By Ron Allison, MD and Eric Gressen, MD
The following interview of Leonard Gunderson, MD, FASTRO, was conducted on May 16, 2016, by Ron Allison, MD and Eric Gressen, MD.
Ron Allison: Okay, I guess it’s official now. This is Ron Allison. It’s a great honor to be with Dr. Gunderson. Thanks for your time. There’s an outlined interview so we’ll follow the outline. But certainly add whatever or subtract whatever you want.
Leonard Gunderson: Sure.
Ron Allison: The first question, of course, is where were you born?
Leonard Gunderson: Great Falls, Montana.
Ron Allison: Excellent. Tell us a little bit about your parents and what happened that way.
Leonard Gunderson: The reason I was born in Great Falls is that we lived a hundred miles away. While we had a local family practitioner, my folks usually preferred a little higher level of health care. And so my mom, with her pregnancies, normally went down and stayed with friends in Great Falls for several weeks before her anticipated deliveries. I was raised on a farm and ranch in Northern Montana. Our nearest neighbors were five miles away, and the northern border of our farm and ranch was five miles from the Canadian border. The nearest two towns were 30 miles away - one of 300 plus people and the other with a thousand plus people.
My parents felt strongly about education. In fact, my mom had a two-year college certificate after finishing her high school.
Ron Allison: Where did you go to high school?
Leonard Gunderson: In Joplin, Montana, which was the town of 300 and some people. There was a high school of 50 kids in four grades.
Ron Allison: Did you have to walk uphill both ways in the snow to get home?
Leonard Gunderson: No. I went to grade school in a one-room country schoolhouse. I started 1st grade at age 5 with one classmate, but the teacher had me progress at my own rate to catch up with the next class. When I entered high school, I was 12 years old, and was 16 on entering college.
Ron Allison: How did high school treat you? Were you a great student, I suppose?
Leonard Gunderson: I was the top student in a class of 17. Often when a country kid began going to town school, the town kids kind of gave them a bad time at first. Since I was so young and wasn’t going to compete for places on a sports team or for girlfriends, I was treated more like their little brother.
Ron Allison: Did you offer protection in exchange for exam questions and anything like that?
Leonard Gunderson: I had friends who sometimes wanted to study for tests with me.
Ron Allison: Excellent. Obviously, if you did that well, you went on to college. Was college always part of your process?
Leonard Gunderson: Yeah. My folks encouraged all of us to go to college and supported us in that direction. My siblings and I all went to college. The only one that didn’t graduate was my older sister who ended up marrying after her freshman year and didn’t continue on in college. But the rest of us got college degrees.
Ron Allison: Were you interested in science in college? Where did that come from?
Leonard Gunderson: Well, since I was born and raised on a farm and a ranch and my dad did his own veterinary work, if I hadn’t had so many allergies I would likely have gone to veterinary school instead of medical school.
Ron Allison: But you did well while in college?
Leonard Gunderson: I did well and graduated magna cum laude.
Eric Gressen: Did you say where you went to college?
Leonard Gunderson: I went to Montana State University in Bozeman, Montana.
Eric Gressen: What did your parent do for a living?
Leonard Gunderson: My dad was a farmer and a rancher.
Eric Gressen: And so was your mom at that point?
Leonard Gunderson: She was a homemaker.
Ron Allison: Switching back to college, so you’re obviously a smart guy and were thinking about veterinary school but went to medical school instead?
Leonard Gunderson: I got a Master’s in Anatomy before going to medical school.
Ron Allison: What was your major? You had the Master’s in Anatomy. What’s your college major? We would like that for your interview.
Leonard Gunderson: My college major was biological sciences.
Ron Allison: Very good. So you picked medical school. Was that a desire?
Leonard Gunderson: My paternal grandmother and my high school English teacher both encouraged me to consider that. It was something that was on my mind. My college degree was actually a premed sort of curriculum.
Ron Allison: Okay. I guess it was there sort of in the background?
Leonard Gunderson: Yeah.
Ron Allison: Other than veterinary school and medical school, were there any other thoughts for a career?
Leonard Gunderson: No.
Ron Allison: Okay. Did you do any sports or any activities or you’re mostly studying?
Leonard Gunderson: When you go to a high school as small as I have, pretty much everybody has to participate in everything or you don’t have it. I wondered why my folks wouldn’t let me play football as a freshman, but I was only 5’1” and 100-some pounds. I didn’t participate in football until my junior year when I achieved my full height. I was involved with football, basketball, played in the band, sang in the choir and was Valedictorian of my graduating class.
Ron Allison: Did you continue any of those in college?
Leonard Gunderson: I continued on in musical activities in college. My mom encouraged me to take voice lessons, which I did, and I sang in various choirs, a barbershop quartet and a musical. When I was a senior, my future wife and I were in a 16-voice singing group called The Montanans that went on a 6-week USO tour to entertain U.S. troops in Germany.
Ron Allison: Wow. Do you still continue to sing?
Leonard Gunderson: We do. Now it’s mostly in church as part of mixed voice or men’s choirs or in special music numbers with visiting family members. When we were in Rochester, Minnesota, while I was on the staff of the Mayo Clinic in Rochester, I sang in a civic chorale group for several years. We’ve enjoyed music most of our lives. Our kids have been musicians as well.
Ron Allison: Very nice. Did you do any music during medical school or did you take a break on that part?
Leonard Gunderson: I took voice lessons in the 2nd year of medical school before I was involved in clinical activities. I actually went to Kentucky as a second year medical student. In the process of getting my Master’s in Anatomy, I’d taken first year medical school courses. When I decided I wanted to go to medical school, instead of getting a PhD in Anatomy, there were five schools in the country that were willing to accept people as sophomores. I applied to those. The first school that interviewed me was the University of Kentucky in Lexington. They offered me a spot a week later, so I didn’t bother interviewing with any of the other schools.
Ron Allison: Very good. Lexington is a beautiful area, a lot warmer. Did you change your lifestyle now in the warm weather?
Leonard Gunderson: Well, when you’re going to medical school, you don’t have time for much change in lifestyle.
Ron Allison: At this point in medical school, did you get any exposure to radiation oncology? Or how did that come about?
