Marvin Rotman

By David Hussey, MD, and Gus Montana, MD

On October 4, 2004, David Hussey, MD, and Gus Montana, MD, both members of ASTRO’s History Committee, met with Marvin Rotman, MD, to discuss his experiences in radiation oncology.

Question: So, Marv, we’ll start with your background and how you got interested in medicine and radiation oncology.

Dr. Rotman: I was born and raised in Philadelphia. I always wanted to go into medicine so I went to Central High School, UNSINUS College and then Jefferson Medical College. I was first given a lecture in radiation therapy by Dr. Simon Kramer when he first came over from England. He gave lectures to our class in radiation oncology on Saturday mornings. I went into internal medicine at the Einstein Center in Philadelphia and after a year of a rotating internship, I did a year of residency at the southern division in internal medicine, which was called the old Mount Sinai Hospital in Philadelphia. Then I went in the Air Force where I did internal medicine. I volunteered to go in, some patriotism was involved, but I felt I wanted to get my service obligations out of the way. And as it turns out, it probably was a wise move because people in my residency group ended up going to Vietnam. When I was in the Air Force, I realized that I didn’t want to do internal medicine, although I enjoyed the clinical work very much. Because my father had severe heart disease, I thought I would do something more involved in cardiology and yet I didn’t want to do cardiology research. I was very interested in clinical research.

Question: Did you finish the residency in internal medicine?

Dr. Rotman: No, I went into the Air Force and I did internal medicine and then I decided to go into radiology. I always liked looking at X-rays, like it was clinical pathology, and I ended up going into a residency up at Montefiore Hospital in the Bronx. Harold Jacobson was the chair and when I got into radiotherapy, Charles Botstein was the chief. I found it to be exactly what I wanted as a career for several reasons. My father had been very ill with severe rheumatic heart disease with angina. He was in a great deal of pain most of the time and whatever methods we used to treat angina in those days, (i.e., ablating the thyroid and diuretics) never worked very well. I remember seeing a picture of his chest, he had a heart that almost filled the entire chest, and so I used to have to get up at night and give him injections of morphine to stop his pain. When I got to radiotherapy, half the patients were treated palliatively.

Question: Now, this was part of a general radiology residency?

Dr. Rotman: Part of a general radiology residency, which I believe I began in about 1962. It was a one-year rotation in radiotherapy.

Question: And you would be eligible to take boards in both?

Dr. Rotman: Well, they called it radiology boards and you were examined in both. In fact, you could practice radioisotopes as well. When I got into radiotherapy at Montefiore, and having been in internal medicine for residency and in the Air Force, I was clinically adept compared to the other radiology residents who were interested only in radiology. I took on all patients and I found also that there was a weakness in clinical care of the patients. Residents didn’t want to treat anyone who made them uncomfortable, and there I was and there was a tremendous opportunity to grow. But I felt that care was rather primitive and that there was a lot of upside potential for original thinking in radiotherapy.

Question: Describe for us the status of the equipment and what the department was like.

Dr. Rotman: Botstein was a believer in getting the latest equipment, which was the reason he developed such a good friendship with Gilbert Fletcher. Fletcher used to come up to the department often and Botstein put in this Brown Boveri betatron—the first in the United States. He had a telecesium unit, a cobalt unit and he had this huge Brown Boveri betatron which, if I remember correctly, had electrons up to 35 MeV.

During that time I did a locum tenens. The office had a 250 kV machine and a small practice in radiotherapy. I never forgot the time a patient came in with bladder cancer and a rubber grid was placed over the area of the bladder and the 250 kV machine with a cone or something was put on the grid and the bladder cancer was treated this way. I was astounded at the primitive nature of radiotherapy and I soon learned that this wasn’t uncommon. Although Botstein had a Brown Boveri, a lot of the radiotherapy in the New York area was being practiced in a rather primitive way. The reputation of the radiation therapist was someone who would burn the skin and, of course, they used a grid—the rubber grid with holes—to try to develop some areas of normal skin. In those days, Hodgkin’s disease in young boys was a death sentence.

