Nisar Syed, MD
By Christopher Rose, MD, FASTRO
The following interview of Nisar Syed, MD, was conducted on February 14, 2018, by Christopher Rose, MD, FASTRO.
Christopher Rose: Today we’re going to be interviewing A.M. Nisar Syed who is a professor of radiation oncology at the University of California, Irvine, as well as the chairman of the department of Radiation Oncology at the Todd Cancer Institute Long Beach Memorial Medical Center at the Long Beach Memorial Medical Center system. Good morning, Nisar.
Nisar Syed: Good morning, Chris. Thank you very much. I’m honored to be interviewed for this history committee. I don’t think that I deserve it, but I appreciate it.
Christopher Rose: Well, the committee corporately and Dr. Phillips and I beg to disagree, but we’ll figure out why that is. Why don’t you tell us where you were born and where you grew up.
Nisar Syed: Yes. Let me say first I was born in India. I did my medical school in India, which is Gandhi Medical College, Osmania University. This is in my state. At that time, Chris, when I completed my MD degree which is MBBS, what they call it in India, I was exposed to cancer because my father-in-law was a radiation oncologist. When I got married and I saw he was so involved in the radiation oncology, it was very early period of radiation oncology evolution and was very primitive. But still the way he established the hospital in my city, which is Hyderabad, I was exposed to cancer at that time with radiation. Then once I completed, I didn’t work in India.
After my internship in India, I went to England because I wanted to be a surgeon, and I did my surgical residency. I went through all - different surgical specialties including general surgery, orthopedic surgery, urology, thoracic surgery, to even open heart surgery, Et cetera. So I finished surgical training. I did my Fellowship, which is like surgical boards in the US, from Edinburgh and London, both Royal College of Surgeons. At that time, when I started to work, they called Registrar, i.e. Chief Resident or Junior Staff. They are under the consultants and I was doing most of the time surgery. But I was seeing at that time and reading that these were the days when super radical surgical procedures were being performed on a lot of cancers. Like I saw some head and neck cancers with super radical surgery deforming patients. Gastrostomies, tracheostomies. Not a good functional life. I thought there must be a better way.
Having been a surgeon for a couple of years and then having been exposed to radiation oncology in India, I thought maybe I should get into radiation oncology and try to practice both. So at that time I contacted Dr. Henschke who at that time was at Sloan Kettering in New York, and then I said whether I could work with him although I was not a radiation oncologist yet. Then I visited both John Hopkins, as well as the Sloan Kettering. They offered me the residency in both places, but I thought I better get basic training in England. Because at that time I believed radiation oncology was much advanced in England than in U.S.A. in the early ‘70s.
Christopher Rose: That was in 1970, that you went to Manchester.
Nisar Syed: Yeah, Manchester. At that time I get better exposure there in basic training, so I went to Christie Hospital which was one of the best known cancer centers in England, just like what we have, M.D. Anderson, in the U.S.A. So I went through the radiation training. I got my Radiation Oncology Board. At that time, at Christie, they were doing radium implants for cancers of the cervix, tongue and anal canal. I thought that we may combine minimal surgery with external irradiation with possible radioactive implants.
Chris, just like literally radium needles and cesium and cobalt needles were used with Manchester applicator. So I saw just a few cases, and I thought there may be a way. At that time, Dr. Henschke was the one who got into the brachy while he was at Sloan Kettering Institute, New York, and converted those preloaded techniques into kind of afterloading, putting the plastic catheters into the tumors.
Christopher Rose: Sam Hellman told me about Dr. Henschke thinking about and inventing the afterloader at Howard University and then taking it to Africa as the least technologically difficult way to deliver radiation to communities that didn’t have high tech. You must have worked with him before you went to USC, is that right?
Nisar Syed: That is correct. So I went to work with Dr. Henschke. He selected me because I was already a surgeon. I was already board certified in radiation oncology and surgery, he said you come and work with me and develop some techniques. So I went there, but he moved to Howard University in Washington D.C.
Christopher Rose: Right.
Nisar Syed: So I went to him. At that time, yes, he developed a kind of a semiautomatic afterloader. He had a Greek physicist work with him and developed it. They had a handle to crank in the source literally manually into the catheters, that was what he developed, and he had a cobalt machine at his institution and no LINAC. These two were the basic technologies. So I saw him implant on the chest wall and then I saw one or two cases into the tongue, but that was not of course in those days most sophisticated. So that gave me really an idea that you can develop techniques to delivery radiation into the tumors. And I was seeing a lot of the GYN cases which were too advanced for the routine intracavitary applications. Those were too extensive and non-surgical.
So having got some basic idea from him after afterloading technique, I thought there may be ways to develop new techniques. He did not have a lot of patients at the hospital for me to really do much or develop. Dr. Frederick George at USC, Chairman of Radiation Oncology, offered me a job.
Christopher Rose: For the sake of the people who are reading this, that’s Dr. Frederick W. George III who is the chair of radiation therapy at USC.
Nisar Syed: Yeah, at USC. So he offered me a position of assistant professor to come and work at USC. But I was not yet board certified in U.S.A., so they recognized my training in surgical and radiation oncology and they said you just stay as a fellow for a year and you can appear for the Radiation Oncology boards. So he put me as a fellow although I was working as a staff, and I got my board certification. Then at USC, you know how it was in L.A. County, a lot of patients with extensive IIIB cervical cancers and advanced stage head and neck cancers. Huge primary oral cavity tumors with neck masses. I also started to see locally advanced prostate and breast cancers, i.e. T3 and T4.
So that was not possible to control these tumors with external irradiation alone. I started first to work on the GYN cancers. I saw how best to implant the needles into the cervix and parametria where we were unable to delivery sufficient radiation. So initially I designed an applicator with my medical physicist, David Neblett. I told him this is what I want, let’s do something that I can go through the perineum and implant these needles. So we came up with this design - the GYN template, very original template - and then we drilled holes in that one in the circumferential manner.
Dr. Philip Disaia was the chairman of the GYN oncology at USC. So I talked to him. I told him that I want to try this technique. At that time, there was nothing, any RBI or anything like that, so I was very lucky. He said, fine, go ahead and try to treat these patients with such a poor prognosis. I started to implant needles into the parametria and where I could not get the tandem into the cervix with the needles. At that time dosimetry computer was coming up. Literally it took us whole overnight to develop one page of dosimetry by the computer. When David Neblett was developing dosimetry for these applications it took almost 24 hours to get just one page of the dosimetry. So that was how primitive it was.
Christopher Rose: So Nisar, maybe you could clarify. with the original implants using the template and radium needles or had you already figured out that you would put catheters in and then put iridium strands into those.
Nisar Syed: Oh no. I put the hollow steel needles into the tumors and loaded iridium-192 sources into these needles because that was what was being used by Dr. Henschke. So I used iridium-192 sources. I had the company here, Alpha-Omega in California, who made iridium 192 sources and Best Industries who supplied Iridium-192 sources to Dr. Henschke. Alpha Omega and Best worked very closely with me to develop a lot of these tools. Alpha Omega made the templates according to our specifications and design for the U.S. and supplied the iridium 192 sources.
