a 280 kV orthovoltage machine. When I arrived there, they had obtained a simulator very recently. In some ways, treating patients on those poor machines challenges you more as a clinician, because there is less room for error.
Dr. Glatstein: It forces you to know your equipment better so you know its strengths and its weaknesses.
Dr. Tepper: That’s exactly right.
Dr. Montana: Sam Hellman was very influential in Herman Suit coming into MGH.
Dr. Glatstein: I have to interrupt you to give you a story about CC. The first time I ever met him officially, I was sitting in the front row and he was talking about intra oral cones for oral cavity cancers. He said ideal patients have big mouths. He looks at me and says “Eli you’re perfect.” I couldn't help but to remember that one. There are loads of great CC stories I could probably gradually dredge them out of my memory. He had all these sayings that he used to come up with. Things like “in the land of the blind the one eyed man is king.” The other one that I remember was when he walks in the room and he says to the patient, “Worst thing man can do is get the wrong job. Worst thing a woman can do is marry the wrong man. Worst thing a patient can do is to get the wrong doctor.”
Dr. Tepper: That sounds like typical CC Wang.
Dr. Glatstein: His passing is a real loss.
Dr. Tepper: Yes, he was quite an individual. I got along with CC very well. Not everyone did. He taught me a lot. When I came off of his service, I understood head and neck cancer. I really understood it in a depth that you often don't understand diseases, and I think I still keep some of that even though I haven't treated head and neck cancer in decades.
Dr. Montana: Let me add one comment too that Milford Schultz is really somewhat undervalued and under recognized.
Dr. Tepper: I agree. He wasn't a flashy person, but he did a lot in the field and I only wish I could have spent more time with him. He was also a character. We went over to his house once with the residents, and he had about 50 cuckoo clocks that were going off on the hour.
Dr. Montana: Any recollections about your career and how things were in Boston?
Dr. Tepper: There was talk in Boston about using the Harvard Cyclotron, which had been built in 1947 for physics research, for proton therapy and there had actually been a medical annex built at the Harvard Cyclotron that was being used by Ray Kjellberg, who was a neurosurgeon at Mass General. He understood the potential of being able to stop the beam in a precise localization for radiation delivery. He started treating pituitary tumors and gradually expanded into treating other CNS diseases, such as AVMs, with protons. The medical annex, believe me, was not fancy at all. It looked like a physics lab (which is what it was), but it had a medical line output from the cyclotron. In the 70s the cyclotron wasn't being used a lot for physics research, because it was pretty old and only 160 MEV peak energy. Between the Joint Center and the Mass General, there were discussions about using this for radiation therapy. I don't know the politics of what went on, but it sounded to me as if Sam Hellman and the Joint Center group lost interest, but Herman did not lose interest at all and started developing it for therapy. Herman Suit had hired a physics PhD, who had a background in high energy physics who knew nothing about medical physics by the name of Michael Goitein, who subsequently received an ASTRO Gold Medal, to work on that project and then later hired another high-energy physicist, Lynn Verhey, to work on protons. I don't remember the details, but I also got involved and Herman Suit, Michael Goitein and I treated the first three patients with protons with fractionated radiation therapy (I was definitely the junior participant in this group). Although there were earlier patients treated with protons for pituitary diseases at the MGH (Ray Kjellberg) and Berkeley (John Lawrence), these were the first patients treated in the US with fractionated proton radiation therapy for cancer, and the description of these three patients became my first oral presentation at an ASTRO meeting in Key Biscayne. It was at the time of no simultaneous sessions and I was the last presenter at the meeting, (I think I was number 60). The report did not engender much wide interest within the field at this point. It took quite a while before there was a broader interest in proton therapy, but this started the whole proton effort.
There were two separate clinical efforts that were started at the Cyclotron at that time. One was the fractionated more conventional radiation therapy with protons, and the other was the small field program for treatment of choroidal melanomas. I was heavily involved in treatment of the first few patients with choroidal melanomas. During the time I was doing research there we were working on clinical treatments, but we were also doing laboratory experiments exploring in more detail the RBE of protons, because it was not very well known. We did a mouse skin irradiation experiment with many fractions of radiation, and were doing every three hours fractionated radiation therapy on mouse skin over the course of a long weekend and Herman was in there late at night doing the radiations also. He didn't just pass it off on junior people to do it. He also brought in people from the outside to use their individual techniques for further RBE determination. So I don't know if either of you remember M Raju? He was quite well known and worked at the Los Alamos National Lab for a number of years. I still occasionally hear from him as he is in India working to provide radiation therapy to the underserved at a clinical facility that he set up there. Eric Hall came in and also did RBE experiments. It was a great experience meeting these people and assisting them on some of their work. It was wonderful to help develop a new clinical modality from scratch, and developing and working with an amazing set of individuals.
For the eye treatments we had to develop techniques on how to localize the choroidal melanomas. The original work was with an ophthalmologist who subsequently moved to Australia and then with Evangelos Gragoudas who helped to develop the technique of putting small tantalum circles on the back of the eye for localization. There was a camera to visualize the eye to be sure it did not move during therapy. It was really a very exciting time developing this approach. But this was also around the time of the Vietnam War, which Eli knows a lot about. I had signed up when I was still in medical school for the Berry Plan, which was something where you received a deferment, but you committed to go into the military in your specialty when you finished your residency. So, I had signed up a number of years earlier. The war was over by that time, but I was one of the last Berry planners. When I finished residency I went into the military and had the good fortune of going to Andrews Air Force Base in DC.
Dr. Glatstein: This is how Joel and I got together.
Dr. Tepper: And that's the reason for the good fortune. This was a small cobalt facility, and it was not very busy. I had time to read. I actually wrote a somewhat theoretical article, while I was there, on tumor modeling, and in essence what we now call stem cells. But most importantly, about the time I arrived at Andrews, Eli arrived at the NCI and said it would be a great idea to bring together the people in the armed services as well as the NCI and set up a journal club. Groups from all of the services, the Army, the Navy and the Air Force participated, but my little operation in the Air Force was by far the smallest. We met monthly for journal club and I guess, Eli, you and I got along okay from that experience.
Dr. Glatstein: Oh, yes. Joel was very special. Anyone who can’t get along with Joel shouldn't be on this planet.
Dr. Tepper: After two years in the Air Force I assumed I was going to go back to Boston for a job at the MGH, but Eli offered me a job.
Dr. Glatstein: Yes, I offered you a job but what I was trying to do was get people on board who would be in charge of things. We didn't have a large number of patients in Bethesda, but we had a population. And since Joel had an interest in sarcomas, I thought it was natural for him to come and basically head our sarcoma program and that worked out.