Leonard Gunderson: Not really. I was planning to be a surgeon when I finished medical school. We had a very strong surgical department at the University of Kentucky. I applied for and was accepted as one of six straight surgery interns at the University of Utah in Salt Lake City. We had a one-month elective during which a friend, also a straight surgical intern, did an elective in radiation oncology and decided that instead of going to DeBakey’s cardiothoracic program in Houston that he was going to go into radiation oncology. He suggested that I should look into it, too. I’d already done my month elective in anesthesiology because I wanted to know what was going on at the opposite end of the table.
During our internship, they let us have a half-day off every week to go skiing, since that was a prime skiing area. Instead, I spent those half days rotating with Dr Henry Plenk, Chair of Radiation Oncology at LDS Hospital/Intermountain Health Care. I decided that radiation oncology was an excellent, wide-open field that needed lots of good people, so I changed from surgery to radiation oncology.
Ron Allison: One year of surgery and then switched right into radiation?
Leonard Gunderson: I did. I was willing to complete another year in surgery because I’d made that commitment. However, since I had a direction I preferred to go, they released me from my surgery commitment. I proceeded to do the radiation oncology residency in a joint program with LDS Hospital and the University of Utah.
Ron Allison: Well, that’s quite fair and nice of them, I suppose.
Leonard Gunderson: It was.
Ron Allison: Tell us a little bit about radiation residency. What years are these? What hospitals?
Leonard Gunderson: My radiation oncology residency was between the years of 1970 to 1974. My internship was 1969 to ‘70. Medical school was three years, 1966 to ‘69. My Master’s in Anatomy was 1964 to 1966.
Ron Allison: Yes. Tell us a little bit about the residency in radiation. Quite a bit of difference, I suppose, from surgery.
Leonard Gunderson: At that time, radiation oncology had started to become its own specialty separate from diagnostic radiology. In fact, the person who my fellow intern and I trained under, Dr Henry Plenk, had been trained and practiced as a diagnostic radiologist but he had a special interest in treating patients with cancer. That’s how radiation oncology evolved as a specialty.
For some diagnostic radiologists who were willing to treat cancer patients, it became their whole practice, which is what had happened with Dr Plenk. One of the interesting aspects of training with Dr Plenk was that in addition to learning about cancer, we also learned how to interpret diagnostic images. Dr Plenk taught us to interpret images for ourselves before we looked at the diagnostic radiologist’s interpretation of such. Basically, the residency was learning how to care for cancer patients, what studies need to be done in the diagnosis, how to work with the diagnostic radiologists in getting the best images we could in treating our patients, how to work with pathologists in defining exactly what sort of tumor that the patient had.
One of the other interesting aspects of being in a fairly small training program was the relationship we developed with oncologic surgeons and the medical oncologist/hematologists. In addition to having weekly tumor conference where a large group of physicians would meet (sometimes the specialists would be trying to present data to justify their own approach), we also had periodic meetings with a much smaller group (radiation oncologists plus the surgical and medical oncologists), where we would talk about problem cases. I think that helped me to see how close interdisciplinary approaches could be in the best interest of the patient where you put aside your own personal biases and say: ‘This patient has a challenging cancer. How do we best combine our various disciplines?’
The other thing that happened was that our residency program was accepted to be part of an NIH training grant. This allowed residents the opportunity to have part of our training outside our parent institution.
During my year of elective time, I spent six months at the University of Utah (radiation oncology – 3mo., medical oncology – 3 mo). Dr Robert Stewart had been appointed Chair of Radiation Oncology at the University of Utah following his residency plus time on staff at Stanford University. He and Dr Plenk decided that RadOnc residents should rotate from one institution to the other. We also had combined teaching conferences in staff homes where residents from both programs would prepare disease-oriented seminars (diagnosis, treatment options, outcomes).
During residency, I also spent 3 months reviewing patient charts at the University of Minnesota, having become aware of some very interesting data during a 3rd or 4th year surgery rotation in medical school. The prior chair of surgery, Dr Owen Wangensteen, had developed some interesting re-operative procedures for patients with prior surgery for gastrointestinal or gynecologic cancers. He felt that for patients who were at high risk for tumor relapse, a reoperation should be performed three to six months after the first surgery to find early evidence of cancer relapse that could be surgically removed. This would potentially change patients from a non-curative to a curative state. If a GI or Gyn cancer is so locally advanced that the initial surgery does not prevent relapse, a second surgery is unlikely to do a better job. The Univ of Minnesota re-operative procedures did, however, unearth some excellent data on where tumors may relapse after an initial cancer surgery.
The opportunity that I had as a resident to go to the Univ of MN to review these charts was facilitated by the chair of surgery at Univ Kentucky (Dr Ward Griffen) who had been on the surgery staff at the Univ MN during the re-operative era. He wrote his Univ MN colleagues and said that I had his blessing to go and review the data.
Review and analysis of the re-operative data yielded intriguing information on where colorectal and gastric cancers tumor relapsed and how to design radiation fields to encompass those potential areas of relapse. This was some early scholarly activity as a resident that led to some important findings and helped get radiation oncology more involved in the treatment of patients with gastrointestinal cancers.
Eric Gressen: I believe that is one of your claims to fame. Your publication became the benchmark for radiation fields for gastric malignancies.
Ron Allison: Yes, truly original work. The idea was planted by a conversation with the chief of surgery or was it more than that?
Leonard Gunderson: It was planted in my mind when I was a medical student in Kentucky. Dr Ward Griffen, chair of surgery at Univ Kentucky during my surgical rotation, would occasionally talk about the Minnesota re-operative data during some of the surgical conferences with the medical students, and I remembered that information. Then when I became a RadOnc resident I said, ‘well, it’s interesting data, but they didn’t go as far as they could have for it to be helpful from a radiation oncology perspective. That’s when I communicated with Dr Griffen and asked if it would be reasonable for me to go to Minnesota and review the data. Dr Griffen gave me the name of Dr Henry Sosin, a surgeon still on staff at Univ MN who had been involved with the re-operative data. When I talked with Dr Sosin and asked if he would be willing for me to come, he said, ‘let me talk to my own residents first’. None of the surgical residents were interested in doing the review. Dr Sosin then essentially told me, ‘well, I’m not sure there’s much there, but if you want to come, you can do so.’ That’s how my family and I came to spend three months in MN so I could review lots of re-operative patient’s charts.
Ron Allison: Was it basically just you?
