By David Hussey, MD, FASTRO, and Roger Robison, MD
This interview with Robert Lindberg, MD, took place at the Gilbert H. Fletcher Society meeting in Las Vegas on April 19, 2002.
Question: Bob, what I would like to do today is divide the interview into two parts. One is to first get an idea of your background: how you were trained, how you got interested in radiation oncology, how you ended up at the MD Anderson Hospital and then at the University of Louisville. And then at the end, get your perception of the changes in radiation oncology during your career. So with that, why don’t we start out with you giving us the background of your early schooling?
Dr. Lindberg: I was born in Los Angeles in 1932. My father was a physician. He had a pathology residency at the Mayo Clinic and then moved to Los Angeles to work in the pathology department at the Los Angeles Tumor Clinic. At that point he became interested in radiotherapy. In 1937, my father moved the family to Tucson, Arizona, and practiced radiotherapy there until he died in 1964. Therefore, my first introduction to radiotherapy was as a child. I always knew I wanted to be a physician- a radiotherapist. My undergraduate education was at the University of Arizona in Tucson. At that time, Arizona did not have a medical school. A survey reported that Arizona would not need a medical school until the year 2004. A second survey concluded that Arizona needed one right away. The pre-medical adviser at the University of Arizona was Dr. Caldwell, the head of the biology department. He was so well respected that his recommendation basically placed you in the medical school where he thought you should go. When I graduated from the University of Arizona, I went to Northwestern Medical School in Chicago even though I had never had an interview at Northwestern. I had other interviews at Tulane and at USC, but Dr. Caldwell recommended Northwestern. At Northwestern, one of the senior medical students asked me, “Do you remember when Dr. Caldwell interviewed you about which medical school you wanted attend?” I said, “Yes.” The senior then asked if there was a school Dr. Caldwell suggested. I said yes, Northwestern. He said, “You’re number 27.”
Question: Now you graduated from Arizona when?
Dr. Lindberg: I graduated from the University of Arizona in 1955 and from Northwestern Medical School in 1959.
Question: Your father was still practicing radiotherapy in Tucson when you left for medical school in 1955?
Dr. Lindberg: Yes, he was still practicing in Tucson. When he moved to Tucson he joined a diagnostic group. There were two diagnostic radiologists and my father. They practiced together for many years, but later split apart and my father had his own free-standing facility. He was there from 1937 to 1964. He was board certified in therapeutic radiology and never had any training in diagnostic radiology. When the American Board of Radiology was established in 1932, they also certified in therapeutic radiology alone. So my father was one of the early diplomats in therapeutic radiology.
Question: Why did he go into therapeutic radiology?
Dr. Lindberg: He became interested in radiotherapy while he was working in pathology at the L.A. Tumor Clinic. So my father was trained and started practicing radiotherapy at the Los Angeles Tumor Clinic.
Question: Dr. Albert Soiland (1873-1946) was the head of that famous Los Angeles clinic, and Soiland was one of the founders of the ACR. During the time that you were at Northwestern, were you always sure that you were going into straight radiation therapy?
Dr. Lindberg: I had gone to medical school with that idea in mind. In fact, I was actually thinking of practicing pathology and radiation therapy like my father because I knew the importance of the pathological diagnosis. In fact, my father did his own biopsies and frozen sections. He had a whole room with photomicrographs on the walls showing all the different diseases.
Question: Were your plans to return to Tucson to work with your father?
Dr. Lindberg: Yes, that was the idea. Having a three-month elective my senior year at Northwestern, 1958-1959, I worked under my father to gain some exposure in radiotherapy. With that aim in mind, I was accepted to a straight radiotherapy residency with Dr. del Regato in Colorado Springs at the Penrose Cancer Hospital. There were not many straight radiotherapy residencies in 1959. Also, that time, you had to take an internship before residency.
Question: And where did you intern?
Dr. Lindberg: I interned in Denver because it was close to Colorado Springs, Colorado. I did a rotating internship at St. Luke’s Hospital. It was an easy move from Denver to Colorado Springs.
Question: What were your options of where you were going to train?
Dr. Lindberg: Well, Dr. William Moss was at Northwestern at that time.
Question: Did you rotate with him?
Dr. Lindberg: No. Radiotherapy was not popular then, but the word got out. Dr. Moss probably doesn’t remember, but he was influential in sending me to Dr.del Regato.
Question: Did they have a therapy training program at Northwestern?
Dr. Lindberg: No, not in straight therapy. When I started the training program with Dr.del Regato, it was only a two-year program. However, Dr.del Regato always insisted that his trainees take a third year, a fellowship. He would place you at different sites and many of his residents went to France to take their third-year rotation or fellowship.
Question: Did Dr. William T. Moss train with Dr. del Regato at the Ellis Fischel State Cancer Hospital in Columbia, Mo.?
Dr. Lindberg: Dr. Moss was trained at Ellis Fischel under Dr. del Regato. He went into radiotherapy after a year of surgical training. Dr. del Regato arranged further fellowships for him at NCI, at the Radium Institute in Paris and at the Holt in Manchester.