Dr. Tepper: After speaking with Eli I thought it would be a good idea to come to the NCI so I told Herman that I wasn't coming back to Boston. There was also talk about starting an intraoperative radiation therapy program at the NCI at the same time. I did some biology experiments on dogs with Bill Sindelar from the Surgery Branch at the NCI while I will still in the Air Force because I wasn't that busy.
Dr. Montana: So Joel you were there from ’79 to ?
Dr. Tepper: I was in the Air Force from ‘77 to ’79. Part of the time I was going over to the NCI and working with Bill Sindelar. It was actually at the Armed Forces Radiologic Research Institute where we did the radiation experiments because they were able to use animals there.
Dr. Glatstein: They were set up to do some experimental work, and at the time we weren’t set up to do it at the NCI until we got our new department.
Dr. Tepper: We did those experiments and reported on those results for a number of years afterwards as the animals matured through three and five year follow-up. My two responsibilities in coming to the NCI were to work with intraoperative radiation therapy and sarcomas. I actually got involved in GI cancer mostly through the intraoperative radiation therapy work because I was dealing with pancreatic and other abdominal tumors. Steve Rosenberg, the head of the surgery branch, had treatment protocols for sarcomas that I got involved with fairly quickly studying limb conservation as well as adjuvant chemotherapy. The limb conservation study is still a pretty unique study of randomizing patients between amputation versus limb preservation, which is a tough randomization. But we were able to get a modest number of patients on that. About 30 in each arm.
Dr. Glatstein: It was loaded two to one.
Dr. Tepper: It was a two to one randomization, but still a small study with results that appeared consistent with Herman Suit's single institutional study with soft tissue sarcomas.
Dr. Glatstein: Herman was a champion for preoperative treatment, which I think is probably the better way to go. But you couldn't treat people preoperatively at that time.
Dr. Tepper: The time at NCI was exciting, because we had a young vibrant group. Every faculty member there became a department chair. We had Eli as our leader. Allen Lichter, became a chair and a dean at Michigan. Tim Kinsella became a chair at a few departments and Jim Schwade, who went into private practice but for a while was chair at the University of Miami. We had many stimulating conversations about a large variety of research that was going on at the NCI and about new developments in oncology that you wouldn’t find in most radiation oncology departments where the focus would be entirely on radiation therapy. It was intellectually very exciting, we pushed each other and we worked well together.
Dr. Glatstein: We worked well within ourselves but we also worked well with the other specialties. There was no sense of an adversarial relationship. We really got along well with medicine, surgery and pediatrics. It's not to say we didn't have an occasional player, but we really got along. We enjoyed it. It was a lot of fun.
Dr. Tepper: Yes, it was a lot of fun. The exciting part is that it was really intellectual and challenging, and it was not tightly focused on just the technical issues of radiation therapy. It was broad. It was oncology, but it was radiation oriented oncology more the radiation oncology. That has always been my image of the way departments should run. It was academically an extremely productive time for me, because I was reporting on both clinical and biological work with intraoperative radiation therapy. I was being exposed to a whole group of people in a whole new sphere that I hadn’t been used to before. There were people like Steve Rosenberg, Murray Brennan, John Minna, Bob Young, Dan Ihde, Paul Bunn and others.
Dr. Glatstein: They’re a terrific bunch of people. They’re the golden era for NCI.
Dr. Tepper: I was there in a golden era. People were really smart and dedicated and it was a phenomenal environment. Despite how good it was Herman gave me a call. He told me that Len Gunderson was leaving MGH to go back to the Mayo Clinic. Since I had been involved in the intraoperative radiation therapy for GI tumors, Herman asked if I wanted to come back to run the GI service at the MGH. Boston was still kind of my home, and I figured this might be where I’d want to end up. So I unhappily left Eli and the group at the NCI, but moved on to Mass General where I took over the GI service and the intraoperative radiation therapy program. The department had developed a fair bit from what it was when I was a resident. Milford Schultz wasn't there anymore, but CC Wang and Bill Shipley were there. The physics group had Michael Goitein, Lynn Verhey and Cliff Ling. It was still a pretty strong group. We had a small group of surgical oncologists who were also important. Al Cohen, who went to Sloan Kettering a number of years later as head of the colorectal service there and was later a cancer center director. Bill Wood, who left to become chair of surgery at Emory for 25 years or more. Andy Warshaw did the pancreatic surgery and later became chair of surgery at the MGH. They were great people to work with. I expanded my horizons by working with individuals with different orientations. That was a wonderful experience, but it didn't have some of the intellectual ferment that the NCI had. I think the NCI was unique, and you probably couldn't reproduce that at any other institution. It was a good six years at the MGH, but the frustration I had was feeling a little bit too confined. I had a lot of flexibility to do what I wanted in my area, but other things were happening in the department where I would have liked to be more involved. This isn't a criticism of Herman as I wasn't chair. But I was getting calls to be chair and to look at jobs on a fairly regular basis, enough so that I periodically came home and walked in the door and said, “Laurie, how about Cleveland?” She said no. “How about Milwaukee?” No. Literally I would just say, “How about someplace”, and Laurie knew what I was talking about. Then one day, I came home and I said, “How about Chapel Hill, North Carolina?” Laurie said that sounded interesting.
Dr. Glatstein: How did you meet Laurie?
Dr. Tepper: Laurie and I met while I was in medical school. I had a very close friend in medical school who was more interested in movies than in medicine. He was writing movie reviews for the St. Louis Post Dispatch (the major St. Louis newspaper) while he was a medical student. I was good friends with him, and he would show movies in his apartment. One time he had a movie showing, and he rented a small theater and he invited many people to it. So, I went and another classmate came with his date. I was standing outside, the car pulled up and I went and opened the door for his date, who happened to be my future wife. I don’t know what I said, but I said a few words to her. The next day I ended up eating supper in the hospital cafeteria with this other classmate. He said something about how she had broken up with him. I said, “You mind if I call her?” So I did. She later told me that she ended up breaking up with him because when she saw me she looked at me and said, “Why am I going with this other guy?” So, we dated and we got married a year later.
Dr. Glatstein: That’s a wonderful story.
Dr. Tepper: Laurie is a wonderful person.
Dr. Glatstein: She is. And she deserves a lot of credit for what Joel’s been able to do.
Dr. Tepper: She does, and I've been remiss in not mentioning her. Along the way, while we were both at NCI and in Boston, we had our two children. Miriam, the eldest, who was born in Boston during residency and Abby, who was born at the Bethesda Naval Hospital. They're fully grown with my six grandsons. We had talked in the past that perhaps the ideal place for us to live would be in a college town, but Laurie said nothing colder than Boston. I came down to Chapel Hill for an interview. At that time, it was a division of radiology and I said, “Look, this is interesting to me, but I'm not interested unless you make it a department.” I didn't hear from them for a year and a half. Then I got a call from them again saying, “Okay, it's a department. Do you want to look at it?” And my comment at that time was, “Well, yeah. But I’m not going to make a second trip unless you are seriously interested in me.” So they got off the phone and called me back a week later. In the meantime, I spoke to a few people about the job. One of the people I remember speaking to was Eli, because he was my “go to” person. Eli, I remember saying the strength you have here is it's a large strong university. With the strength of the university, you can build that into a good program. That was a large factor in my coming. I thought that even though there wasn't a whole lot there at the time, there were strengths that I could build off of to make a program. I knew I would’ve been happy with that. I like the idea that it wasn't too large.