I implanted the 17-gauge hollow steel needles through the template into the parametria and into the cervix. Then obviously we had just the x-rays, orthogonal films and the dosimetry was done by Mr. Neblett. That was the initial phase. There was no treatment planning on computers like we have today. But that was clearly meticulous and helpful. So that’s how it started, and that was the GYN case. We got much more efficient in that one, and then the template was made even in a better way where we used the alcohol just to go through the needle holes in the template which works like lubricant and grips the needles after the alcohol evatoraded. That was a great achievement.
Then some cases with Dr. Disaia. We did a few open procedures. We did laparotomy to see the needles how far they come up and how they were encompassing the parametria and cervix so that we were satisfied with those cases.
Christopher Rose: Just for the sake of the folks who weren’t around at that time, your initial work was with - as you said - orthogonal x-rays.
Nisar Syed: Yeah.
Christopher Rose: And also what you would learn from anatomy from the open procedure.
Nisar Syed: Correct.
Christopher Rose: It was a few years later that you finally had the opportunity to have CT scans to confirm what you were doing made sense.
Nisar Syed: Exactly. Then we started to have better computers, better planning and all of the cases had CT-based planning . So we published the very first paper on the GYN cases with about 100 patients. But I had almost 10 percent fistulae at that time because the patients had very extensive tumors and involved the vagina, parametria, bladder and rectum, with high central doses. We modified the distribution of the Iridium sources, based upon our initial experience and morbidity resulting in significantly reduced morbidity and much less fistulae, i.e. one percent or two percent, for many years. That’s how this technique evolved.
We then started to develop our own remote magnet driven afterloader. But finally we had better machines available, i.e. Varisource and Nucletron. We trained Radiation Oncologists, residents, fellows, surgeons, medical physicists and nursesfrom all over the world. We used to conduct many national and international workshops and conferences, in different states of across the U.S.A. and other countries.
So when I was doing the GYN cases with vaginal cancers, cervical cancers, endometrial, then I started to look into the prostate cancers. At that time, Chris, Malcolm Bagshaw reported his external beam data by delivering 60 Gy with good results. But his urology chairman did the biopsies and showed persistent tumors in almost 60 percent to 70 percent of the cases. So that was not good and had a lot of controversy regarding the significance of persistent tumors.
At the same time, Drs. Henschke and Hilaris published the data on the permanent Iodine-125 seed implants. During that era, again when they did the biopsies after the implants, almost 25 percent to 30 percent of the patients has persistent tumors. We did about 50 cases of permanent Iodine-125 seed implants but ended up with 40 percent with persistent disease. So I thought this is not the best way to treat cancers of the prostate.
So I thought why not I apply the same GYN technique to the prostate. Surprisingly what I did was -- I wanted to try it on a cadaver not thinking properly, and I went to a cadaver to try to do it on a cadaver. We could not separate the legs to get to the perineum due to rigor mortis. Then I had to do it on a live patient. I was lucky at that time in that I had a lot of cooperation by urologists at USC. So they allowed me to do it both at USC and California Hospital in Los Angeles.
So I used a similar template and device for the prostate. Circumferential, knowing the anatomy, et cetera. And having done quite a few permanent seed implants, I felt comfortable to use this technique along with retroperitoneal lymph node dissection for staging. That was the thing at that time for the permanent seed implants. Initially, we did the implants by guiding the needles through the retropubic space along with staging pelvic lymphadenectomy. The needle distribution was much more symmetrical by then and afterloaded with iridium-192 sources manually as we did not yet have afterloaders available.
Again just very first publication was only 28 patients, and we did the biopsies. The persistent tumor was only in 10 percent of the patients. So between the iodine and the iridium, very big difference. We added the external beam after the brachytherapy to these patients, and they did well. Serious complications were minimal. Then I started to talk about it. But the permanent seed implanters were very upset. They said, well, you don’t know how to do the permanent seed implants that’s why you have persistent tumors. We treated early stage, with brachytherapy alone and others with combination of brachytherapy and external irradiation. So that’s how the prostate technique evolved. That was pretty successful and many people adopted it all over the world.
These were the two major developments in the pelvic area, including the prostate and the gynecological cancers. Then at that time breast cancers were being treated by either mastectomy for early stage disease and external beam irradiation for advanced stage. I started boosting the tumors by using afterloading plastic catheters.
The other major impact, I think was in the head and neck cancers because we had so many head and neck cancers, especially being at a county hospital, with smokers and alcoholics with tongue, oropharynx and floor of the mouth. We could not deliver with external beam more than 6 Gy at that time. There was no conformal or IMRT techniques available. It was just the bilateral opposed fields.
Then I developed several implant techniques for cancers of the tongue, floor of the mouth, tonsillar fossa, soft palate and even into the larynx and pharynx including naso, oro, hypopharynx. We tested both for primary, as well as recurrent tumors and published a lot of the data of our outcomes. That was gratifying because even with the early tongue cancers, there was 30 percent to 40 percent rate of recurrence even after surgery and/or external radiation. But when we started to do the brachytherapy, the recurrence rate was much less, especially for the base of the tongue and the tonsillar fossa. We achieved much better local and regional controls and also much better cosmesis and functional results.
When I moved from California Hospital to Long Beach Memorial Medical Center, I started to have a lot of training programs. We conducted once a year workshops and symposiums for brachytherapy. Physicians, surgeons, gynecologists and medical physicists attended from all over the world. We did about four days intensive workshops on the models and live procedures being done in the operating room with the attendees watching from the conference hall. Dr. Ajmel Puthawala and I were doing the procedures, and then had lectures from radiologists, physists and experienced brachytherapists. So a lot of people attended with their teams - with radiation oncologists, medical physicists, technologists and nurses - to learn our operating room procedures, loading and unloading, and physics.
We did 22 annual workshops in U.S.A. at Long Beach Memorial Medical Center and many international workshops in South America, Brazil, Australia, New Zealand, Europe, India, Pakistan, the Middle Ease, etc.
Then came the starting of a Society of Endocurietherapy and then the start of a journal. When Dr. Henschke was alive, Chassan and Pierajuan from Europe and Hilaris and I arranged a meeting in Los Angeles in 1982 At the Bonaventure Hotel. That was the first meeting of that hotel. At that time I initiated the formation of a Brachytherapy Society. So I had few people join me and we called it Pacific Endocurietherapy Society. That was the beginning of the society. We started to conduct annual meetings and established chapters in many states all over the U.S.A. and other countries including South America, India and Japan and they started to establish endocurietherapy brachytherapy societies which gave a big impetus for the journal.
We then started the journal ‘in-house’ literally speaking. Dr. Khalid Sheikh, who was Vice President of research at Long Beach Memorial Medical Center, became the managing editor. We started the first issue of the journal and we called it Endocurietherapy International Journal. It was published quarterly. As it went on later the name of the journal was changed to American Brachytherapy International Journal.
Same thing happened to the society. Because the society started to have hundreds of people register and membership increased, the society members decided to change endocurietherapy to brachytherapy. So the name was converted to American Brachytherapy Society.
So that’s how the journal and the society gave the real credibility to the brachytherapy subspecialty of Radiation Oncology. I think that gave impetus to many other countries. They started to have a lot of workshops and presentations. So now we have a lot of collaboration internationally.