Leonard Gunderson: I was the one that went through all of the records and organized what data I wanted to collect for future analysis. I let Dr Sosin know about what I was going to be doing. He also gave me permission to communicate with physicians of those patients to get additional information on patterns of relapse and other information including patient status (alive with disease, DOD, etc).
Ron Allison: Did you go back ever into the data? Or was this a one-time visit?
Leonard Gunderson: It was a one-time extensive review of the records in Minnesota, extracting pertinent findings onto written flow sheets, and copying operative and pathology reports. I analyzed the data when we returned to Utah. Following the analysis, I decided to work with an artist to put the patterns of relapse in diagrammatic fashion and illustrate/indicate potential radiation fields.
Ron Allison: Again, was that a part of your idea as an anatomist to do that sort of visual?
Leonard Gunderson: My anatomy background undoubtedly influenced that sort of approach.
Ron Allison: From the time that you first got your hands on these records to a time that you got the artist to complete it, about how long was that?
Leonard Gunderson: I presented the rectal data at an ASTRO meeting while I was still a resident and had the manuscript accepted for publication. I never did present the gastric data at a national meeting. My initial manuscript of the gastric data was felt to be too extensive by journal reviewers and I was asked to shorten the paper. It was several years before I ended up revising the manuscript and had it accepted in a peer-reviewed journal.
Ron Allison: When you presented at the ASTRO, what was the response?
Leonard Gunderson: It was very positive. Before I presented the data at ASTRO, I actually presented it at a conference at MD Anderson where I did a 3-month rotation as a resident. Dr Charles Votava, the second RadOnc staff at LDS hospital along with Dr Plenk, had trained at the Univ of Iowa and then did a fellowship at MD Anderson. He helped arrange for a three-month rotation at MD Anderson, again, as part of my year away. He let Dr Gilbert Fletcher know that I was coming and that I had the re-operation data. I actually had a private audience with Dr Fletcher who then asked me to present the data at a morning RadOnc conference. I did that with charts that my wife put together on poster board.
Ron Allison: I’m sure that with Dr. Fletcher doing and agreeing with that, that must have been very encouraging.
Leonard Gunderson: Before I went to MD Anderson, Dr Votava was very helpful in telling me how to best interact with the various staff at MD Anderson because he’d been there as a fellow. It, accordingly, ended up being a very fruitful three months.
I went there as an observer because in those days, if you were only going to be there for three months, you had no hands-on experience with patients. I went basically to gain more knowledge about head and neck cancer because those patient volumes were low at the LDS Hospital. I also wanted to see more GYN cancer patients. As I said, the rotation also gave me some interesting personal time with Dr Fletcher.
Ron Allison: What was he like?
Leonard Gunderson: In his own domain, he was a much different person than what you saw at national meetings. He spoke a much more discernible English language with a French accent. Some people said when he gave talks at national meetings, it was hard for them to understand him. But in morning conferences and the personal interactions with him, it wasn’t a problem. I had delightful interactions with him. But like I say, I had been carefully instructed on how to interact with him.
When I was a young junior staff at Mass General Hospital, Dr Fletcher invited me to be part of a panel that he put together at an international conference in Buenos Aires.
Ron Allison: That’s delightful. That’s a gigantic project for residency. Is that what you did for the rest of the residency or it’s just part of what you did?
Leonard Gunderson: Well, it was part of what I did. I also performed an analysis of treatment outcomes for patients with small cell cancer of the cervix treated at the LDS Hospital. The reoperative papers and the small cell cervix cancer paper were my main academic projects while I was a resident.
Ron Allison: Were you considered a superstar with it by your other residents? How did that go?
Leonard Gunderson: Well, you’d have to ask them.
Ron Allison: Through residency, quite a bit of diagnostic radiology experience, do you think that’s a shortcoming these days?
Leonard Gunderson: It probably is. If there’s time for people to do a rotation on diagnostic radiology and imaging, I think it’d be very helpful. Of note, my residency training was prior to the era of CT imaging. I learned how to interpret CT images when I was on staff at Massachusetts General Hospital (MGH). In fact, when I was initially on staff at MGH, they didn’t have a CT scanner. There was one CT scanner in greater Boston. The only way you could get images was to have an approved, written protocol. The RadOnc protocol was to define gross tumor volumes (GTV), pre-CT, and then to see whether the CT images altered the GTV.
When MGH subsequently purchased a CT scanner, Dr Joseph Ferrucci, a GI diagnostic radiologist, and I learned how to interpret CT scans together. My cross-section anatomy training was undoubtedly helpful in that endeavor.
Ron Allison: Were there any other memories or highlights from residency that you might want to tell the History Committee and those reading this interview?
Leonard Gunderson: It was a very clinically oriented residency program that prepared me well with regard to clinical care of patients and, as noted previously, interactions with other disciplines.
Eric Gressen: How about any mentors? You mentioned Henry Plenk and, of course, Fletcher. Any mentors you want to mention from your residency?
Leonard Gunderson: During my Master’s in Anatomy program from 1964-66 I had a wonderful mentor, Dr Frank Lowe, who definitely influenced my career. He taught me a scientific method of inquiry and critical evaluation of the literature. There is little doubt that once I decided to become involved with academic radiation oncology and scholarly production, my time with Dr Lowe influenced both my clinical research efforts and scholarly activities.
From a radiation oncology perspective, important mentors were Drs Henry Plenk and Charles Votava at the LDS Hospital, University of Utah - Drs Robert Stewart and James Elteringham, MD Anderson Hospital – Drs Gilbert Fletcher, Robert Lindberg, and Luis Delclos. Those are the people that had a very positive influence and helped create a solid foundation for clinical practice, education and research.
My time with Dr Stewart was interesting because it preceded the era of CT scans. In spite of that, he preferred to consider 3D treatment approaches before they became feasible because of CT anatomy. He would have us use cross-sectional anatomy textbook images to try and reconstruct tumor vs normal organ/structure relationships.
Residency mentors outside radiation oncology included Dr Charles Smart, Merrill Wilson, and Charles Edwards, (surgical oncologists we worked closely with). The three medical oncology/hematology mentors were Drs William Reilly, Stanley Altman and Joseph Quagliana.
Ron Allison: Once residency was coming to a close, I suppose you were just thinking of an academic type of job that could allow you to pursue some of these interests. Did you have other things?