Dr. Glatstein: My sense was that you were looking for something that you felt you would be able to manage.
Dr. Tepper: Right I didn't want to be a full-time administrator doing no clinical work, which I still don't. The other person I spoke to about the job was Norm Coleman, who was at the Joint Center, at that time and was very helpful, I looked at UNC and thought that this was a place where I could live and could develop a strong program and where the science would be good. So, I came down here in 1987 and have been here for 27 years. It's been a pretty good ride.
Dr. Montana: You have done a terrific job. You brought the department to the high standard that it needed to reach and contributed enormously to the development of the UNC Cancer Center.
Dr. Tepper: Gus knows about UNC.
Dr. Montana: I think this has been wonderful but perhaps we could move on to ASTRO. I would love to hear a little bit of your thoughts regarding the future of our specialty. And looking back, what has given you the most satisfaction in your illustrious professional career?
Dr. Tepper: First of all my involvement with ASTRO was interestingly not that great for a number of years. I was on some committees, but I didn't have any major role. In 1995, I was pretty sick for a while and didn't want to do anything with ASTRO. After a few years, an old friend of mine, Drew Turrisi, suggested that I run for ASTRO President, and I said “No, I'm not ready to do that right now. I need more time” More time went on, and I was feeling better and decided it was a good idea. I called Drew and told him that if he wanted to nominate me now that he could. So I was nominated and elected. I ran because there were things that I wanted to do within ASTRO to try to impact certain issues in the field, which I think are still issues. One issue was the fact that radiation oncology started as a field that was deeply embedded in biology, everything from Puck and Marcus on understanding cell survival curves to tumor clonogens and basic tumor biology that all started from radiation oncology.
Dr. Glatstein: The discovery of the cell cycle came from a radiation biologist.
Dr. Tepper: Yes, right.
Dr. Glatstein: That's as basic as you can get.
Dr. Tepper: Absolutely. I thought we were devolving into too much of a technical specialty where we were becoming technicians and only interested in the latest machinery and giving up cancer biology to medical oncologists. I wanted to see if I could make at least a little impact into changing that. So we worked over the course of a number of years to set up some multidisciplinary conferences. The GI Cancer Symposium with ASCO, and a couple of other societies, was established during this time. Working with Marge Foti I tried to set up a separate meeting with AACR that was oriented towards radiation biology. That fell through but Marge has tried to bring the radiation sciences more into AACR. I tried to set up a time at the Annual Meeting to have presentations from ASCO and AACR that would give people an idea of the important developments in these other areas. I was fortunate to be followed in my presidency by Ted Lawrence, because Ted and I had a number of discussions on the same issue. Ted obviously is a very strong scientist and our interest in this matter was exactly the same. But if you ask the question of what are the issues in radiation oncology now, and think those same issue are still there, although I think there has been some improvement.
Dr. Glatstein: Yes, I don’t think they’ve cleared up, getting a little better perhaps. They still need a lot of attention.
Dr. Tepper: We have the advantage now that there are a lot of people coming into radiation oncology who are really good scientists with very strong backgrounds, who want to get involved and bring the latest science into radiation oncology. That is a really good sign. The bad part is that it’s often hard for these people to find jobs, and a lot of departments are reluctant to hire scientists because they’re afraid that the revenue flow won’t be as great. That really hinders the development of these very talented junior people who could make major contributions. Obviously it is also hurt right now by the funding level at the NCI. This, I think, remains a challenge to the field. We have made huge investments in being able to localize radiation dose distributions to within a few millimeters in many situations. But many times we still don't know where the tumor is with that level of accuracy, and we cannot have the primary focus of our field being to go from 3 mm accuracy to 2 mm accuracy. That is simply not going to make substantial improvements.
Dr. Glatstein: I like to say we’re not going to change the price of eggs in Okinawa.
Dr. Tepper: That's a much more colorful way to put it. It's not going to make a real difference, and the field needs to fully embrace what is going on in biology. Over the last 10-12 years I have made a significant change in my career, in that I've always been mostly a clinical trialist. I've been very active in the NCI, clinical trial development, being head of the GI steering committee, and so on, and this has been a major part of who I am academically. What you may not realize Gus, is I've spent a lot of my time over the last 10 years in other areas. I was director of the UNC GI SPORE grant, and that is obviously a much broader initiative. I've been involved with the TCGA, the Cancer Genome Atlas, and worked heavily in the TCGA on colorectal cancer and, to some extent, in pancreatic cancer. I’ve gotten involved over the last four or five years in nanotechnology, and I'm co-director of a large nanotechnology grant. We've been able to bring in a junior faculty member, Andy Wang, in radiation oncology with basic laboratory work within nanotechnology. So, I think these types of changes reflect the type of things that I wish more people were doing. I am very happy when I see a couple radiation oncologists who are Cancer Center directors such as Paul Okunieff and Wally Curran, since there used to be nobody. I still don't think, other than me, there's ever been a SPORE director who has been a radiation oncologist- but radiation oncologists need to get involved in broader areas and as a field we should not be insular.
Dr. Glatstein: I sat on the SPORE review committee not too long ago, and there was not a single proposal for radiation oncology even as part of a SPORE grant, I was shocked.
Dr. Tepper: But we need to be developing these things. Radiation oncologists need to understand we are foremost oncologists and we are secondarily radiation oncologists. Our modality is radiation and our modality is obviously extraordinarily important to us, but we need to be oncologists who work with radiation. Medical oncology has done a much better job of presenting themselves as oncologists who work with chemotherapy drugs. I always tell my residents that they need to understand, as radiation oncologists, medical oncology much better than medical oncologists understand radiation oncology. And, we need to understand surgical oncology much better than surgical oncologists understand radiation therapy. You need to understand the other field much better than they understand you. That is really critical for us to function well, and it's also critical for us being good physicians. You can't be a good radiation oncologist in GI unless you understand the operation that the surgeons do, their limitations, and understanding what the medical oncologists do and what their limitations are. That needs to be a big push within our field.
Dr. Montana: On behalf of ASTRO and our specialty, I want to thank you for what you have done and the tremendous effort that you have put in all aspects of your professional career. Eli do you have anything to add?