Christopher Rose: I wanted to just ask you about -- I guess I would use the word persistence. So you clearly developed a better mousetrap, there is no doubt about it, and 40 years later it’s hard to argue with this. But remembering, going back to the 1970s, the whole academic enterprise in the United States was either external beam radiation alone or radiation and intracavitary applicators - the Henschke applicator obviously and of course the Fletcher-suit applicator. Those of us on the East Coast with informed wisdom had some little idea in our heads that there was this crazy guy across the United States on the West Coast pushing needles into tumors, and the alternative obviously was using external beam and making it smaller. The anatomy, I mean even less favorable. But somehow doing a couple of afterloading applicators, I mean it really took --
Of course the initial dosimetry was not so good and the cancers were huge, and so there were those complications. But they were tumor complications, not technique complications. How did you manage to persist and to -- I wouldn’t use the word win versus lose, but how did you manage to convince people of the validity of what you were doing? It must have been pretty hard in the mid to late 1970s.
Nisar Syed: Absolutely. You’re right, Chris. When I started at USC itself, when I wanted to put the needles into the head and neck, anesthesiologists and others said how could you do that, you are not a surgeon. There was so much of resistance about it. So I told them that I am a trained surgeon. I am a fellow of the Royal College of Surgeons of England and Edinburgh, so they could not stop me.
But on the other hand, they were discouraging. When I started to perform brachytherapy in cancers of the breast, the chief of staff stopped me from going to the operating room. He said, “No, you cannot. You are not a surgeon to do these procedures.” I had to go through and convince them that I am a surgeon, that I am qualified and board-certified in England. Finally, they allowed me to perform the procedures. The surgeons were initially against me because they were afraid of losing the business, losing the mastectomies, so they wanted to stop me. The same surgeons who objected to me going to the operating room became the biggest referrals to me for the breast cancers. I had to show them the results with local control and good cosmesis. The same was true with the head and neck cancers. Eventually, they too were convinced.
The same thing happened in the GYN cancers. The procedures were being performed by the GYN oncologists at USC and criticized “here this fellow comes, an Indian guy from England, and he was trying to do the procedures himself”. So I told them, “Look, this is a radiation technique. I am not only a radiation oncologist, I’m a trained surgeon, so I should be allowed to do it.” So even there was a resistance for me to do the GYN procedures. Yes, I faced a lot of difficulties. Each time I had to convince the surgeons and physicians everywhere I did the procedures. I had to go through the chief of the surgery, to convince them that I’m a trained physician.
But my problem was not myself. They allowed me because I was a qualified Board Certified and trained surgeon. But I was worried about the other radiation oncologists who did not have surgical experience. So I made sure at that time, to most of these operating room and hospital executives, et cetera, that there should not be a demand of surgical training for radiation oncologists to be able to do the procedures. I told them that radiation oncologists are trained in these procedures during their residency and fellowship so they don’t have to have the surgical training. I said they spent time, they do the procedures. They already have all the knowledge of the anatomy. They should be allowed.
So that was most concerning to me, because they will allow me because I’m a surgeon but I wanted everybody else to do it. That took a long time for me to convince them, but finally they all agreed. As a result most of the hospitals, they allowed all my trainees and associates to be able to do the procedures including Dr. Puthawala. There was a lot of resistance anytime and anywhere you go especially from the surgical groups. Surgeons, the GYN oncologists, the head and neck surgeons, they always felt threatened because we were going to take their business away. But no, it became complementary. I always involved them, whether it was GYN or head and neck. I tell them, “Look, you can come and do the tracheostomy. You can do the gastrostomy. I don’t want to do your procedures.” Although I could do tracheostomy myself, I said no. It’s your procedure, you do it.
So I worked with the ENT surgeons, the GYN oncologists, the urologists in a way that they felt me as their colleague working together rather than competing with them. I think that was the feeling I had to create so that they did not feel I was competing with them but rather I’m working with them. Whenever we did prostate implant, I gave them the credit. I said this is your facility, you are doing it. So that’s the way I think they accepted slowly. But it was definitely a struggle, Chris. The initial few years were the biggest struggle for me.
Christopher Rose: So Nisar, the other thing as I look at your CV and your innovations, in the early days of head/neck cancer and also recurring cancers, perhaps you and Dr. John Byfield on the West Coast and Dr. Brady on the East Coast were using 5-FU concomitantly with your implants, and he was using methotrexate, I believe. How did you come to decide that you could get some help in terms of radiosensitization? And I get it 5-FU is the major agent in this.
Nisar Syed: Yes. You know, that’s very interesting. Do you remember Dr. John Byfield?
Christopher Rose: Yes.
Nisar Syed: He was radiation oncologist and chairman at UC San Diego. He was the one who was one of the initial Radiation Oncologists who started using 5-FU as a radiosensitizing drug. So when he published those papers, then myself and Dr. Puthawala, who had always been with me, we started to use 5-FU and methotrexate in locally advanced and recurrent head and neck cancers. But the problem happened, Chris, when the patients had neck dissection and developed recurrent tumors and we used methotrexate with brachytherapy. Unfortunately, we had two carotid blowouts, and that was very serious. The whole implanted area necrosed. Fortunately they didn’t die of the bleeding, but survived. But that was caused by methotrexate in patients who received reradiation. The combination of high dose methotrexate in re-irradiated patients can cause serious complications.
Since then we stopped methotrexate, especially if the patient had surgery. Because when they had the neck dissection, the surgeons skeletonized the carotid artery and there was not much tissue between the skin and the arteries. A third patient who had carotid blowout was admitted to the hospital and they ligated the vessel. So this happened to the methotrexate experience with reradiation in surgically operated patients.
So that was how we started, when John Byfield promoted 5-FU. But at that time also primarily they were using both methotrexate and 5-FU combined, and that was our mistake using both in previously operated patients. Today, we use 5-FU as a radiosensitizing agent. Sometimes in younger patients we use cisplatin and 5-FU in locally advanced and recurrent cancers.
Christopher Rose: Now maybe we could switch gears. We have about 15 minutes.
Nisar Syed: Yes.
Christopher Rose: So what do you envision. You’re a department chair now. I know you are looking at protons. What do you envision for the future of radiation oncology?
Nisar Syed: Well, a couple of things, Chris, which you all know. You know better than me. Number one, I am concerned about the brachytherapy utilization in U.S.A. for many reasons. Because the reimbursements are gone down so low that there is not much incentive among radiation oncologists to spend time in the operating room, to learn and take care of these patients, to take all the responsibilities for hardly any reimbursement. If you look at the reimbursement for the brachytherapy versus external, you make a lot more revenue by doing the external rather than brachytherapy. Whereas, in the brachytherapy, you have to admit the patients, you have to go very early to the operating room and do the procedures, unload/load, daily visits, removing the implant, etc. There’s a lot of work for the best outcome for the patients, but revenues are dwindling. As a result of this, a lot of radiation oncologists who are competent and capableare reducing the brachytherapy. So I’m afraid that this is a very negative disincentive. Unless people like yourself and people in power and high positions work on proper reimbursements, I think this is not going to be used as much. That’s number one.
Number two, people think IMRT has replaced brachytherapy, which is definitely not true. Even with IMRT, there is a dose limit. But the tumors which are much larger and recurrent, you cannot give enough dose even with IMRT/IGRT. So that’s why these are the concerns of mine for the brachytherapy field.
Second, what I’m looking at is the increasing interest in hypofractionation where again brachytherapy led the way by establishing the high doses per fraction where the external beam is going. Many radiation oncologists started to use similar fractionation to reduce the number of fractions in external beam radiotherapy. Which I think is a must, which is in the right direction. I’m sure that’s what is going to happen.