Leonard Gunderson: Actually, had there been a good private practice opportunity in the Northwest, I’d likely have proceeded in that direction. I wasn’t actually thinking of an academic career when I finished residency. I looked at private practice opportunities in Oregon and Washington. When nothing was available, I accepted the offer from Dr Henry Plenk to be on staff @ LDS Hospital/Intermountain Health Care. At LDS Hospital/IHC, I spent two years on staff with Drs Henry Plenk and Richard Brown (1974-76) functioning as a general RadOnc. I evaluated/treated patients with every type of malignancy and served as the GI cancer expert for our group of three physicians.
While on staff at LDS Hospital, I was invited by Dr Herman Suit to give a lecture at MGH as part of their residency-training course. Two weeks before I came he said, “Oh, by the way, I want you to look at a staff position to be the GI cancer radiation oncologist.”
Ron Allison: That was history, right?
Leonard Gunderson: Well, it was not totally history because we weren’t planning to move. We had just built a new home in Salt Lake. I was planning to try out for the Mormon Tabernacle Choir, my continuation of musical interests. But Herman was a very special recruiter; we received something from him nearly weekly in the mail. We ended up deciding that it was a reasonable opportunity after analyzing things in a variety of ways, including trying to get some spiritual input. However, while it was of clinical and academic interest, the initial financial offer was not competitive, which I noted to Dr Suit on a subsequent phone call. He said, “Well, let me make some calls and I’ll get back to you.” Several weeks later, he called me back and said, “You’re right. We aren’t competitive. What would it take for you to come?” I mentioned one figure. But I said my wife would be more comfortable at a slightly higher figure. Dr Suit ended up offering the higher salary.
Ron Allison: Your wife gave you the green light?
Leonard Gunderson: Pardon?
Ron Allison: Did your wife give you the green light? How did that go?
Leonard Gunderson: She did. This was a joint decision. We always make major decisions together. If your wife/spouse isn’t happy, it’s just not going to work out, so we’ve always believed in making joint decisions. However, my year away during my RadOnc residency was originally going to be in London. When I talked with my wife about possibly going to Univ Minnesota and MD Anderson instead of London, that possibility initiated some interesting discussions.
Ron Allison: What was Boston like for you?
Leonard Gunderson: We enjoyed our time there. My wife and I are both Montana natives, so spending time on the East Coast was eye opening for both of us. It was wonderful to learn more about the history of the U.S. relative to that part of the country. We created numerous opportunities to enjoy our time there even though we were raising our young family (Cape Cod, Boston Pops, Boston Red Sox and Celtics, etc).
Bill Shipley was one of my colleagues at Mass General. They had a family home on the Cape and invited us down for a weekend several times. Bill and I cross-covered one another during the time that I was on staff at MGH. When he was on vacation, I covered his GU service, and when I was on vacation he would cover the GI service along with his own GU patients.
Dr Suit had me see soft tissue sarcoma patients with him, so that began my interest in sarcomas in addition to GI cancers. I had been interested in continuing to see GYN patients as I had done at LDS Hospital, but at that time, Dr C.C. Wang was taking care of all the head and neck and GYN cancer patients and preferred to continue doing such. Accordingly, when Dr Suit had me become involved with the residency training program, we normally had two residents rotating with Dr Wang at all times (none were first-year residents). So he had two residents and a wonderful nurse to help take care of his 50-plus patients under treatment.
Ron Allison: Was this just at one location or did you guys have to travel to any other locations?
Leonard Gunderson: We didn’t treat at any other locations. I did attend an outreach tumor board once or twice a month, alternating with Dr Noah Choi.
Ron Allison: So these are all gigantic names in the world of radiation, so what was it like on a daily basis to be the new guy in town?
Leonard Gunderson: When Dr Suit recruited me to MGH, he wanted me to set up a program in GI radiation oncology, treating patients with a uniform approach in conjunction with surgical and medical oncology colleagues. He was willing to give me pretty much free rein as long as I was doing things logically and tracking the data for future outcomes analyses.
He recruited me with the idea that I was going to be an 80:20 physician: 80% clinical care of patients, 20% research (clinical rather than basic). However, I didn’t take advantage of that balance initially because I thought I needed to prove that I was an excellent clinician. Accordingly, I performed clinical activities five days a week and was trying to do all of my research activities in the evening from 9:00pm until or after midnight (after our kids were in bed). When I developed some associated medical problems, I went back to Dr Suit and said, ‘Can I have my research day back?’ He replied, ‘I didn’t take it from you, you just weren’t using it’.
I subsequently started spending one day a week in my home office where my wife protected me from interruptions and kept our kids out of the office, and I was on-call to my resident. From that time on (at MGH and Mayo Clinic), my weekly calendar was planned to have me spend one full day plus one to two evenings a week in my home office for clinical research, protocol development and writing of manuscripts.
Ron Allison: So how would you summarize your time at Mass General?
Leonard Gunderson: My MGH experience was an outstanding time period. I worked very closely with surgeons, medical oncologists, GI pathology and GI diagnostic radiology at Mass General, in addition to my RadOnc colleagues and allied health staff. Drs Herman Suit, CC Wang and Samuel Hellman were wonderful RadOnc mentors during my Jr Staff era at MGH/Harvard in helping me create a solid foundation for clinical practice, education and research. I greatly enjoyed the relationship I had with my other MGH RadOnc colleagues (Bill Shipley, Noah Choi, Rita Lingood, John Munzenrider).
I attempted to educate the surgeons who performed colo-rectal surgery about the potential value of leaving surgical clips to mark areas of marginal resection and performing pelvic reconstruction. I would show them small bowel films in patients where that hadn’t been done which demonstrated a pelvis full of small bowel, and let them know that if they left clips and did pelvic reconstruction to keep the small bowel away from areas of marginal resection I would have the opportunity to safely boost the area at risk with higher doses of irradiation. I was working closely with them, as a team member, to say ‘here’s what we can do to work together to be beneficial to our patients’.
I reviewed select pathology findings with the pathologists, as I had been taught during my residency at LDS Hospital in Salt Lake City. In patients with rectal cancer, Dr James Galdabini (GI pathologist at MGH) would determine if/how far the lesion extended beyond the rectal wall and the amount of uninvolved radial surgical margin.