About that time, Norman Simon and Sidney Silverstone were two of the major voices in clinical radiotherapy in New York. They had a private practice that they had taken over from a Dr. Harris who had come down from Harvard where he was trained. He started as chief of Radiotherapy at Mount Sinai Hospital. At the same time, Milton Freedman was practicing at NYU and Harris got the first cobalt unit in New York, some claim the first cobalt unit in America. He put it into a private office rather than at Mount Sinai. Simon invited me to become a partner in their practice which did radiology, radioisotopes and radiotherapy. They were quite busy. They promised me a partnership, except I found out I was the 13th person in a row who was promised a partnership and they never came through with partnerships. So after two years, I was offered a job to take over a fledgling department at Flower Hospital at New York Medical College. Botstein earlier had sent me down to M.D. Anderson where I became friendly with Fletcher. I could say that 90 percent of what I learned about clinical radiotherapy came from my relationship with Fletcher. Though, how to deal with patients and how to act with them, a great deal of that came from Botstein. I did a year of radiotherapy with Botstein after my residencies. I did some of the very early iridium implants of the tongue and I did radium needle implants of the tongue and a lot of the intracavitary. So I did iridium and I became pretty good at it — base of tongue, anterior two-thirds of the tongue, etc. And then Simon made me this offer, so I thought that was a terrific opportunity.

Question: Marv, lead us into your career.

Dr. Rotman: I got to New York Medical College where it turned out that the OB/GYN department was very strong and a fellow by the name of Sandy Sall was interested in gynecologic oncology and doing a lot of surgery. I got a lot of patients during that time that had gynecologic malignancies, so some of my early papers were on GYN cancers. One of my early papers was on the Ernst applicator and the high degree of complications from it. The Ernst applicator was an expandable rigid applicator that was preloaded. In those days the radiation therapist would get a phone call to come to the OR, ‘I have this patient up here with cervical cancer. Load the Ernst and bring it up.’ The radiation therapist would bring it up to the OR and the gynecologist would put it in the uterus and pack around it and say, ‘Well, you take it out when you feel you should take it out.’ I put an end to that when I got up to Flower and I did all the insertions, which gave rise to a few battles early on. With Fletcher, we started the afterloading system that Botstein started as well. I became a member of the GOG in its third or fourth year of existence and became very active. At Montefiore, there was a head and neck surgeon by the name of Max Som who was an excellent surgeon, very aggressive. Botstein fought with him constantly for control of the patients. Botstein would do his own biopsies of the vocal cord often without anything other than topical anesthesia. There were turf battles and I came up through that atmosphere; Fletcher never shirked a good battle. I got the impression that Fletcher dealt with the head and neck surgeons and with the gynecologists confrontationally. He held his own, although some he got along with and some he didn’t.

Anyway, I was a little bit more confrontational about the turf of radiation oncology at GOG. We had a radiotherapy committee in those days and I think Luther Brady and Jack Mier were on it. I believed that cervical cancer should be treated by radiation. About that time, Fletcher was invited up to the Academy of Medicine to have a debate with Brunchwick who was chairman of Gynecologic Oncology at Memorial Hospital. He was revered by his residents and fellows. Fletcher really couldn’t stand what Brunchwick said and thought he was ridiculous in his approach to the treatment of cervical cancer, so they had this debate. Brunchwick was an older man and really had the concept of acting gentlemanly at the debate, but he had the wrong opponent when he debated Fletcher. Fletcher just really tore him apart. I’ll never forget that. It was so bad that people were feeling sorry for Brunchwick and antagonistic toward Fletcher, but that’s the way Fletcher was.

When Sandy Sall moved on to Einstein, he wanted to take the GOG with him and I wouldn’t let him. So I became a PI and at that time I was only the second PI radiation oncologist at the GOG. The first one was Luther Brady.

Along the way, I did some locums for someone by the name of Jack Freid who had a practice on Park Avenue. Jack Freid was the first radiotherapist in America to go to Paris for further training. He was in Paris and Madam Curie was there at that time and he was with Coutard. Jack practiced radiotherapy into his late 80s and had this practice on Park Avenue. Now, from time to time, he was sent a lumpectomy case from Hagensen on the QT. He didn’t want anyone to know that he wasn’t doing a radical mastectomy and those patients. He would send them to Jack and he would do radiation treatment of the breast in post-lumpectomy patients. He would also have head and neck cases, and he had a nice practice. That was about 1977 or something like that.

During my time as an attending at Montefiore, Botstein sent me over to Paris and Stockholm. In Stockholm, I did some rounds on the radiation therapy floor with Kottmeier. Kottmeier would hold rounds and Einhorn was one of the attendings in his department. Jersy Einhorn at that time was mostly interested in treating the I-131 treatment of thyroid cancer, and Nina, his wife, was doing GYN. I went into the OR when Einhorn was there.

Kottmeier had taken over the department from Hayman. The Karolinska was one of the major centers in Europe. They did an awful lot of GYN because they were the only place in Sweden that had the radium. They used to have the radium safe in the OR behind a partition with a window— unprotected window— they had a table next to that window and the nurse and everyone would put out these preloaded applicators. These were boxes or circles or tandems, preloaded, and the radiotherapists would just sit there and take it off the table and place it in the patient. Well, all right — if you had one case a week. They would have seven or eight cases a day doing it that way. There was no afterloading. The thing about it was they recognized that there was a problem with the radiation, so they gave the radiation oncologists off something like three months a year and by law you had to take off. You couldn’t work in Stockholm if you were a radiation oncologist.