The other thing is the increasing use of SRS and SBRT which is absolutely the way it is going to be. My feeling is the same, Chris. Hypofractionation with immunotherapy and targeted chemotherapy, I think that’s where it is heading rather than the long fractionations of eight to ten weeks of external irradiation in the cancers of the prostate, head and neck, lung, et cetera. Hypofractionation, brachytherapy, SBRT and SRS with or without targeted chemotherapy and immunotherapy is the future. Proton seems to have radiobiological and favorable dose delivery comparing to photons but unless it becomes less expensive it will have limited use although it may play a pretty good role in the left-sided breast cancers, by reducing the coronary artery dose, pediatric tumors, brain and prostate, et cetera. But I think hypofractionation with immunotherapy is going to play, in my opinion, a big role with brachytherapy. Just brachytheapy alone in early stage cancers, external irradiation with brachytherapy boost in Stage II, and combination of external irradiation plus brachytherapy and chemotherapy and immunotherapy in Stage II and Stage IV cancers.
With regard to hyperthermia, Chris, although we have had a very good experience with excellent outcomes using radiation and hyperthermia in locally advanced and recurrent cancers, the reimbursement is extremely low to non-existent. But it has tremendous value. I’m afraid that hyperthermia is not being utilized because of the reimbursement issues.
Christopher Rose: So Nisar, many things we haven’t touched on. One of them is your tremendous philanthropy and giving back. You know there’s a question that we ask about how young radiation oncologists can achieve a global impact. Maybe you might speak about that in terms of your own personal experience with radiation back in India.
Nisar Syed: Sure. Yeah. My mother passed away with, cervical cancer, stage III in the 1970’s in India. At that time I had to get her over to England to have her treatment because there were not good enough facilities in India. So at that time I decided that I should do something in India. Not only establish cancer centers, but also train people in diagnosing and treating patients with cancers. So the very first thing I did was establish a comprehensive cancer center in my hometown which is Hyderabad. That was one of the first privately owned cancer centers in my state and one of a very few in the whole country. I started to install the cobalt-60 unit initially and then a LINAC and started to train people. I had many radiation oncologists and medical physicists from India come over to Long Beach Memorial Medical Center to be trained in brachytherapy and external irradiation. Then I invited them here and they came through being sponsored by UICC, our Endocurietherapy Research Foundation and their institutions.
So I’m very happy that I’ve established quite a number of centers in India - north, south, everywhere - and they are functioning well. As a matter of fact, my son who is a radiation oncologist, is developing many cancer centers all over India and trying to provide the services which are not available or were not available at the time when I was beginning my career. So as a result, I have a lot of these centers which are providing training and free treatment or low cost treatment to the patients who would not otherwise be able to afford treatment.
Also, Chris, we providetraining for UICC fellows. I have been training the fellows from India, Pakistan, Middle Ease, African countries, South American, Europe, United Kingdom, China, Russia, et cetera. My whole family is involved in these activities, for providing the cancer care where it is less available and free or at a low cost.
Christopher Rose: So maybe I might ask you as you brought in your son, why don’t you tell me about your family? Are you married?
Nisar Syed: Yes.
Christopher Rose: How many kids do you have and what your kids do.
Nisar Syed: Yes. Chris, my wife is also a radiation oncologist. I have lots of people now who are radiation oncologists. She practiced here at Martin Luther and Harbor-UCLA Medical Center. She’s a radiation oncologist, but she took care of the children. She helped me to pursue my career. She took care of our four children, out of which, one became a radiation oncologist, the second became an IT specialist working for Kaiser, the third is an attorney. My one daughter did a Masters in psychosocial and married to a radiation oncologist. My son, who is a radiation oncologist, spends time in India and U.S.A. He’s working on developing cancer centers mainly in India, but also in African countries, Bhutan and British Guyana. So they are all kind of involved and dedicated to the oncology field providing facilities for the diagnosis and treatment of cancers, as well as training and research, et cetera.
Christopher Rose: Nisar, you’re a very energetic man. I remember you coming and visiting me in Burbank and helping me with a patient, now almost 40 years ago, with probably the largest tumor I’ve ever seen. She’s still alive and doing fine and functioning well. But you got there I think at the crack of dawn because you had so many responsibilities. How do you balance your active career with some fun? What are your hobbies? What do you do outside of medicine?
Nisar Syed: Not a lot, Chris, unfortunately. Because even outside, whatever time I have, I spend on the patients. There’s hardly any hobbies because my hobby is, just like when I take off, I go to other countries and just give lectures and treat patients. Whatever time I get in between, I go and visit places.
Christopher Rose: Travel.
Nisar Syed: Yes. Otherwise, not a lot of hobbies.
Christopher Rose: So do you have any advice that you would give to young radiation oncologists starting out?
Nisar Syed: Yes. I think my suggestions to them is, yes, not only working hard and sincerely but be as gentle as possible and sensitive to the patients issues, their relatives, and especially dealing with colleagues - surgeons, GYN oncologists, head and neck surgeons, et cetera. To have the best of the relationship so that you have a combined effort for the patient care. Not trying to show that you’re competing with them, but complementing them and at the same time working with the hospital executives, not against them, but with them.
Most of the places I saw, Chris, physicians were against the executives and executives against the physicians. I don’t like that. I encourage them to work with the executives so that they’ll support you and you support them. I like them to be persistent in their efforts and to never give up, especially for the treatment of the patients. I mean not to just send the patient to hospice, even with too advanced disease who could be treated with modern technology, targeted drugs, immunotherapy to relieve their pain and suffering which may prolong life.
But even more so, Chris, now look at this new trend. The most recent papers coming out, patients with six to seven metastatic lesions from lung, prostate, and kidney cancers treated to 40 to 50 Gy to the primary site and stereotactic body radiotherapy to 5-6 metastatic lesions, with immunotherapy improving three times the survival. So you cannot give up if you have a little more advanced disease. But I don’t want them to also go overboard where there is no hope and causing more misery. And always I don’t like to be solo. I always like to associate with others and work with everybody. That’s my advice to them.
Christopher Rose: It has been truly a joy to talk to you, Nisar.
Nisar Syed: Thank you.
Christopher Rose: Before we hang up, is there anything that we’ve forgotten that you would want to memorialize?
Nisar Syed: Let me think. The main people who have really worked in this field, there are many which we didn’t have a chance to talk about, especially people like Henschke, Fletcher, Hilaris and many others who had a lot of contributions in the field of radiation and brachytherapy.
Christopher Rose: I’m glad we got a chance for you to honor your long-time colleague, Ajmel Puthawala.
Nisar Syed: Absolutely, Dr. Puthawala, David Neblett, my first physicist, and myself worked very closely in developing brachytherapy technique, treating the patients, submitting publications and training. And then Dr. Anil Sharma has been with me for a long time helping to develop applications, training and continued research. So there have been a lot of people involved in this journey, Chris. But again I want to give the credit to everybody. I get the credit for everybody’s work, but I’m only representing this teamwork. I often feel that I’m credited too much alone, but I want to share it with everybody, especially Dr. Puthawala, Dr. Sharma and David Neblett, who helped me to get where I am with this technology.
Christopher Rose: Well, again, thank you so very, very much.