Dr. Glatstein: I just think that Joel has described his personal goals very similar to my own and the way I view our field. We have terrific young talent. We have to use it. We have to keep a strong scientific base, and we have to interdigitated with our colleagues of other fields. These are the central problems that we have, and they are not going to go away. They need direct attention. Joel Tepper has given us some of that. We need more people to do it.
Dr. Montana: Indeed, I want to thank you again.
Dr. Tepper: Well Gus thank you for asking me. Eli I really enjoyed having you on the phone, I appreciate it and thank you for the kind words.
Dr. Tepper: I was born in Brooklyn, New York. I lived in Flatbush in Brooklyn; lived there till I was seven, or so. I have some memories of the time when I lived there, but not too much. I didn't know New York City very well. I had a grandmother who lived on the other side of Brooklyn, in Williamsburg. When I was about seven years old we moved to Fall River, Massachusetts which is in southeastern Massachusetts, 50 miles from Boston, physically. It’s about 5,000 miles from Boston, socially. I grew up in Fall River. Fall River is not a wealthy community. It was an old mill town. Its heyday was in the 1910-1920s era and the economy was originally based on cotton mills. The mills gradually got abandoned or converted to some other functions, but that was often the case with towns like that. It was a nice place to grow up and you had your own group there that was very nice and pleasant. I started school in Fall River when I was in second grade and went through high school, just public schools. There was, maybe, one high school. Everyone went to the same school but it was a big high school. There were about 750 people in my graduating class.
Dr. Montana: Can you tell us about your family?
Dr. Tepper: When I was growing up in Flatbush, it was a prototypical Jewish family from the 1950s. Three of my grandparents were immigrants, and the fourth was born in the United States. The one that was born here, her parents came over in the 1880s. My mother's side came from Russia, actually from Ukraine. They lived outside Kiev and they came over with a whole group of people. I had one conversation with my grandmother when she was very elderly. She had an easier time coming over than many people, because they had relatives here. She was eight or nine when they immigrated, and they had family who had found a place for them to live, and the community from Kiev lived largely together in Williamsburg.
Dr. Montana: Did any members of your family have a college education?
Dr. Tepper: Well, one grandfather was a pharmacist, and he immigrated when he was about 17 and went to school here. He always talked about being a farmer, but he ended up going to pharmacy school. I had a step-grandfather on my father’s side who became a dentist. So there was a fair amount of academic interest, which was pretty common in the Jewish community at that time. People often were poor, but education was paramount and it was inculcated into all of us. My father went to college and became a certified public accountant. My father always said that he would have loved to have been a physician, but he really couldn't afford it. He went to college, night school and was working at the same time. The idea of being able to manage medical school was something he didn't think was realistic. But he said a number of times that medical school was something he always wanted to do. My mother was the eldest of two daughters and she went to Hunter College, which is now part of CCNY, and then got a masters degree from Columbia. So again, education was important to her family, and it clearly had a bearing on how I lived my life and what was emphasized within the family.
Dr. Montana: You went to Washington University and got a degree in electrical engineering, right?
Dr. Tepper: Not quite right, but we'll get there in a minute. The other thing that was important, in ways that are hard to define, was that when I was very young, between the ages of two and three, I was very sick. I was in the hospital for about nine months, and that had, I think, a major influence in terms of what I could do and how my life developed. It’s hard to define how, because I don’t know what would have happened without that illness. But the illness was important in my life. If you’re in the hospital for nine months that's got to have an impact on a two-year-old.
Dr. Montana: Where was that Joel, in what hospital?
Dr. Tepper: Most of it was in a hospital that I don't think exists anymore. It was mostly at a rehab hospital called Haverstraw a little ways upstate in New York. It was a bit distant, so my parents could visit me only on weekends, but that's about it. It doesn't exist as a standalone hospital anymore.
Dr. Montana: You have memories of that?
Dr. Tepper: Not really, I can't remember. There was a picture or two but it's not a real memory. My parents didn't like to talk about it very much. It wasn't the high point of their life, but those things tend to have an influence in unknown ways. I guess they can strengthen you and they can destroy you. It did have implications for my life.
Dr. Montana: Do you have any siblings, Joel?
Dr. Tepper: Yes, I have two sisters. One sister is two years older than I am, and the other one is eight years younger. Not surprisingly, I had very different interactions with my two sisters. The older one and I were close enough that we got along well, but we also fought like siblings do. The younger one was very much a baby sister. It was a different relationship with each sister. We still keep in pretty close touch. During problem times we always come together.
Dr. Montana: Okay, so now we’re coming up on MIT.
Dr. Tepper: Yes. In high school, I was always good in the sciences, which I guess is true of a lot of people in medical school. I was always much more oriented towards the physical sciences. The biological sciences, in many ways, were a challenge. It was more memorization in high school than it was in really understanding biology. To me, memorization was terrible. I could never memorize anything. I still can't, but I can remember concepts. It’s mathematics and physics that can challenge you in a very discreet way. So I applied to colleges and ended up going to MIT. Originally I thought I'd be a physics major, which of course is the true love of probably a third of people entering MIT. A lot of people have the same type of experience, math and physics is what they can relate to in high school. I did reasonably well at MIT. The curriculum at that time had a lot of requirements, and the requirements were very heavily related to the physical sciences. So we were required to take four semesters of math and four semesters of physics, and this is MIT math and physics. In the second year I entered an honors physics class. Everyone was taking physics and there were 30 people taking the honors physics class. I tell you, this was the smartest group of people I've ever been around, and there’s no question that I was the dumbest person in that class. I decided that I could be a physicist, but I wasn't going to be a really outstanding physicist. So I needed to think of other approaches for my life, so I left the physics major and went into electrical engineering. This wasn’t because I had any intention of being an electrical engineer, but it was, in many ways, close to physics and I was in the honors electrical engineering program. It was a much more theoretically oriented electrical engineering class. It was not very practical, but MIT was a terrific experience because it does a phenomenally good job in terms of making one think in ways that I think many undergraduate educations do not do. You would have problem sets for homework, but the problem sets would not just be practicing how to solve problems you learned in class, but they were developing new course material. So you would actually develop the course material doing the problem sets, and you would develop the things that you needed to know. Tests were almost always open book. It was not so important that you memorized an equation, but it was important that you understood how to use it. Often, when you had a problem set, you would “set it up.” You would write out the way to solve the problem, and then go on to the next problem. I wouldn't solve it because you received mostly full credit if you set it up right. They didn't really care about the right answer. You knew how to get to the right answer, but if you made a technical mistake in solving it, that didn't hurt you very much in terms of grades. So it was a wonderful experience in terms of how to think and how to analyze, and I've always used that. It's been one of my strengths, and I give MIT a fair amount of credit for that. I get to learn how to think. As I said, I didn't want to be an electrical engineer because I didn't think I would enjoy doing that, but medicine had always been in the background. My father talked about it and I was a nice Jewish boy growing up, so medicine was there. I always thought that medicine might be a good profession, but I was afraid that I would hate medical school. But I decided, what the heck, even if I hated medical school, that's okay. I ended up taking a biology course, because you have to take a biology course to get into medical school. I took one that was the forerunner of a molecular biology course. Molecular biology did not exist, but that was its orientation.. It was not comparative anatomy or zoology or any of those things.