As noted previously, I learned how to interpret CT abdomen/pelvis films with Dr Joseph Ferrucci who ended up being one of the outstanding GI diagnostic radiologists in the country. He wanted to know the patient symptoms, and we would sit down and evaluate the images together.
I had one medical oncologist who especially liked to see GI cancer patients (Dr Donald Kaufman). While we didn’t see patients in multi-disciplinary clinics, we would have them scheduled in virtual clinics in different locations, discuss them by phone and make decisions on how to proceed.
During my time at MGH there were two young surgical oncologists: Dr William Wood and Dr Alfred Cohen. Both were outstanding multi-disciplinary oriented colleagues, and we enjoyed having joint patients (GI cancer, sarcoma). I also interacted closely with general surgeons in the care of patients with pancreas and colorectal cancer (Drs George Nardi, Andrew Warshaw, Steven Hedberg, Claude Welch, Gordon Donaldson and Grant Rodkey). Dr Welch was a very well known senior surgeon who ultimately became supportive of intraoperative radiation (IORT) as a component of treatment for select patients with GI cancer.
The development of IORT was an interesting story at Mass General. IORT was something that Herman Suit had been interested in, and he, Bill Shipley and I talked about it conceptually. Dr Suit was willing to try and convince the institution to put an orthovoltage machine in the operating room. However, the head of physics, Dr Edward Epp, and I said ‘no, we’d rather go through the hassle of transporting patients down to the treatment area in the radiation oncology department and use electrons’. We started the IORT electron program at MGH in 1978 using the transport approach. Although it was inconvenient, it allowed us to deliver a boost dose of electron irradiation, at the time of planned surgery, in patients with marginally resected rectal cancer, locally unresectable pancreas cancer or marginally resected retroperitoneal sarcoma.
In addition to my being recruited as one of the first, if not the first, GI radiation oncologists in the U.S., Drs Suit, Shipley and I initiated the second US program in intraoperative radiation, preceded only by the IORT program at Howard University in 1976.
Ron Allison: So you’re back to being a surgeon?
Leonard Gunderson: I always felt very comfortable in the operating room because of my straight surgery internship. IORT brought my surgical interest together with my radiation oncology interest. It’s also a fantastic way to develop working relationships with surgeons. You demonstrate your willingness to interact with them on their turf and make team decisions regarding whether this is a patient in whom it is worthwhile to transport down to radiation oncology for IORT.
At MGH, the surgical ORs were not a floor or two above radiation oncology, but were two connected buildings away. When we finished the surgical exploration/resection, we would pass through those connected buildings down to radiation oncology. The first several times that we transported patients for IORT through non-patient floors where there were hospital employees, there were some wide eyes as they saw us wheeling patients down their corridor.
Ron Allison: I can imagine.
Leonard Gunderson: Luckily, there were no problems with the initial transport of patients and we continued the practice. The transport of patients for IORT continued until MGH developed a dedicated IORT suite in the surgical OR area in 1996.
Ron Allison: So you had a tremendous experience. So what made you want to move on?
Leonard Gunderson: We did not go to Mass General planning to stay long term, as we were a ‘Western family’. My parents’ and my grandparents’ major medical institution was Mayo Clinic in Rochester MN. My grandfather was operated on by the grandfather of one of the colorectal surgeons I worked with at Mayo Clinic, Rochester. We went to MGH/Boston with the idea of staying there for five-plus years. During my fifth year at MGH, Drs Charles Moertel and John Earle at Mayo Clinic Rochester called and said Dr Donald Childs was retiring and asked if I would be interested in looking at his slot as a GI cancer radiation oncologist.
Ron Allison: Is that something that you wanted deep down?
Leonard Gunderson: I hadn’t thought about it in detail. While I was still on staff at LDS Hospital, Dr Moertel had actually called me to see if I was interested in looking at the chair position, which ultimately went to Dr John Earle. I said, “No I’m way too young. I don’t want to be a chair at this point in my life.”
Dr Moertel and I had made contact early in my career because I was invited, as a young Jr staff, to be one of the radiation oncologists that would speak on GI cancer panels at regional or national meetings. Accordingly, I had met Dr Moertel, and we had been on panels together. Years later, as noted, he called to say ‘We have a position in Radiation Oncology for someone with GI cancer expertise, would you be interested in coming?’ This was at a time when Mayo was still a Department of Oncology with Divisions of Medical Oncology, Radiation Oncology, and Oncology Research. Dr Moertel was the Chair of both the Oncology Department and Division of Medical Oncology. Dr John Earle was the Chair of Radiation Oncology. Their proposal was that I would come and be the lead GI cancer radiation oncologist. After Dr Don Childs retired, the remaining GI cancer radiation oncologist was Margaret Holbrook.
Ron Allison: So can you give us a snapshot of your time at Mayo?
Leonard Gunderson: At Mass General I had basically done phase 2 studies combining radiation and chemotherapy with surgery for GI cancer patients and in an attempt to optimize treatment approaches. Going to Mayo was a chance to go a next step further, with phase III studies, because at that time, Mayo was involved with several multi-disciplinary study treatment groups, including ECOG and NCCTG (they had also been part of the GI Tumor Study Group [GITSG], which was phased out before I arrived at Mayo). Dr Moertel had organized and was chair of the North Central Cancer Treatment Group (NCCTG), and Dr Earle chaired the Radiation Oncology subcommittee.
A major difference at Mayo Clinic Rochester was that Dr Moertel had already instituted multi-disciplinary clinics long before my arrival. I essentially saw all of my new and follow-up GI cancer patients three half-days a week in multi-disciplinary clinics side by side with the medical oncologists, and separate surgeons would join us as indicated (a single surgeon was not assigned to the half-day clinics). Each new GI cancer patient had the benefit of being part of an individual patient’s tumor conference. We would review the images together, evaluate the patient and develop a treatment approach that we would present sequentially to the patient to get their input. It was a wonderful way to practice.
For patients with extremity sarcoma, I went to the orthopedic floor and saw them together with the orthopedic surgeons.
Patients who were candidates for IORT were seen jointly with the involved surgeon in the department of Radiation Oncology before starting preoperative irradiation or chemo-radiation. We saw each IORT patient with the surgeon again, just before the subsequent surgical resection and IOERT but after the restaging workup was completed.