Nisar Syed: Thank you indeed, Chris. I appreciate it.
The following interview of Nisar Syed, MD, was conducted on February 14, 2018, by Christopher Rose, MD, FASTRO.
Christopher Rose: Today we’re going to be interviewing A.M. Nisar Syed who is a professor of radiation oncology at the University of California, Irvine, as well as the chairman of the department of Radiation Oncology at the Todd Cancer Institute Long Beach Memorial Medical Center at the Long Beach Memorial Medical Center system. Good morning, Nisar.
Nisar Syed: Good morning, Chris. Thank you very much. I’m honored to be interviewed for this history committee. I don’t think that I deserve it, but I appreciate it.
Christopher Rose: Well, the committee corporately and Dr. Phillips and I beg to disagree, but we’ll figure out why that is. Why don’t you tell us where you were born and where you grew up.
Nisar Syed: Yes. Let me say first I was born in India. I did my medical school in India, which is Gandhi Medical College, Osmania University. This is in my state. At that time, Chris, when I completed my MD degree which is MBBS, what they call it in India, I was exposed to cancer because my father-in-law was a radiation oncologist. When I got married and I saw he was so involved in the radiation oncology, it was very early period of radiation oncology evolution and was very primitive. But still the way he established the hospital in my city, which is Hyderabad, I was exposed to cancer at that time with radiation. Then once I completed, I didn’t work in India.
After my internship in India, I went to England because I wanted to be a surgeon, and I did my surgical residency. I went through all - different surgical specialties including general surgery, orthopedic surgery, urology, thoracic surgery, to even open heart surgery, Et cetera. So I finished surgical training. I did my Fellowship, which is like surgical boards in the US, from Edinburgh and London, both Royal College of Surgeons. At that time, when I started to work, they called Registrar, i.e. Chief Resident or Junior Staff. They are under the consultants and I was doing most of the time surgery. But I was seeing at that time and reading that these were the days when super radical surgical procedures were being performed on a lot of cancers. Like I saw some head and neck cancers with super radical surgery deforming patients. Gastrostomies, tracheostomies. Not a good functional life. I thought there must be a better way.
Having been a surgeon for a couple of years and then having been exposed to radiation oncology in India, I thought maybe I should get into radiation oncology and try to practice both. So at that time I contacted Dr. Henschke who at that time was at Sloan Kettering in New York, and then I said whether I could work with him although I was not a radiation oncologist yet. Then I visited both John Hopkins, as well as the Sloan Kettering. They offered me the residency in both places, but I thought I better get basic training in England. Because at that time I believed radiation oncology was much advanced in England than in U.S.A. in the early ‘70s.
Christopher Rose: That was in 1970, that you went to Manchester.
Nisar Syed: Yeah, Manchester. At that time I get better exposure there in basic training, so I went to Christie Hospital which was one of the best known cancer centers in England, just like what we have, M.D. Anderson, in the U.S.A. So I went through the radiation training. I got my Radiation Oncology Board. At that time, at Christie, they were doing radium implants for cancers of the cervix, tongue and anal canal. I thought that we may combine minimal surgery with external irradiation with possible radioactive implants.
Chris, just like literally radium needles and cesium and cobalt needles were used with Manchester applicator. So I saw just a few cases, and I thought there may be a way. At that time, Dr. Henschke was the one who got into the brachy while he was at Sloan Kettering Institute, New York, and converted those preloaded techniques into kind of afterloading, putting the plastic catheters into the tumors.
Christopher Rose: Sam Hellman told me about Dr. Henschke thinking about and inventing the afterloader at Howard University and then taking it to Africa as the least technologically difficult way to deliver radiation to communities that didn’t have high tech. You must have worked with him before you went to USC, is that right?
Nisar Syed: That is correct. So I went to work with Dr. Henschke. He selected me because I was already a surgeon. I was already board certified in radiation oncology and surgery, he said you come and work with me and develop some techniques. So I went there, but he moved to Howard University in Washington D.C.
Christopher Rose: Right.
Nisar Syed: So I went to him. At that time, yes, he developed a kind of a semiautomatic afterloader. He had a Greek physicist work with him and developed it. They had a handle to crank in the source literally manually into the catheters, that was what he developed, and he had a cobalt machine at his institution and no LINAC. These two were the basic technologies. So I saw him implant on the chest wall and then I saw one or two cases into the tongue, but that was not of course in those days most sophisticated. So that gave me really an idea that you can develop techniques to delivery radiation into the tumors. And I was seeing a lot of the GYN cases which were too advanced for the routine intracavitary applications. Those were too extensive and non-surgical.
So having got some basic idea from him after afterloading technique, I thought there may be ways to develop new techniques. He did not have a lot of patients at the hospital for me to really do much or develop. Dr. Frederick George at USC, Chairman of Radiation Oncology, offered me a job.
Christopher Rose: For the sake of the people who are reading this, that’s Dr. Frederick W. George III who is the chair of radiation therapy at USC.
Nisar Syed: Yeah, at USC. So he offered me a position of assistant professor to come and work at USC. But I was not yet board certified in U.S.A., so they recognized my training in surgical and radiation oncology and they said you just stay as a fellow for a year and you can appear for the Radiation Oncology boards. So he put me as a fellow although I was working as a staff, and I got my board certification. Then at USC, you know how it was in L.A. County, a lot of patients with extensive IIIB cervical cancers and advanced stage head and neck cancers. Huge primary oral cavity tumors with neck masses. I also started to see locally advanced prostate and breast cancers, i.e. T3 and T4.
So that was not possible to control these tumors with external irradiation alone. I started first to work on the GYN cancers. I saw how best to implant the needles into the cervix and parametria where we were unable to delivery sufficient radiation. So initially I designed an applicator with my medical physicist, David Neblett. I told him this is what I want, let’s do something that I can go through the perineum and implant these needles. So we came up with this design - the GYN template, very original template - and then we drilled holes in that one in the circumferential manner.
Dr. Philip Disaia was the chairman of the GYN oncology at USC. So I talked to him. I told him that I want to try this technique. At that time, there was nothing, any RBI or anything like that, so I was very lucky. He said, fine, go ahead and try to treat these patients with such a poor prognosis. I started to implant needles into the parametria and where I could not get the tandem into the cervix with the needles. At that time dosimetry computer was coming up. Literally it took us whole overnight to develop one page of dosimetry by the computer. When David Neblett was developing dosimetry for these applications it took almost 24 hours to get just one page of the dosimetry. So that was how primitive it was.
Christopher Rose: So Nisar, maybe you could clarify. with the original implants using the template and radium needles or had you already figured out that you would put catheters in and then put iridium strands into those.
Nisar Syed: Oh no. I put the hollow steel needles into the tumors and loaded iridium-192 sources into these needles because that was what was being used by Dr. Henschke. So I used iridium-192 sources. I had the company here, Alpha-Omega in California, who made iridium 192 sources and Best Industries who supplied Iridium-192 sources to Dr. Henschke. Alpha Omega and Best worked very closely with me to develop a lot of these tools. Alpha Omega made the templates according to our specifications and design for the U.S. and supplied the iridium 192 sources.