I took one semester of a biology lab which was taught by an amazing professor whose name was Jerry Letvin. He was an MD who taught electrical engineering and biology and, I think, psychology. He tended to think most MDs were stupid. So we would make our own devices for measuring electrical signals from the frog optic tectum, and things like that, but we had to construct the electronics in order to do it. It was as much electrical engineering as it was biology. I took organic chemistry at Harvard over the summer. That was basically eight weeks where you went to class three hours a day, and then you had the rest of the day as lab. On Friday afternoons there was a test, and so that was a pretty intensive organic chemistry course. Then I applied to medical school and a couple of places turned me down instantly, probably because they thought I didn't have their prerequisites. But I got into Washington University.
What happened with getting into Wash U was a bit strange, because I applied and I thought I should have heard something about interviews. So I called them up and they looked and said, “Oh yeah, do you want to come for an interview?” I said, “Okay, is it going to be worth my while to come for an interview?” They basically said yes and so I got down there. It wasn’t much of an interview. I met with this guy, and he said, “Well you’re pretty minimal on your premedical studies and all, but I guess it's okay.” He accepted me on the spot, so it was rather bizarre – they clearly had decided before the interview that I was going to be accepted as long as I could speak the language, or that I didn't look like a total MIT nerd, or something like that.
But it was pretty bizarre for an interview, because I walked out of the interview and I called my mother and I said, “Hey, they accepted me.”
The first year I really despised it, but I had hesitated to go to medical school because I thought I would despise the first year, so it lived up to my expectations. It seemed to be all memorization, with very little understanding. During the first year I did okay, though I certainly didn't set a record for my grades. I came back the first day of the second year, and I walked into class and a number of people came up to me and said, “You came back!” I said, “Did you think I wasn't?” They said, “Well, we heard that there was one person who had not flunked out but had just decided not to come back. We figured it must be you.” After that it got better. I got a little more into the swing of things, understood a little more of the style of medical school and decided I would just put up with the memorization. As it went on it got more interesting. I can’t say that I enjoyed the first two years of medical school. Everything was new during the first years of medical school. I told you what my one biology course was like and the other students had taken comparative anatomy, zoology, and other premed courses, so they already knew much of the information. Everything I heard was totally new to me. I didn't know any of this stuff. Then I started to think of what I wanted to do for a career. I considered doing internal medicine and I thought about doing radiology. I took a radiology elective and I spoke to a pulmonary radiologist, Jack Forest, about careers. I didn’t want to be a radiologist and sit in the dark and read films all day. I told him what I liked, and he said, “You know, you should look at radiation oncology. It sounds like more of the kind of thing you'd like. It has a lot of technical pieces to it, but you see patients and do different types of things.” So I explored that a little bit, not nearly as much as you might think, certainly not by today's standards. I went to speak to one of the radiation oncologists, and the person I spoke to was Carlos Perez. I just chatted with Carlos generally. He was in the middle of a lab experiment with mice. We talked about radiation oncology and it sounded interesting, but I don't think I spoke to anyone else within the radiation oncology division at that time. I certainly never took an elective in radiation oncology. Later, I was taking a pathology rotation and I was interacting with Lauren Ackerman who was one of the preeminent surgical pathologists of his era. I ended up having a long chat with. I'm sure Carlos would have been furious if he knew this at the time but Ackerman said, “If you're going into radiation oncology, you should do a residency with Herman Suit. He just moved to the MGH in Boston. You should train with him.”
Dr. Montana: That would have been around 1968, or so?
Dr. Tepper: This would've been around 1971. I think Herman Suit was just moving from MD Anderson, right about then. This sounded kind of nice to me because I like Boston. Before I went to Boston for a senior elective, I called up Dr. Suit and said, “I am a medical student and I am interested in going into radiation oncology. Can I meet with you?” He said sure, and I came over and we talked for probably two hours. We had a long chat, so I guess he kind of liked me. I never actually submitted an application for residency, but at one point, I just called Herman and said that I would like to do a residency. He basically said okay and I didn't meet with anyone else. I never had an interview process, he just accepted me. It was a pretty new program at Mass General. It had been a division of radiology before that, so it wasn't starting from scratch. I ended up doing an internal medicine internship at Presbyterian St. Luke's Hospital in Chicago, which I had applied to and got in before I met with Herman. I was there for a year and got a good intensive clinical experience.
I then moved back to Boston and started my residency. It was new as a department, having recently separated from radiology, but it was interesting because they did have two very senior people who were there already. The most senior person was Milford Shultz, an individual who is not now remembered by many people in our field, but he was the first full-time radiation oncologist in New England. He was the only radiation oncologist for a while. He's the person who initially set up radiation oncology at Mass General. He was very much an old-fashioned individual in a number of different ways. He was heading towards retirement when I got there, but I did a rotation with him. His notes would be two to three sentences long, such as, “Fifty-four year old man with a T-1 vocal cord tumor on his right cord. Will treat it with radiation.” That was basically the note. He used to tell stories about what things were like when he was young. Initially, the way patients would pay for radiation oncology treatment was that the patient would go down to an office and they would buy a ticket for 10 treatments. After each treatment you would get the ticket punched until you used up the 10 punches on the ticket, and then you would buy another ticket for the next 10 treatments. That was well before my time. Milford was one of the original founders of the club that became ASTRO. There's a picture that I've seen a number of times with about 12 founding members of the radiation oncology club, the predecessor of ASTRO, sitting around a table in Chicago. Milford was one of those at the table and was one of the early pioneers in the field.
The other person who was already at the MGH was CC Wang. CC was very much Milford’s junior partner and Milford trained him. CC already had a substantial reputation and he was certainly a very knowledgeable person about cancer. CC understood how cancer was supposed to behave and understood the natural history of the disease extremely well. He knew what was going on and treated a lot of patients with some pretty lousy equipment. When I got there we had three machines. The first year in the old department, they were building a new physical department at the time, and we had a 55 cm isocentric cobalt unit, a 2 MEV Van de Graaff generator and a 280 kV orthovoltage machine. When I arrived there, they had obtained a simulator very recently. In some ways, treating patients on those poor machines challenges you more as a clinician, because there is less room for error.
Dr. Glatstein: It forces you to know your equipment better so you know its strengths and its weaknesses.
Dr. Tepper: That’s exactly right.
Dr. Montana: Sam Hellman was very influential in Herman Suit coming into MGH.