Question: We haven’t done too much on the eye yet.

Dr. Rotman: I was at Flower Hospital and they had this red hot, very bright ophthalmologist who would get these melanomas and he didn’t want to do enucleations. So he asked me, ‘Can you figure out how it should be treated?’ So we sent away for these cobalt-60 eye plaques Amersham manufactured in England. When you got them, you got a card, the right-hand corner of the card had an isodose curve where it showed you where the 4,000 rad dose was located. So they devised these plaques to deliver 4,000 in a certain length of time to the eye at a certain depth. The reason they did that was because these eye plaques were created to treat retino blastoma, but they began using them to treat melanoma. We knew that the melanoma had a very high extrapolation number and they had the belief that melanoma was resistant to radiation. So, the first few cases I treated with melanoma of the eye using the eye plaque, I must have given several hundred thousand rads to the base of the tumor. The tumor disappeared and the eye would stay intact. Then I used several insertions and slowly reduced the dose to about 8,000 an insertion and I think you could go even lower in dose.

Frank Ellis visited to see our results. He did radiotherapy at Oxford and later went to Memorial. He came to visit me and I went over and visited with Lederman who used to treat conjunctival cancers with radium D and C plaques, but he didn’t know how to treat choroidal melanoma. I went to Saint Barth’s Hospital in London and reviewed their data. They were using cobalt to treat melanoma and mostly retinoblastoma. Mind you, they would see eight or nine retinoblastomas in an afternoon and another four or five melanomas. Bedford was in charge of it and later McFall. There was a meeting at Cambridge University and I gave a talk on my results on treating the eye. I had no failures. It’s just amazing. And I gave a talk and saw that these guys didn’t know what they were doing. Stallard was doing work and Fletcher put his chapter in his first textbook. Stallard treated over 140 patients with choroidal melanoma. He would treat, but they really didn’t know what they were doing. They only had this one isodose curve. Later, other people began working on the dosimetry. At Flower, we began looking into it using a computer Monte Carlo dosimetry, film dosimetry, etc., so I began treatment of choroidal melanoma.

Around that time, I presented this data at the New York Roentgen spring meeting and someone got up from the back of the room. He pointed to a slide I showed of a choroidal melanoma and he said, ‘That’s not a choroidal melanoma.’ He was Chairman of Ophthalmology at Einstein. You have to understand, I was being attacked for unethical behavior for treating choroidal melanoma with radiation because they felt that the eye should be enucleated. This was true up at Columbia Presbyterian and a few guys would do it on the QT, but they would use old decayed plaques and the dose rate they were getting was something like 8 or 9 rads to the apex per hour. And so these tumors wouldn’t budge, right? So I became interested in the dose rate.

A fellow by the name of Zimmerman was in charge of pathology at AFIP and he began looking into choroidal melanoma and he noticed that the patients who had enucleation all died of metastases. He figured that somehow removing the eye was bad and I was lecturing that irradiating the eye and leaving it intact increased the numbers of tumor-associated antibodies. We didn’t have much immune work in those days. I said, ‘If you enucleate the eye, you lose this effect, so it’s better to sterilize the tumor and leave the cell membrane intact and you have a source of antigen antiserly production.’

We called a special task force to the AFIP National Eye Institute, and he said, ‘I had one of your failures, Dr. Rotman.’ It was the same guy who was chair at Einstein. I couldn’t get the words out. I was so astounded by someone saying that I was lying. I said, ‘Why didn’t you tell me you had one of my patients to get some history on the patient and what we did?’ I got back to New York and I called that department and I had the radiation oncologists speak to the Chief Resident of Ophthalmology and they never had a case like that. In the three years of his residency, no failure of radiation oncology ever came into his department. This guy had lied. So I called Zimmerman back and I said, ‘This man has lied.’ Zimmerman liked me because I was supporting his concept that you shouldn’t enucleate the eye. He was being attacked right and left, too, because his was a major voice in ophthalmology, so I said, ‘I want an announcement out to everyone in that meeting.’ He said, ‘Now, Dr. Rotman, please, everyone knows that he is crazy. Just ignore it.’ During that time when I was attacked like that, I sat down. As I told you, I got so upset, I couldn’t talk. I sat down and Jerry Shields was next to me and I had lectured his group on how to do the eye plaque work and he started doing it at the Wills Eye Hospital after that. He said, ‘Oh, I’ve done 30 cases and we haven’t had a failure.’ I used to lecture at the national meetings and I said, ‘You people are more interested in preserving vision than life. You’re not interested in survival in this disease.’ They gave rise to the COMS and they asked me to write an initial part of the radiation grant for COMS.