I implanted the 17-gauge hollow steel needles through the template into the parametria and into the cervix. Then obviously we had just the x-rays, orthogonal films and the dosimetry was done by Mr. Neblett. That was the initial phase. There was no treatment planning on computers like we have today. But that was clearly meticulous and helpful. So that’s how it started, and that was the GYN case. We got much more efficient in that one, and then the template was made even in a better way where we used the alcohol just to go through the needle holes in the template which works like lubricant and grips the needles after the alcohol evatoraded. That was a great achievement.
Then some cases with Dr. Disaia. We did a few open procedures. We did laparotomy to see the needles how far they come up and how they were encompassing the parametria and cervix so that we were satisfied with those cases.
Christopher Rose: Just for the sake of the folks who weren’t around at that time, your initial work was with - as you said - orthogonal x-rays.
Nisar Syed: Yeah.
Christopher Rose: And also what you would learn from anatomy from the open procedure.
Nisar Syed: Correct.
Christopher Rose: It was a few years later that you finally had the opportunity to have CT scans to confirm what you were doing made sense.
Nisar Syed: Exactly. Then we started to have better computers, better planning and all of the cases had CT-based planning . So we published the very first paper on the GYN cases with about 100 patients. But I had almost 10 percent fistulae at that time because the patients had very extensive tumors and involved the vagina, parametria, bladder and rectum, with high central doses. We modified the distribution of the Iridium sources, based upon our initial experience and morbidity resulting in significantly reduced morbidity and much less fistulae, i.e. one percent or two percent, for many years. That’s how this technique evolved.
We then started to develop our own remote magnet driven afterloader. But finally we had better machines available, i.e. Varisource and Nucletron. We trained Radiation Oncologists, residents, fellows, surgeons, medical physicists and nursesfrom all over the world. We used to conduct many national and international workshops and conferences, in different states of across the U.S.A. and other countries.
So when I was doing the GYN cases with vaginal cancers, cervical cancers, endometrial, then I started to look into the prostate cancers. At that time, Chris, Malcolm Bagshaw reported his external beam data by delivering 60 Gy with good results. But his urology chairman did the biopsies and showed persistent tumors in almost 60 percent to 70 percent of the cases. So that was not good and had a lot of controversy regarding the significance of persistent tumors.
At the same time, Drs. Henschke and Hilaris published the data on the permanent Iodine-125 seed implants. During that era, again when they did the biopsies after the implants, almost 25 percent to 30 percent of the patients has persistent tumors. We did about 50 cases of permanent Iodine-125 seed implants but ended up with 40 percent with persistent disease. So I thought this is not the best way to treat cancers of the prostate.
So I thought why not I apply the same GYN technique to the prostate. Surprisingly what I did was -- I wanted to try it on a cadaver not thinking properly, and I went to a cadaver to try to do it on a cadaver. We could not separate the legs to get to the perineum due to rigor mortis. Then I had to do it on a live patient. I was lucky at that time in that I had a lot of cooperation by urologists at USC. So they allowed me to do it both at USC and California Hospital in Los Angeles.
So I used a similar template and device for the prostate. Circumferential, knowing the anatomy, et cetera. And having done quite a few permanent seed implants, I felt comfortable to use this technique along with retroperitoneal lymph node dissection for staging. That was the thing at that time for the permanent seed implants. Initially, we did the implants by guiding the needles through the retropubic space along with staging pelvic lymphadenectomy. The needle distribution was much more symmetrical by then and afterloaded with iridium-192 sources manually as we did not yet have afterloaders available.
Again just very first publication was only 28 patients, and we did the biopsies. The persistent tumor was only in 10 percent of the patients. So between the iodine and the iridium, very big difference. We added the external beam after the brachytherapy to these patients, and they did well. Serious complications were minimal. Then I started to talk about it. But the permanent seed implanters were very upset. They said, well, you don’t know how to do the permanent seed implants that’s why you have persistent tumors. We treated early stage, with brachytherapy alone and others with combination of brachytherapy and external irradiation. So that’s how the prostate technique evolved. That was pretty successful and many people adopted it all over the world.
These were the two major developments in the pelvic area, including the prostate and the gynecological cancers. Then at that time breast cancers were being treated by either mastectomy for early stage disease and external beam irradiation for advanced stage. I started boosting the tumors by using afterloading plastic catheters.
The other major impact, I think was in the head and neck cancers because we had so many head and neck cancers, especially being at a county hospital, with smokers and alcoholics with tongue, oropharynx and floor of the mouth. We could not deliver with external beam more than 6 Gy at that time. There was no conformal or IMRT techniques available. It was just the bilateral opposed fields.
Then I developed several implant techniques for cancers of the tongue, floor of the mouth, tonsillar fossa, soft palate and even into the larynx and pharynx including naso, oro, hypopharynx. We tested both for primary, as well as recurrent tumors and published a lot of the data of our outcomes. That was gratifying because even with the early tongue cancers, there was 30 percent to 40 percent rate of recurrence even after surgery and/or external radiation. But when we started to do the brachytherapy, the recurrence rate was much less, especially for the base of the tongue and the tonsillar fossa. We achieved much better local and regional controls and also much better cosmesis and functional results.
When I moved from California Hospital to Long Beach Memorial Medical Center, I started to have a lot of training programs. We conducted once a year workshops and symposiums for brachytherapy. Physicians, surgeons, gynecologists and medical physicists attended from all over the world. We did about four days intensive workshops on the models and live procedures being done in the operating room with the attendees watching from the conference hall. Dr. Ajmel Puthawala and I were doing the procedures, and then had lectures from radiologists, physists and experienced brachytherapists. So a lot of people attended with their teams - with radiation oncologists, medical physicists, technologists and nurses - to learn our operating room procedures, loading and unloading, and physics.
We did 22 annual workshops in U.S.A. at Long Beach Memorial Medical Center and many international workshops in South America, Brazil, Australia, New Zealand, Europe, India, Pakistan, the Middle Ease, etc.
Then came the starting of a Society of Endocurietherapy and then the start of a journal. When Dr. Henschke was alive, Chassan and Pierajuan from Europe and Hilaris and I arranged a meeting in Los Angeles in 1982 At the Bonaventure Hotel. That was the first meeting of that hotel. At that time I initiated the formation of a Brachytherapy Society. So I had few people join me and we called it Pacific Endocurietherapy Society. That was the beginning of the society. We started to conduct annual meetings and established chapters in many states all over the U.S.A. and other countries including South America, India and Japan and they started to establish endocurietherapy brachytherapy societies which gave a big impetus for the journal.
We then started the journal ‘in-house’ literally speaking. Dr. Khalid Sheikh, who was Vice President of research at Long Beach Memorial Medical Center, became the managing editor. We started the first issue of the journal and we called it Endocurietherapy International Journal. It was published quarterly. As it went on later the name of the journal was changed to American Brachytherapy International Journal.
Same thing happened to the society. Because the society started to have hundreds of people register and membership increased, the society members decided to change endocurietherapy to brachytherapy. So the name was converted to American Brachytherapy Society.
So that’s how the journal and the society gave the real credibility to the brachytherapy subspecialty of Radiation Oncology. I think that gave impetus to many other countries. They started to have a lot of workshops and presentations. So now we have a lot of collaboration internationally.