The IORT program was a commitment that was made to me before I would leave MGH to go to Mayo Clinic Rochester. Drs John Earle and Moertel were totally supportive, along with the Chair of Surgery, Dr Donald McIlrath. Dr Earle had IORT with electrons, using the transport approach, approved through institution committees before I arrived. However, we had to transport patients from the operating room (OR) for 8 years before we got our dedicated IORT suite at Mayo Rochester.
I had a wonderful working relationship with my radiation oncology colleagues as well as the surgeons (thoracic, oncology, colorectal, general and orthopedic), medical oncologists (gastrointestinal and sarcoma) and gynecologic oncologists at Mayo Clinic Rochester. Individuals by specialty with whom I interacted closely in clinical care and research, disease-site clinics and committees are as follows:
- Thoracic Surgery – Drs Victor Trastek & Claude Deschamps
- Surgical Oncology/General Surgery – Drs J Kirk Martin, David Nagorney, John Donohue, Donald McIlrath, Martin Adson
- Colorectal Surgery – Drs Robert Beart, Heidi Nelson, Roger Dozois, Bruce Wolff, John Pemberton, Richard Devine
- Medical Oncology, GI – Drs Charles Moertel, Michael O’Connell, Larry Kvols, Steve Alberts, Joseph Rubin, Chuck Erlichman, Pat Burch
- OrthoOnc – Drs Frank Sim, Douglas Pritchard, Thomas Shives, Michael Rock Medical Oncology, Sarcoma – Drs John Edmonson, William Maples
- RadOnc, GI/Sarcoma/Gynecologic - Drs James Martenson, Michael Haddock, Ivy Peterson, Scott Stafford, Alvaro Martinez, Mark Schray
- Gynecologic Oncology – Dr Karl Podratz & colleagues
- RadOnc Physics – Dr Ed McCullough, Chair and colleagues
- MCCC/NCCTG Statisticians – Drs HS Wieand, Thomas Fleming, Daniel Sargent
During my nearly 21 years at Mayo Clinic Rochester (Nov 1980-Sept 2001) I had the opportunity to serve as Chair of both Radiation Oncology (1989-96) and the Department of Oncology (1996-2001;Divisions of Radiation Oncology, Medical Oncology, Oncology Research). During my years as Chair of Radiation Oncology, rotating members of the RadOnc Executive Committee included Drs Mark Schray, Edward Shaw, Robert Foote, Paula Schomberg, James Martenson and James Bonner. I was the only radiation oncologist who ever served as chair of the Department of Oncology. When I left Mayo Rochester to move to Mayo Clinic Arizona, Radiation Oncology leaders requested and were allowed to become a separate department.
Ron Allison: Tell us a little more about that part.
Leonard Gunderson: Dr Moertel was not an early morning conference person. When Dr Mike O’Connell and I were asked by Dr Moertel lead the GI cancer program at Mayo Clinic Rochester, we decided that in order to get surgeons coming to GI multi-disciplinary conferences, we had to change our conference time from noon to 7:00 in the morning. Dr Moertel said ‘Fine, but I’m not coming’. So Dr O’Connell and I would meet with Dr Moertel periodically to discuss strategies, so that he was in the loop, but Dr O’Connell and I were responsible for implementing the strategies.
When Dr Moertel stepped aside as Chair of the Department of Oncology, Dr O’Connell was chosen as his successor, and I was the vice chair of Oncology as well as Chair of Radiation Oncology. Dr O’Connell subsequently developed some health problems and had to step aside as Chair of Oncology, but the medical oncologists were willing for me become Chair of Oncology, even though there were more medical oncologists than radiation oncologists. Chairs at Mayo are chosen differently than at many institutions. Internal chairs are usually selected, and it’s normally a consensus about whom the people in the department feel is most appropriate for that position.
Over the years, the Chair of Oncology position at Mayo Clinic Rochester usually passed from one medical oncologist to another medical oncologist because there were more medical oncologists, but the medical oncologists at Mayo Rochester were comfortable with me as chair. When I met with the medical oncology division after the institution asked me to be Chair of the Department of Oncology I said, ‘Well, you should be comfortable with me because I believe in chemotherapy as much as most of you and more than some of you.’ That made them chuckle because it was a fairly conservative medical oncology department at the time, but it was a true statement.
I have always been a believer in an all of the disciplines, having done a three-month rotation in medical oncology during my residency as well as a straight surgery internship. It’s merely a matter of interacting with colleagues to determine which patients need multi-disciplinary treatment and how we should sequence the various modalities.
One of the over-reaching principles of Mayo Clinic is ‘The needs of the patient come first.’ It’s not just an idle statement, but rather is an institutional belief. Individuals/physicians need to learn to work well with one another, to obtain the best possible outcomes for all their patients.
I shifted from Mayo Clinic Rochester to Mayo Clinic Arizona in 2001 (Sept 2001-May 2009) where I served as RadOnc Chair and as Deputy Director for Clinical Affairs at Mayo Clinic Cancer Center-Arizona. I continued to see patients with GI cancer, soft tissue sarcoma and recurrent gynecologic cancer in conjunction with surgery and MedOnc colleagues. I also helped initiate an IOERT program with surgery colleagues and RadOnc physicians and physicists (Chair – Gary Ezzell PhD and colleagues) using the new technology of a mobile electron accelerator. (Thoracic Surgery – Drs Dawn Jaroszewski, Louis Lanza, Victor Trastek; Pancreas/Hepatobiliary Surgery - Drs Adyr Moss, David Mulligan, Sudahkar Reddy; Colorectal Surgery – Drs Jacques Heppell, Tonya Young-Fadok, Jonathan Efron; GynOnc – Drs Paul Magtibay, Javier Magrina; MedOnc, GI – Drs Robert Marschke, John Camoriano, Mitesh Borad, Helen Ross; RadOnc, GI/Sarc/Gyn – Drs Matthew Callister, Jonathan Ashman, Sujay Vora; SurgOnc – Drs Richard Gray, Barbara Pockaj; OrthoOnc – Dr Christopher Beauchamp; MedOnc, Sarcoma – Drs Thomas Fitch, Kelly Curtis). Drs Steve Schild, Michele Halyard and William Wong were the other members of the RadOnc Department during my years at Mayo Clinic Arizona. Dr Schild served as vice chair of RadOnc during my last several years as chair, and I worked closely with Drs Halyard and Wong when we initiated an IORT phase II study in breast cancer patients.