Dr. Glatstein: I have to interrupt you to give you a story about CC. The first time I ever met him officially, I was sitting in the front row and he was talking about intra oral cones for oral cavity cancers. He said ideal patients have big mouths. He looks at me and says “Eli you’re perfect.” I couldn't help but to remember that one. There are loads of great CC stories I could probably gradually dredge them out of my memory. He had all these sayings that he used to come up with. Things like “in the land of the blind the one eyed man is king.” The other one that I remember was when he walks in the room and he says to the patient, “Worst thing man can do is get the wrong job. Worst thing a woman can do is marry the wrong man. Worst thing a patient can do is to get the wrong doctor.”
Dr. Tepper: That sounds like typical CC Wang.
Dr. Glatstein: His passing is a real loss.
Dr. Tepper: Yes, he was quite an individual. I got along with CC very well. Not everyone did. He taught me a lot. When I came off of his service, I understood head and neck cancer. I really understood it in a depth that you often don't understand diseases, and I think I still keep some of that even though I haven't treated head and neck cancer in decades.
Dr. Montana: Let me add one comment too that Milford Schultz is really somewhat undervalued and under recognized.
Dr. Tepper: I agree. He wasn't a flashy person, but he did a lot in the field and I only wish I could have spent more time with him. He was also a character. We went over to his house once with the residents, and he had about 50 cuckoo clocks that were going off on the hour.
Dr. Montana: Any recollections about your career and how things were in Boston?
Dr. Tepper: There was talk in Boston about using the Harvard Cyclotron, which had been built in 1947 for physics research, for proton therapy and there had actually been a medical annex built at the Harvard Cyclotron that was being used by Ray Kjellberg, who was a neurosurgeon at Mass General. He understood the potential of being able to stop the beam in a precise localization for radiation delivery. He started treating pituitary tumors and gradually expanded into treating other CNS diseases, such as AVMs, with protons. The medical annex, believe me, was not fancy at all. It looked like a physics lab (which is what it was), but it had a medical line output from the cyclotron. In the 70s the cyclotron wasn't being used a lot for physics research, because it was pretty old and only 160 MEV peak energy. Between the Joint Center and the Mass General, there were discussions about using this for radiation therapy. I don't know the politics of what went on, but it sounded to me as if Sam Hellman and the Joint Center group lost interest, but Herman did not lose interest at all and started developing it for therapy. Herman Suit had hired a physics PhD, who had a background in high energy physics who knew nothing about medical physics by the name of Michael Goitein, who subsequently received an ASTRO Gold Medal, to work on that project and then later hired another high-energy physicist, Lynn Verhey, to work on protons. I don't remember the details, but I also got involved and Herman Suit, Michael Goitein and I treated the first three patients with protons with fractionated radiation therapy (I was definitely the junior participant in this group). Although there were earlier patients treated with protons for pituitary diseases at the MGH (Ray Kjellberg) and Berkeley (John Lawrence), these were the first patients treated in the US with fractionated proton radiation therapy for cancer, and the description of these three patients became my first oral presentation at an ASTRO meeting in Key Biscayne. It was at the time of no simultaneous sessions and I was the last presenter at the meeting, (I think I was number 60). The report did not engender much wide interest within the field at this point. It took quite a while before there was a broader interest in proton therapy, but this started the whole proton effort.
There were two separate clinical efforts that were started at the Cyclotron at that time. One was the fractionated more conventional radiation therapy with protons, and the other was the small field program for treatment of choroidal melanomas. I was heavily involved in treatment of the first few patients with choroidal melanomas. During the time I was doing research there we were working on clinical treatments, but we were also doing laboratory experiments exploring in more detail the RBE of protons, because it was not very well known. We did a mouse skin irradiation experiment with many fractions of radiation, and were doing every three hours fractionated radiation therapy on mouse skin over the course of a long weekend and Herman was in there late at night doing the radiations also. He didn't just pass it off on junior people to do it. He also brought in people from the outside to use their individual techniques for further RBE determination. So I don't know if either of you remember M Raju? He was quite well known and worked at the Los Alamos National Lab for a number of years. I still occasionally hear from him as he is in India working to provide radiation therapy to the underserved at a clinical facility that he set up there. Eric Hall came in and also did RBE experiments. It was a great experience meeting these people and assisting them on some of their work. It was wonderful to help develop a new clinical modality from scratch, and developing and working with an amazing set of individuals.
For the eye treatments we had to develop techniques on how to localize the choroidal melanomas. The original work was with an ophthalmologist who subsequently moved to Australia and then with Evangelos Gragoudas who helped to develop the technique of putting small tantalum circles on the back of the eye for localization. There was a camera to visualize the eye to be sure it did not move during therapy. It was really a very exciting time developing this approach. But this was also around the time of the Vietnam War, which Eli knows a lot about. I had signed up when I was still in medical school for the Berry Plan, which was something where you received a deferment, but you committed to go into the military in your specialty when you finished your residency. So, I had signed up a number of years earlier. The war was over by that time, but I was one of the last Berry planners. When I finished residency I went into the military and had the good fortune of going to Andrews Air Force Base in DC.
Dr. Glatstein: This is how Joel and I got together.
Dr. Tepper: And that's the reason for the good fortune. This was a small cobalt facility, and it was not very busy. I had time to read. I actually wrote a somewhat theoretical article, while I was there, on tumor modeling, and in essence what we now call stem cells. But most importantly, about the time I arrived at Andrews, Eli arrived at the NCI and said it would be a great idea to bring together the people in the armed services as well as the NCI and set up a journal club. Groups from all of the services, the Army, the Navy and the Air Force participated, but my little operation in the Air Force was by far the smallest. We met monthly for journal club and I guess, Eli, you and I got along okay from that experience.
Dr. Glatstein: Oh, yes. Joel was very special. Anyone who can’t get along with Joel shouldn't be on this planet.
Dr. Tepper: After two years in the Air Force I assumed I was going to go back to Boston for a job at the MGH, but Eli offered me a job.
Dr. Glatstein: Yes, I offered you a job but what I was trying to do was get people on board who would be in charge of things. We didn't have a large number of patients in Bethesda, but we had a population. And since Joel had an interest in sarcomas, I thought it was natural for him to come and basically head our sarcoma program and that worked out.
Dr. Tepper: After speaking with Eli I thought it would be a good idea to come to the NCI so I told Herman that I wasn't coming back to Boston. There was also talk about starting an intraoperative radiation therapy program at the NCI at the same time. I did some biology experiments on dogs with Bill Sindelar from the Surgery Branch at the NCI while I will still in the Air Force because I wasn't that busy.
Dr. Montana: So Joel you were there from ’79 to ?
Dr. Tepper: I was in the Air Force from ‘77 to ’79. Part of the time I was going over to the NCI and working with Bill Sindelar. It was actually at the Armed Forces Radiologic Research Institute where we did the radiation experiments because they were able to use animals there.