Christopher Rose: I wanted to just ask you about -- I guess I would use the word persistence. So you clearly developed a better mousetrap, there is no doubt about it, and 40 years later it’s hard to argue with this. But remembering, going back to the 1970s, the whole academic enterprise in the United States was either external beam radiation alone or radiation and intracavitary applicators - the Henschke applicator obviously and of course the Fletcher-suit applicator. Those of us on the East Coast with informed wisdom had some little idea in our heads that there was this crazy guy across the United States on the West Coast pushing needles into tumors, and the alternative obviously was using external beam and making it smaller. The anatomy, I mean even less favorable. But somehow doing a couple of afterloading applicators, I mean it really took --
Of course the initial dosimetry was not so good and the cancers were huge, and so there were those complications. But they were tumor complications, not technique complications. How did you manage to persist and to -- I wouldn’t use the word win versus lose, but how did you manage to convince people of the validity of what you were doing? It must have been pretty hard in the mid to late 1970s.
Nisar Syed: Absolutely. You’re right, Chris. When I started at USC itself, when I wanted to put the needles into the head and neck, anesthesiologists and others said how could you do that, you are not a surgeon. There was so much of resistance about it. So I told them that I am a trained surgeon. I am a fellow of the Royal College of Surgeons of England and Edinburgh, so they could not stop me.
But on the other hand, they were discouraging. When I started to perform brachytherapy in cancers of the breast, the chief of staff stopped me from going to the operating room. He said, “No, you cannot. You are not a surgeon to do these procedures.” I had to go through and convince them that I am a surgeon, that I am qualified and board-certified in England. Finally, they allowed me to perform the procedures. The surgeons were initially against me because they were afraid of losing the business, losing the mastectomies, so they wanted to stop me. The same surgeons who objected to me going to the operating room became the biggest referrals to me for the breast cancers. I had to show them the results with local control and good cosmesis. The same was true with the head and neck cancers. Eventually, they too were convinced.
The same thing happened in the GYN cancers. The procedures were being performed by the GYN oncologists at USC and criticized “here this fellow comes, an Indian guy from England, and he was trying to do the procedures himself”. So I told them, “Look, this is a radiation technique. I am not only a radiation oncologist, I’m a trained surgeon, so I should be allowed to do it.” So even there was a resistance for me to do the GYN procedures. Yes, I faced a lot of difficulties. Each time I had to convince the surgeons and physicians everywhere I did the procedures. I had to go through the chief of the surgery, to convince them that I’m a trained physician.
But my problem was not myself. They allowed me because I was a qualified Board Certified and trained surgeon. But I was worried about the other radiation oncologists who did not have surgical experience. So I made sure at that time, to most of these operating room and hospital executives, et cetera, that there should not be a demand of surgical training for radiation oncologists to be able to do the procedures. I told them that radiation oncologists are trained in these procedures during their residency and fellowship so they don’t have to have the surgical training. I said they spent time, they do the procedures. They already have all the knowledge of the anatomy. They should be allowed.
So that was most concerning to me, because they will allow me because I’m a surgeon but I wanted everybody else to do it. That took a long time for me to convince them, but finally they all agreed. As a result most of the hospitals, they allowed all my trainees and associates to be able to do the procedures including Dr. Puthawala. There was a lot of resistance anytime and anywhere you go especially from the surgical groups. Surgeons, the GYN oncologists, the head and neck surgeons, they always felt threatened because we were going to take their business away. But no, it became complementary. I always involved them, whether it was GYN or head and neck. I tell them, “Look, you can come and do the tracheostomy. You can do the gastrostomy. I don’t want to do your procedures.” Although I could do tracheostomy myself, I said no. It’s your procedure, you do it.
So I worked with the ENT surgeons, the GYN oncologists, the urologists in a way that they felt me as their colleague working together rather than competing with them. I think that was the feeling I had to create so that they did not feel I was competing with them but rather I’m working with them. Whenever we did prostate implant, I gave them the credit. I said this is your facility, you are doing it. So that’s the way I think they accepted slowly. But it was definitely a struggle, Chris. The initial few years were the biggest struggle for me.
Christopher Rose: So Nisar, the other thing as I look at your CV and your innovations, in the early days of head/neck cancer and also recurring cancers, perhaps you and Dr. John Byfield on the West Coast and Dr. Brady on the East Coast were using 5-FU concomitantly with your implants, and he was using methotrexate, I believe. How did you come to decide that you could get some help in terms of radiosensitization? And I get it 5-FU is the major agent in this.
Nisar Syed: Yes. You know, that’s very interesting. Do you remember Dr. John Byfield?
Christopher Rose: Yes.
Nisar Syed: He was radiation oncologist and chairman at UC San Diego. He was the one who was one of the initial Radiation Oncologists who started using 5-FU as a radiosensitizing drug. So when he published those papers, then myself and Dr. Puthawala, who had always been with me, we started to use 5-FU and methotrexate in locally advanced and recurrent head and neck cancers. But the problem happened, Chris, when the patients had neck dissection and developed recurrent tumors and we used methotrexate with brachytherapy. Unfortunately, we had two carotid blowouts, and that was very serious. The whole implanted area necrosed. Fortunately they didn’t die of the bleeding, but survived. But that was caused by methotrexate in patients who received reradiation. The combination of high dose methotrexate in re-irradiated patients can cause serious complications.
Since then we stopped methotrexate, especially if the patient had surgery. Because when they had the neck dissection, the surgeons skeletonized the carotid artery and there was not much tissue between the skin and the arteries. A third patient who had carotid blowout was admitted to the hospital and they ligated the vessel. So this happened to the methotrexate experience with reradiation in surgically operated patients.
So that was how we started, when John Byfield promoted 5-FU. But at that time also primarily they were using both methotrexate and 5-FU combined, and that was our mistake using both in previously operated patients. Today, we use 5-FU as a radiosensitizing agent. Sometimes in younger patients we use cisplatin and 5-FU in locally advanced and recurrent cancers.
Christopher Rose: Now maybe we could switch gears. We have about 15 minutes.
Nisar Syed: Yes.
Christopher Rose: So what do you envision. You’re a department chair now. I know you are looking at protons. What do you envision for the future of radiation oncology?
Nisar Syed: Well, a couple of things, Chris, which you all know. You know better than me. Number one, I am concerned about the brachytherapy utilization in U.S.A. for many reasons. Because the reimbursements are gone down so low that there is not much incentive among radiation oncologists to spend time in the operating room, to learn and take care of these patients, to take all the responsibilities for hardly any reimbursement. If you look at the reimbursement for the brachytherapy versus external, you make a lot more revenue by doing the external rather than brachytherapy. Whereas, in the brachytherapy, you have to admit the patients, you have to go very early to the operating room and do the procedures, unload/load, daily visits, removing the implant, etc. There’s a lot of work for the best outcome for the patients, but revenues are dwindling. As a result of this, a lot of radiation oncologists who are competent and capableare reducing the brachytherapy. So I’m afraid that this is a very negative disincentive. Unless people like yourself and people in power and high positions work on proper reimbursements, I think this is not going to be used as much. That’s number one.
Number two, people think IMRT has replaced brachytherapy, which is definitely not true. Even with IMRT, there is a dose limit. But the tumors which are much larger and recurrent, you cannot give enough dose even with IMRT/IGRT. So that’s why these are the concerns of mine for the brachytherapy field.
Second, what I’m looking at is the increasing interest in hypofractionation where again brachytherapy led the way by establishing the high doses per fraction where the external beam is going. Many radiation oncologists started to use similar fractionation to reduce the number of fractions in external beam radiotherapy. Which I think is a must, which is in the right direction. I’m sure that’s what is going to happen.