Eric Gressen: Can you describe your work with the major medical organizations - ASTRO, RTOG - and give us some insight into that?
Leonard Gunderson: I was involved with RTOG from 1976 to 1981 while I was at MGH and from 1987-2009 at Mayo Clinic in Rochester and Arizona. While at MGH, I was a member of the RTOG GI Cancer Committee. On my arrival at Mayo Rochester in 1981, Mayo was not a part of RTOG. However, when I was asked to chair the RTOG GI Cancer Committee in 1987, Dr John Earle and I agreed that it would be good for Mayo to be heavily involved in RTOG.
I served as Chair of the RTOG GI Cancer Committee from 1987 to 1994, was RTOG Vice Chair for Disease Sites for an additional seven years (1994 to 2001) and served on the Executive and research Strategy Committees from 1987-2001. During the time I served in RTOG Leadership, RTOG Chairs were Drs James Cox and Wally Curran.
One of the things that we did during the time that I was chair of the GI Committee was to have medical oncology as well as surgical oncology co-chairs. They were part of a small working group within the GI Committee in which we developed protocol strategies, and got buy-in from all three disciplines before presenting protocol concepts to the entire GI Committee. RTOG statisticians with whom I worked closely included Thomas Pajak PhD, Kathryn Winter and Jennifer Moughan.
I have always felt that RTOG was an outstanding NCI study group and was the main study group that addressed radiation oncology-oriented questions. I was delighted to be a part of the RTOG leadership and membership and am aware that they are now part of the NRG Oncology study group.
My involvement with ASTRO started early in my career at the ASTRO 1978 Annual Meeting when I was asked to present a colorectal cancer refresher course, and subsequent involvement extended over 35+ years. My service included further ASTRO Annual Meeting refresher courses/ education sessions, panels and Presidential Courses, ASTRO committees, ASTRO Board of Directors, ASTRO representative on GI Cancer Symposium Program and Steering Committee and Red Journal/IJROBP reviewer (1977-2017) and Editorial Board (1986-2011).
Annual meeting refresher courses on which I was involved included ‘Colorectal Cancer’ (1978-87), ‘Upper GI Cancer’ (1982-87), ‘GI Cancer’ (1988-89), ‘Lower GI Cancer’ (1990-91), ‘Intraoperative Irradiation’ (1994-2000) and ‘Gastric Cancer’ (2006-07). Annual Meeting panels included ‘Colorectal Cancer’ (chair/speaker, 1982), ‘Intraoperative Irradiation’ (1983 [chair/speaker], 1984),’GI Cancer Treatment Technique, Gastric Cancer’ (2001), ‘Rectal Cancer’ (2006–moderator/speaker, 2008). I was involved in Annual Meeting President’s Courses in 2001 (Esophagus Cancer panel moderator), 2004 (Gastric cancer), 2011 (introductory presentation on Multi-disciplinary Care in my Presidential Course on Gastrointestinal Cancer) and 2015 (Co-Moderator of Dr. Bruce Minsky’s Presidential Course on Rectal and Esophagus Cancer).
My involvement with ASTRO committees started in 1988 when I was an abstract reviewer for the Scientific Program Committee (1988-98, 2002) and continues to the present. Other committees on which I was involved include Constitution and Bylaws (2001-04), Combined Modality Therapy subcommittee of the Scope of Radiation Oncology Working Group (1999-2001), Finance Committee (chair, 2003-08; member 2009-2012), Annual Meeting and Program Committee (member 2003-08, chair 2011-12), Nominations Committee (member 2010-11, chair 2011-12), Gold Medal Committee (member 2011-2013, 2015, 2016; chair 2012), Ethics Committee (member 2013-14, vice-chair 2014-17, chair 2017-20) and ASTRO representative on the Gastrointestinal Cancer Symposium Program Committee (2004-06) and Steering Committee (member, 2006-09; chair 2009-10).
I had the opportunity to serve on the ASTRO Board of Directors (BOD) for 9 years (2003-08,2009-13) and greatly enjoyed my service to ASTRO members, ASTRO staff and fellow ASTRO BOD members. On my initial 5-yr term on the BOD, I served as Treasurer/Secretary from 2003-08 (Chair of the Finance Committee during that time). I was subsequently elected as ASTRO President-elect in 2009 and served a 4-year term in the ASTRO leadership line as President elect (2009-10), President (2010-11), Chair (2011-12), Past-Chair (2012-13). I especially enjoyed the ASTRO Presidential year when I had the opportunity to serve as Chair of the 2011 Annual Meeting/Program Committee, was intimately involved in developing and moderating the Presidential Course and had the opportunity to deliver a Presidential Address on ‘Work-Life Balance and Effective Communication’.
During my service on the ASTRO BOD, I worked very closely with Laura Thevenot-CEO, Terry Karras-CFO and BOD members. Individuals who served as President-elect, President or Chair of ASTRO during my time on the BOD included Joel Tepper, Ted Lawrence, Prabhakar Tripuraneni, Kian Ang, Lou Harrison, Patricia Eifel, Tim Williams, Anthony Zietman, Michael Steinberg, Colleen Lawson and Bruce Haffty.
The culmination of my time and service to ASTRO was when I had the honor of being selected as an ASTRO 2014 Gold Medalist along with Drs Nancy Tarbell and Mary Gospadarowicz. For a radiation oncologist, that is the ultimate recognition as a clinician, researcher and scholar.
Eric Gressen: There’s a personal part to these interviews so some of the other questions we have are more family related. Like your wife, when did you marry, your children, the career of your children?
Leonard Gunderson: I want to acknowledge my family as the essence of unity and teamwork and a joy to come home to after a busy day at work. My wife Katheryn (Kit) and I celebrated our 50th anniversary in December of 2014.
Eric Gressen: Mazel tov.
Leonard Gunderson: We make joint decisions. She is my best friend, equally yoked partner, and the love of my life. She helped to change me from a stoic Norwegian to a more effective communicator. When we were dating, if we had a disagreement or mis-communication, she wouldn’t let me go home until the issue was resolved or at least discussed and clarified.
Ron Allison: Is that possible?
Leonard Gunderson: Pardon?
Ron Allison: Is it possible to change a Norwegian? Is it?
Leonard Gunderson: Oh, a little bit.
Ron Allison: You’ve been very personal on this call I must say.