Dr. Glatstein: They were set up to do some experimental work, and at the time we weren’t set up to do it at the NCI until we got our new department.
Dr. Tepper: We did those experiments and reported on those results for a number of years afterwards as the animals matured through three and five year follow-up. My two responsibilities in coming to the NCI were to work with intraoperative radiation therapy and sarcomas. I actually got involved in GI cancer mostly through the intraoperative radiation therapy work because I was dealing with pancreatic and other abdominal tumors. Steve Rosenberg, the head of the surgery branch, had treatment protocols for sarcomas that I got involved with fairly quickly studying limb conservation as well as adjuvant chemotherapy. The limb conservation study is still a pretty unique study of randomizing patients between amputation versus limb preservation, which is a tough randomization. But we were able to get a modest number of patients on that. About 30 in each arm.
Dr. Glatstein: It was loaded two to one.
Dr. Tepper: It was a two to one randomization, but still a small study with results that appeared consistent with Herman Suit's single institutional study with soft tissue sarcomas.
Dr. Glatstein: Herman was a champion for preoperative treatment, which I think is probably the better way to go. But you couldn't treat people preoperatively at that time.
Dr. Tepper: The time at NCI was exciting, because we had a young vibrant group. Every faculty member there became a department chair. We had Eli as our leader. Allen Lichter, became a chair and a dean at Michigan. Tim Kinsella became a chair at a few departments and Jim Schwade, who went into private practice but for a while was chair at the University of Miami. We had many stimulating conversations about a large variety of research that was going on at the NCI and about new developments in oncology that you wouldn’t find in most radiation oncology departments where the focus would be entirely on radiation therapy. It was intellectually very exciting, we pushed each other and we worked well together.
Dr. Glatstein: We worked well within ourselves but we also worked well with the other specialties. There was no sense of an adversarial relationship. We really got along well with medicine, surgery and pediatrics. It's not to say we didn't have an occasional player, but we really got along. We enjoyed it. It was a lot of fun.
Dr. Tepper: Yes, it was a lot of fun. The exciting part is that it was really intellectual and challenging, and it was not tightly focused on just the technical issues of radiation therapy. It was broad. It was oncology, but it was radiation oriented oncology more the radiation oncology. That has always been my image of the way departments should run. It was academically an extremely productive time for me, because I was reporting on both clinical and biological work with intraoperative radiation therapy. I was being exposed to a whole group of people in a whole new sphere that I hadn’t been used to before. There were people like Steve Rosenberg, Murray Brennan, John Minna, Bob Young, Dan Ihde, Paul Bunn and others.
Dr. Glatstein: They’re a terrific bunch of people. They’re the golden era for NCI.
Dr. Tepper: I was there in a golden era. People were really smart and dedicated and it was a phenomenal environment. Despite how good it was Herman gave me a call. He told me that Len Gunderson was leaving MGH to go back to the Mayo Clinic. Since I had been involved in the intraoperative radiation therapy for GI tumors, Herman asked if I wanted to come back to run the GI service at the MGH. Boston was still kind of my home, and I figured this might be where I’d want to end up. So I unhappily left Eli and the group at the NCI, but moved on to Mass General where I took over the GI service and the intraoperative radiation therapy program. The department had developed a fair bit from what it was when I was a resident. Milford Schultz wasn't there anymore, but CC Wang and Bill Shipley were there. The physics group had Michael Goitein, Lynn Verhey and Cliff Ling. It was still a pretty strong group. We had a small group of surgical oncologists who were also important. Al Cohen, who went to Sloan Kettering a number of years later as head of the colorectal service there and was later a cancer center director. Bill Wood, who left to become chair of surgery at Emory for 25 years or more. Andy Warshaw did the pancreatic surgery and later became chair of surgery at the MGH. They were great people to work with. I expanded my horizons by working with individuals with different orientations. That was a wonderful experience, but it didn't have some of the intellectual ferment that the NCI had. I think the NCI was unique, and you probably couldn't reproduce that at any other institution. It was a good six years at the MGH, but the frustration I had was feeling a little bit too confined. I had a lot of flexibility to do what I wanted in my area, but other things were happening in the department where I would have liked to be more involved. This isn't a criticism of Herman as I wasn't chair. But I was getting calls to be chair and to look at jobs on a fairly regular basis, enough so that I periodically came home and walked in the door and said, “Laurie, how about Cleveland?” She said no. “How about Milwaukee?” No. Literally I would just say, “How about someplace”, and Laurie knew what I was talking about. Then one day, I came home and I said, “How about Chapel Hill, North Carolina?” Laurie said that sounded interesting.
Dr. Glatstein: How did you meet Laurie?
Dr. Tepper: Laurie and I met while I was in medical school. I had a very close friend in medical school who was more interested in movies than in medicine. He was writing movie reviews for the St. Louis Post Dispatch (the major St. Louis newspaper) while he was a medical student. I was good friends with him, and he would show movies in his apartment. One time he had a movie showing, and he rented a small theater and he invited many people to it. So, I went and another classmate came with his date. I was standing outside, the car pulled up and I went and opened the door for his date, who happened to be my future wife. I don’t know what I said, but I said a few words to her. The next day I ended up eating supper in the hospital cafeteria with this other classmate. He said something about how she had broken up with him. I said, “You mind if I call her?” So I did. She later told me that she ended up breaking up with him because when she saw me she looked at me and said, “Why am I going with this other guy?” So, we dated and we got married a year later.
Dr. Glatstein: That’s a wonderful story.
Dr. Tepper: Laurie is a wonderful person.
Dr. Glatstein: She is. And she deserves a lot of credit for what Joel’s been able to do.
Dr. Tepper: She does, and I've been remiss in not mentioning her. Along the way, while we were both at NCI and in Boston, we had our two children. Miriam, the eldest, who was born in Boston during residency and Abby, who was born at the Bethesda Naval Hospital. They're fully grown with my six grandsons. We had talked in the past that perhaps the ideal place for us to live would be in a college town, but Laurie said nothing colder than Boston. I came down to Chapel Hill for an interview. At that time, it was a division of radiology and I said, “Look, this is interesting to me, but I'm not interested unless you make it a department.” I didn't hear from them for a year and a half. Then I got a call from them again saying, “Okay, it's a department. Do you want to look at it?” And my comment at that time was, “Well, yeah. But I’m not going to make a second trip unless you are seriously interested in me.” So they got off the phone and called me back a week later. In the meantime, I spoke to a few people about the job. One of the people I remember speaking to was Eli, because he was my “go to” person. Eli, I remember saying the strength you have here is it's a large strong university. With the strength of the university, you can build that into a good program. That was a large factor in my coming. I thought that even though there wasn't a whole lot there at the time, there were strengths that I could build off of to make a program. I knew I would’ve been happy with that. I like the idea that it wasn't too large.