The other thing is the increasing use of SRS and SBRT which is absolutely the way it is going to be. My feeling is the same, Chris. Hypofractionation with immunotherapy and targeted chemotherapy, I think that’s where it is heading rather than the long fractionations of eight to ten weeks of external irradiation in the cancers of the prostate, head and neck, lung, et cetera. Hypofractionation, brachytherapy, SBRT and SRS with or without targeted chemotherapy and immunotherapy is the future. Proton seems to have radiobiological and favorable dose delivery comparing to photons but unless it becomes less expensive it will have limited use although it may play a pretty good role in the left-sided breast cancers, by reducing the coronary artery dose, pediatric tumors, brain and prostate, et cetera. But I think hypofractionation with immunotherapy is going to play, in my opinion, a big role with brachytherapy. Just brachytheapy alone in early stage cancers, external irradiation with brachytherapy boost in Stage II, and combination of external irradiation plus brachytherapy and chemotherapy and immunotherapy in Stage II and Stage IV cancers.
With regard to hyperthermia, Chris, although we have had a very good experience with excellent outcomes using radiation and hyperthermia in locally advanced and recurrent cancers, the reimbursement is extremely low to non-existent. But it has tremendous value. I’m afraid that hyperthermia is not being utilized because of the reimbursement issues.
Christopher Rose: So Nisar, many things we haven’t touched on. One of them is your tremendous philanthropy and giving back. You know there’s a question that we ask about how young radiation oncologists can achieve a global impact. Maybe you might speak about that in terms of your own personal experience with radiation back in India.
Nisar Syed: Sure. Yeah. My mother passed away with, cervical cancer, stage III in the 1970’s in India. At that time I had to get her over to England to have her treatment because there were not good enough facilities in India. So at that time I decided that I should do something in India. Not only establish cancer centers, but also train people in diagnosing and treating patients with cancers. So the very first thing I did was establish a comprehensive cancer center in my hometown which is Hyderabad. That was one of the first privately owned cancer centers in my state and one of a very few in the whole country. I started to install the cobalt-60 unit initially and then a LINAC and started to train people. I had many radiation oncologists and medical physicists from India come over to Long Beach Memorial Medical Center to be trained in brachytherapy and external irradiation. Then I invited them here and they came through being sponsored by UICC, our Endocurietherapy Research Foundation and their institutions.
So I’m very happy that I’ve established quite a number of centers in India - north, south, everywhere - and they are functioning well. As a matter of fact, my son who is a radiation oncologist, is developing many cancer centers all over India and trying to provide the services which are not available or were not available at the time when I was beginning my career. So as a result, I have a lot of these centers which are providing training and free treatment or low cost treatment to the patients who would not otherwise be able to afford treatment.
Also, Chris, we providetraining for UICC fellows. I have been training the fellows from India, Pakistan, Middle Ease, African countries, South American, Europe, United Kingdom, China, Russia, et cetera. My whole family is involved in these activities, for providing the cancer care where it is less available and free or at a low cost.
Christopher Rose: So maybe I might ask you as you brought in your son, why don’t you tell me about your family? Are you married?
Nisar Syed: Yes.
Christopher Rose: How many kids do you have and what your kids do.
Nisar Syed: Yes. Chris, my wife is also a radiation oncologist. I have lots of people now who are radiation oncologists. She practiced here at Martin Luther and Harbor-UCLA Medical Center. She’s a radiation oncologist, but she took care of the children. She helped me to pursue my career. She took care of our four children, out of which, one became a radiation oncologist, the second became an IT specialist working for Kaiser, the third is an attorney. My one daughter did a Masters in psychosocial and married to a radiation oncologist. My son, who is a radiation oncologist, spends time in India and U.S.A. He’s working on developing cancer centers mainly in India, but also in African countries, Bhutan and British Guyana. So they are all kind of involved and dedicated to the oncology field providing facilities for the diagnosis and treatment of cancers, as well as training and research, et cetera.
Christopher Rose: Nisar, you’re a very energetic man. I remember you coming and visiting me in Burbank and helping me with a patient, now almost 40 years ago, with probably the largest tumor I’ve ever seen. She’s still alive and doing fine and functioning well. But you got there I think at the crack of dawn because you had so many responsibilities. How do you balance your active career with some fun? What are your hobbies? What do you do outside of medicine?
Nisar Syed: Not a lot, Chris, unfortunately. Because even outside, whatever time I have, I spend on the patients. There’s hardly any hobbies because my hobby is, just like when I take off, I go to other countries and just give lectures and treat patients. Whatever time I get in between, I go and visit places.
Christopher Rose: Travel.
Nisar Syed: Yes. Otherwise, not a lot of hobbies.
Christopher Rose: So do you have any advice that you would give to young radiation oncologists starting out?
Nisar Syed: Yes. I think my suggestions to them is, yes, not only working hard and sincerely but be as gentle as possible and sensitive to the patients issues, their relatives, and especially dealing with colleagues - surgeons, GYN oncologists, head and neck surgeons, et cetera. To have the best of the relationship so that you have a combined effort for the patient care. Not trying to show that you’re competing with them, but complementing them and at the same time working with the hospital executives, not against them, but with them.
Most of the places I saw, Chris, physicians were against the executives and executives against the physicians. I don’t like that. I encourage them to work with the executives so that they’ll support you and you support them. I like them to be persistent in their efforts and to never give up, especially for the treatment of the patients. I mean not to just send the patient to hospice, even with too advanced disease who could be treated with modern technology, targeted drugs, immunotherapy to relieve their pain and suffering which may prolong life.
But even more so, Chris, now look at this new trend. The most recent papers coming out, patients with six to seven metastatic lesions from lung, prostate, and kidney cancers treated to 40 to 50 Gy to the primary site and stereotactic body radiotherapy to 5-6 metastatic lesions, with immunotherapy improving three times the survival. So you cannot give up if you have a little more advanced disease. But I don’t want them to also go overboard where there is no hope and causing more misery. And always I don’t like to be solo. I always like to associate with others and work with everybody. That’s my advice to them.
Christopher Rose: It has been truly a joy to talk to you, Nisar.
Nisar Syed: Thank you.
Christopher Rose: Before we hang up, is there anything that we’ve forgotten that you would want to memorialize?
Nisar Syed: Let me think. The main people who have really worked in this field, there are many which we didn’t have a chance to talk about, especially people like Henschke, Fletcher, Hilaris and many others who had a lot of contributions in the field of radiation and brachytherapy.
Christopher Rose: I’m glad we got a chance for you to honor your long-time colleague, Ajmel Puthawala.
Nisar Syed: Absolutely, Dr. Puthawala, David Neblett, my first physicist, and myself worked very closely in developing brachytherapy technique, treating the patients, submitting publications and training. And then Dr. Anil Sharma has been with me for a long time helping to develop applications, training and continued research. So there have been a lot of people involved in this journey, Chris. But again I want to give the credit to everybody. I get the credit for everybody’s work, but I’m only representing this teamwork. I often feel that I’m credited too much alone, but I want to share it with everybody, especially Dr. Puthawala, Dr. Sharma and David Neblett, who helped me to get where I am with this technology.
Christopher Rose: Well, again, thank you so very, very much.
Nisar Syed: Thank you indeed, Chris. I appreciate it.