Leonard Gunderson: We raised six wonderful children (three sons and three daughters - Chad, Valerie, Whitney, Stacie, Ryan & Scott). I acknowledge and appreciate Kit and our children with regard to their love, friendship and understanding as we engaged as a family in the pursuit of happiness outside of medicine, and for their support of my life as a physician.
Five of our children married and have given us seventeen grandkids to enjoy and spoil. All 29 of us went on a cruise in May 2015 to help celebrate our 50th anniversary. Our eldest daughter, Valerie, was not a part of that celebration. She died in the spring of her high school senior year due to the actions of a former boyfriend who decided if he couldn’t have her no one could. We left Rochester, Minnesota after 21 years, as we didn’t want to be there when he got out of prison.
Eric Gressen: I’m sorry.
Ron Allison: Oh my.
Ron Allison: Where did you go on your cruise, can we ask?
Leonard Gunderson: We did an Eastern Caribbean cruise with Royal Caribbean.
Ron Allison: Everybody on the same boat?
Leonard Gunderson: Yes, all 29 of us were on the boat (total of ~ 6,000 people on the cruise). They came to AZ to be with us the week after our 50th (Dec 2014) and 22 of the 29 of us sang a four-part musical number in our church congregation on Sunday. The family musical tradition continues with our grandkids. A number of them love music and are very much involved in both choirs and piano. So it’s fun to see that continue. In our children’s high school, we were the only family with six kids who were part of ‘Southtown Singers’, the high school’s top singing group.
Ron Allison: So did they have a choice other than singing or is it singing or nothing?
Leonard Gunderson: Our sons all play guitar and our daughters were all involved with piano. My maternal grandfather studied piano at the Boston Conservatory of Music, but in those days you couldn’t support yourself as a musician. So he ended up being a farmer and a politician, but he always played the grand piano. My mother preceded her dad in death, so when my grandfather died, my mother’s share of the inheritance was split between my four siblings and me. My wife and I used our share to get a grand piano, which our daughters loved to play. After that, we didn’t have to encourage them to practice their piano lessons; they ended up doing so willingly.
Ron Allison: That’s lovely.
Eric Gressen: Any of your children or grandchildren choose a career in medicine?
Leonard Gunderson: Our youngest son is an optometrist and we have a daughter-in-law who’s a pediatrician.
Eric Gressen: Okay. Now in the last part of our interview we’d like you to reflect on your career, any favorite sayings?
Leonard Gunderson: It was a fantastic career. When I hear people say that they’re disillusioned with medicine and wouldn’t encourage kids or grandkids to go into medicine, I just don’t agree with that. I think it’s still a wonderful profession. People may need to have different expectations than they did before, but I would do it all over again. I once ran into a colleague in a Minnesota airport who said, “Leonard, you’ve had a storybook career” It has been an extra-ordinary career.
Eric Gressen: Any repeated themes that you do with your residents? That’s where we do our favorite sayings or anything like that that you try to make sure everyone understood and carry through their career?
Leonard Gunderson: I have greatly enjoyed the opportunity to teach, mentor and be stimulated by numerous residents at my own institutions, as visiting professor and at professional meetings. One of the reasons that it was hard to transfer from Mayo Rochester to Mayo Clinic Arizona is that we didn’t have a residency program in Arizona. In teaching/mentoring residents, I tried to use patients to help the residents learn about a disease and how you should not buttonhole a patient into a certain box as far as how they were going to be treated. I didn’t want residents to memorize ways to treat patients but rather learn to see patients as individuals and then treat them as such based on how the disease presented itself.
Ron Allison: Did we miss anything in this interview that you’d like to mention?
Leonard Gunderson: One of the things I didn’t mention about my parents is that they taught me a superb work ethic, the value of a loving and supportive family, the value of a loving and spiritual foundation, and not to borrow against next year’s crop. When I worked for my dad on the farm between school years (high-school, college), wake-up call was at 5:15am for a 5:30 breakfast and the evening meal was 6:30 or 7:00pm six days a week. Sunday we went to church together as a family and then went to the lake for a family picnic and water-skiing.
My parents and grandparents created an environment for and interest in learning and higher education. Good grades were expected, and were not rewarded with cash. As noted previously, my paternal grandmother, as well as my parents, encouraged and supported my career in medicine.
During my residency, Dr Henry Plenk had a workweek philosophy similar to the Dept of Surgery at Univ Utah -- where you would alternate taking a half-day off one week with a full day off the next week. Instead of using that time to go skiing or play tennis, I used that time for academic research endeavors during the two years that I was on the faculty at LDS Hospital with Dr Plenk before being recruited to go to MGH/Harvard.
I had wonderful interactions with professional colleagues as a result of serving as a co-editor of several textbooks. Co-editors on two editions of ‘Intraoperative Irradiation’ included Drs Christopher Willett, Felipe Calvo and Louis Harrison. Dr Joel Tepper and I served as co-Sr Editors on four editions of ‘Clinical Radiation Oncology’ and I was blessed to have associate editors who helped me edit chapters on four disease sites: CNS – Drs Edward Shaw, Minesh Mehta; Head/Neck – Kian Ang, Robert Foote; Genitourinary – Colleen Lawton, Anthony Zietman; Gynecologic – Alvaro Martinez, Gillian Thomas. We were indebted to the many individuals who contributed as chapter authors.
Working as multi-disciplinary teams is a wonderful way to take care of patients. The more that can occur the better -- I’m worried, however, that some of the changes that may happen in reimbursement may take people back to thinking less about teams and more as individuals. I hope it doesn’t happen because I think the multi-disciplinary team approach is the best way to take care of patients.
Eric Gressen: I certainly agree with you on that. Anything else you would like to add in the last minute of our discussion?
Leonard Gunderson: I would like to finish the same way I did my ASTRO 2014 Gold Medal talk.
I do believe in and take advantage of spiritual insight into the understanding of and optimal treatment for cancer patients. While I didn’t pray about individual patients, I do acknowledge God’s role in both my personal and professional life. I think it’s helpful in having the strength to carry on when challenges and frailties threaten to overcome us.
Ron Allison: Amen.
Eric Gressen: Thank you so much for your time, we really appreciate it.
Ron Allison: It’s been a real pleasure and an honor, thanks.
Leonard Gunderson: It’s been a pleasure to talk with both of you.