Dr. Glatstein: My sense was that you were looking for something that you felt you would be able to manage.
Dr. Tepper: Right I didn't want to be a full-time administrator doing no clinical work, which I still don't. The other person I spoke to about the job was Norm Coleman, who was at the Joint Center, at that time and was very helpful, I looked at UNC and thought that this was a place where I could live and could develop a strong program and where the science would be good. So, I came down here in 1987 and have been here for 27 years. It's been a pretty good ride.
Dr. Montana: You have done a terrific job. You brought the department to the high standard that it needed to reach and contributed enormously to the development of the UNC Cancer Center.
Dr. Tepper: Gus knows about UNC.
Dr. Montana: I think this has been wonderful but perhaps we could move on to ASTRO. I would love to hear a little bit of your thoughts regarding the future of our specialty. And looking back, what has given you the most satisfaction in your illustrious professional career?
Dr. Tepper: First of all my involvement with ASTRO was interestingly not that great for a number of years. I was on some committees, but I didn't have any major role. In 1995, I was pretty sick for a while and didn't want to do anything with ASTRO. After a few years, an old friend of mine, Drew Turrisi, suggested that I run for ASTRO President, and I said “No, I'm not ready to do that right now. I need more time” More time went on, and I was feeling better and decided it was a good idea. I called Drew and told him that if he wanted to nominate me now that he could. So I was nominated and elected. I ran because there were things that I wanted to do within ASTRO to try to impact certain issues in the field, which I think are still issues. One issue was the fact that radiation oncology started as a field that was deeply embedded in biology, everything from Puck and Marcus on understanding cell survival curves to tumor clonogens and basic tumor biology that all started from radiation oncology.
Dr. Glatstein: The discovery of the cell cycle came from a radiation biologist.
Dr. Tepper: Yes, right.
Dr. Glatstein: That's as basic as you can get.
Dr. Tepper: Absolutely. I thought we were devolving into too much of a technical specialty where we were becoming technicians and only interested in the latest machinery and giving up cancer biology to medical oncologists. I wanted to see if I could make at least a little impact into changing that. So we worked over the course of a number of years to set up some multidisciplinary conferences. The GI Cancer Symposium with ASCO, and a couple of other societies, was established during this time. Working with Marge Foti I tried to set up a separate meeting with AACR that was oriented towards radiation biology. That fell through but Marge has tried to bring the radiation sciences more into AACR. I tried to set up a time at the Annual Meeting to have presentations from ASCO and AACR that would give people an idea of the important developments in these other areas. I was fortunate to be followed in my presidency by Ted Lawrence, because Ted and I had a number of discussions on the same issue. Ted obviously is a very strong scientist and our interest in this matter was exactly the same. But if you ask the question of what are the issues in radiation oncology now, and think those same issue are still there, although I think there has been some improvement.
Dr. Glatstein: Yes, I don’t think they’ve cleared up, getting a little better perhaps. They still need a lot of attention.
Dr. Tepper: We have the advantage now that there are a lot of people coming into radiation oncology who are really good scientists with very strong backgrounds, who want to get involved and bring the latest science into radiation oncology. That is a really good sign. The bad part is that it’s often hard for these people to find jobs, and a lot of departments are reluctant to hire scientists because they’re afraid that the revenue flow won’t be as great. That really hinders the development of these very talented junior people who could make major contributions. Obviously it is also hurt right now by the funding level at the NCI. This, I think, remains a challenge to the field. We have made huge investments in being able to localize radiation dose distributions to within a few millimeters in many situations. But many times we still don't know where the tumor is with that level of accuracy, and we cannot have the primary focus of our field being to go from 3 mm accuracy to 2 mm accuracy. That is simply not going to make substantial improvements.
Dr. Glatstein: I like to say we’re not going to change the price of eggs in Okinawa.
Dr. Tepper: That's a much more colorful way to put it. It's not going to make a real difference, and the field needs to fully embrace what is going on in biology. Over the last 10-12 years I have made a significant change in my career, in that I've always been mostly a clinical trialist. I've been very active in the NCI, clinical trial development, being head of the GI steering committee, and so on, and this has been a major part of who I am academically. What you may not realize Gus, is I've spent a lot of my time over the last 10 years in other areas. I was director of the UNC GI SPORE grant, and that is obviously a much broader initiative. I've been involved with the TCGA, the Cancer Genome Atlas, and worked heavily in the TCGA on colorectal cancer and, to some extent, in pancreatic cancer. I’ve gotten involved over the last four or five years in nanotechnology, and I'm co-director of a large nanotechnology grant. We've been able to bring in a junior faculty member, Andy Wang, in radiation oncology with basic laboratory work within nanotechnology. So, I think these types of changes reflect the type of things that I wish more people were doing. I am very happy when I see a couple radiation oncologists who are Cancer Center directors such as Paul Okunieff and Wally Curran, since there used to be nobody. I still don't think, other than me, there's ever been a SPORE director who has been a radiation oncologist- but radiation oncologists need to get involved in broader areas and as a field we should not be insular.
Dr. Glatstein: I sat on the SPORE review committee not too long ago, and there was not a single proposal for radiation oncology even as part of a SPORE grant, I was shocked.
Dr. Tepper: But we need to be developing these things. Radiation oncologists need to understand we are foremost oncologists and we are secondarily radiation oncologists. Our modality is radiation and our modality is obviously extraordinarily important to us, but we need to be oncologists who work with radiation. Medical oncology has done a much better job of presenting themselves as oncologists who work with chemotherapy drugs. I always tell my residents that they need to understand, as radiation oncologists, medical oncology much better than medical oncologists understand radiation oncology. And, we need to understand surgical oncology much better than surgical oncologists understand radiation therapy. You need to understand the other field much better than they understand you. That is really critical for us to function well, and it's also critical for us being good physicians. You can't be a good radiation oncologist in GI unless you understand the operation that the surgeons do, their limitations, and understanding what the medical oncologists do and what their limitations are. That needs to be a big push within our field.
Dr. Montana: On behalf of ASTRO and our specialty, I want to thank you for what you have done and the tremendous effort that you have put in all aspects of your professional career. Eli do you have anything to add?
Dr. Glatstein: I just think that Joel has described his personal goals very similar to my own and the way I view our field. We have terrific young talent. We have to use it. We have to keep a strong scientific base, and we have to interdigitated with our colleagues of other fields. These are the central problems that we have, and they are not going to go away. They need direct attention. Joel Tepper has given us some of that. We need more people to do it.
Dr. Montana: Indeed, I want to thank you again.
Dr. Tepper: Well Gus thank you for asking me. Eli I really enjoyed having you on the phone, I appreciate it and thank you for the kind words.