Question: I’d like to ask you what you think about our Society?

Dr. Rotman: Every time I come to ASTRO, I feel rejuvenated. I get very excited with our accomplishments. I think we’re coming out of the dark ages finally from the time when I had to treat bladder cancer through a rubber grid.

And now looking at how we’re advancing with chemo-radiation, I think it was a major advancement. It’s funny, when you look at papers from Europe, you see the term concomitant chemo-radiation, that’s the term I used when I lectured over there, and they picked it up. I edited several books on concomitant chemo and radiation, and here in America it’s still called concurrent. But chemo-radiation, we still have a ways to go. I hope it’s not dropped with all effort going into looking at the biologicals.

I was on the Residency Review Committee. We had a lot of discussions and battles in the Residency Review Committee. I worked six years with Luther Brady. There were many weak residencies and programs. We must have cut out about 30 percent of residency programs. This was my era of being involved in the education of residents with the Residency Review Committee. I remember a lot of places like Harvard and Stanford wanted to increase their residency numbers and even Malcolm Bagshaw came to one of the Society of Chairman of Academic Radiation Oncology Programs meetings when I was president to battle why he wanted more residents. There was all this going on within our specialty.

Our present day position in education didn’t arrive on a silver platter. It evolved with certain internal battles as well as the external fighting off the surgeons and the medical oncologists for turf. Juan del Regato was very worried that if we added the word “oncology” to our specialty, ASTRO instead of ASTR, it would dilute our ability to deal with the other specialties. People would think that we’re oncologists like medical oncologists. And despite all this, the specialty progressed.

It’s thrilling sometimes to come to see some of the work that’s being done. We have a fantastic future. I tell that to my residents. However, the one thing that has taken over much of our time and thinking that I worry about in the specialty is the influence of big business. With such high monetary rewards, the influence of the manufacturing industries and their equipment seems to have directed our specialty. I’m wondering if so much of this effort could have been directed elsewhere rather than to try to make a better-looking mousetrap so to speak. I’m hearing about IMRTs and at the same time I hear about one-centimeter margins not only because of lymphatics being around the tumor, but the motion. I think people are using IMRT too frequently. Collegiality has gone out the window with big business and its rewards. When I used to travel to different centers and Europe, it was like being a member of a fraternity. I was welcomed and I was taught about their data. Today, you never know when someone’s going to come in and try to replace you at one of your hospitals, disturbing the training program and the clinical research program because they can see a way of making more money. I worry about that.

Question: You developed the code of ethics, as I recall, for ASTRO.

Dr. Rotman: That’s right, I wrote a code of ethics for ASTRO. I had revised the ethics written for the AMA going back into the middle 1800s and I finally put together a code, but then ASTRO didn’t want to or couldn’t use muscle to go after people who broke that code, so to speak, and so it had to be a code that would try to influence people to try to conduct themselves in an ethical manner. There was no way of enforcing it. Maybe we need more presentations on ethics at our meetings. We need to foster a sense of collegiality.

Question: So that would be one of the changes that you would like to see?

Dr. Rotman: I’m not quite sure how to do it, but I’d like to see more training in ethics. I believe that we’re losing a lot of talent into private practice where there may not be enough time for original work. We are getting a much higher quality resident than we ever did. The programs are competitive. One of the benefits of making a lot of money in radiotherapy is that we are getting a better grade of resident. I’m thrilled about the advancements we’ve made — look back on the way it was when that boy with Hodgkin’s disease had to die and what we can do today. The advances in organ preservation and all the benefits that we’ve gleaned from it, it’s thrilling. I find it thrilling.

Question: You have had a long productive and distinguished career, but what has given you some of the most personal satisfaction?

Dr. Rotman: You know, I remember Joe Newell. He came over from England. He once said to me that everything is forgotten after a while and few of my residents know who Fletcher was. You know? So I can’t say that any one thing that I’ve done as far as advancing the science has given me great satisfaction, but I get a lot of pleasure at seeing my former residents and how some of them have done and how they’ve advanced. I think the residency program that I’ve set up over the years has given me a lot of pleasure. In the science part of things, I would think the concomitant chemo-radiation gives me a lot of pleasure. Also, being in a specialty that had to fight its way out of the competitive nature that we’ve had, the friendships that you make internationally and nationally are very precious.

Question: Dr. Rotman, on behalf of the History Committee, thank you for talking to us and for the viewpoint and the information that you have given us.