Question: What was Penrose Cancer Hospital in Colorado Springs like at that time? Some people may not be aware of the historical significance.
Dr. Lindberg: Penrose Cancer Hospital was established because Spencer Penrose developed laryngeal cancer in 1932 and esophageal cancer in 1939. He was wealthy, an industrialist and he brought in Dr. Henri Coutard to treat him. The Penrose Cancer Hospital was part of the Colorado Springs Hospital, which was run by the Catholic Sisters of Charity. The cancer hospital was a separate building on the hospital campus. The Sisters enticed Dr.del Regato to come from Ellis Fischel in Columbia, Mo., and run it.
Question: Yes, Dr. del Regato wrote extensively about Penrose in his book, “Radiological Oncologists.” [Spencer Penrose (1865-1939) was from a prominent Philadelphia family, corresponded with the Biddles, and graduated from Harvard in engineering. He found gold in Cripple Creek, Colo., about 1892, and then went into gold and copper smelting with great financial success. He settled in Colorado Springs and built the Broadmoor Hotel about 1918. He developed laryngeal cancer in 1932 and went to Paris for X-ray treatments by Dr. Henri Coutard. Coutard (1876-1950) was the chief therapist at the Curie Foundation, and Penrose was cured. In 1939, Penrose developed esophageal cancer and sent for Coutard, who was then in Chicago. Penrose purchased a Maximar 400 kV unit and had it shipped to Colorado Springs for his treatment. After his prolonged treatment, Penrose donated the equipment to the local Catholic Hospital, Glockner, run by the Sisters of Charity. After his death, his widow granted funds for building the Penrose Tumor Clinic, a pavilion at Glockner, and Coutard stayed to run it until about 1948. In 1948, Mrs. Penrose and the Sisters of Charity wanted to expand the pavilion into the Penrose Cancer Hospital, which they did. Dr. del Regato, an old student and colleague of Coutard’s, was enticed from Ellis Fischel as director in January 1949.]
Dr. Lindberg: Of course, that was many years before I was there. In the early 1960’s, it was one of the few places that offered a straight radiotherapy residency training program. Actually, the residency training went from two to three years while I was there. So it became a three-year program and there were nine residents (three a year).
Question: How many years were training in diagnostic radiology at that time?
Dr. Lindberg: I think it was three years.
Question: What kind of equipment did you have?
Dr. Lindberg: Dr. del Regato had one of the first El Dorado cobalt units, which was used for most treatments. In addition, there was a Phillips contact unit, a 110-140 kV unit, and a 250 kV unit along with the El Dorado cobalt.
Question: And there were nine residents. Do you remember any of them? Did you keep in touch?
Dr. Lindberg: Oh yes. One of the residents, who were in my year, was Carl Bogardus and the other was Basil Considine. Dr. Chahin Chahbazian was the other faculty person. Dr. Chahbazian practiced (I guess he is retired now) in California for many years after he left Colorado Springs.
Question: What nationality was Chahbazian?
Dr. Lindberg: It is an Armenian name. He graduated from the American University in Beirut. Chahe took care of all the residents. There was very interesting training program. For instance, as a first-year resident you spent three months in pathology, and I did 30 autopsies. In the second year you spend three months in internal medicine. At that time there was no medical oncology. We ran the inpatient radiotherapy service with internal medicine backup from the staff of the hospital. There was also a large facility for cancer detection. Many people came for “cancer physicals,” so we did a complete physical exam, including proctoscopies and cystoscopies, if indicated. When rotating on the urology service, we assisted the urologist performing the cystocopies in the cancer hospital.
Question: Did you ever find anything?
Dr. Lindberg: Oh yes. Every once in a while you would run across some abnormality.
Question: Now, you said that you didn’t interview for medical school. Did you interview to go to Penrose?
Dr. Lindberg: No.
Question: I’ve heard of people that would go out there on electives, medical students or such.
Dr. Lindberg: The elective type of interview was something that developed later. I don't remember any electives or medical students during the time that I was there. I applied and was accepted.
Question: Did your dad know del Regato?
Dr. Lindberg: No, I don’t think so.
Question: I’ve heard stories about the luncheons with Dr. del Regato. Can you tell us about those?
Dr. Lindberg: Yes. All residents were required to eat lunch with Dr.del Regato. That was part of the mandatory training program. We ate in the cafeteria. Of course at that time, we were paid well. I mean, the stipend was $300 a month tax-free, since it was through an NIH grant. Everyone ate at a reserved table in one corner of the cafeteria dining room, and most of the residents brown bagged it. We brought our lunch; we couldn’t afford to buy it. There was always a discussion which could NOT be based on any current patients. In fact, you couldn’t discuss medicine or cancer, unless it was (for example) the ethical status of abortion. “Is abortion ethical?” was an acceptable topic. Discussing medicine was not allowed unless it was philosophical. When I was there, 1960-1963, there was a lot of interest in Cuban politics, with wide-ranging discussions. There were some very interesting subjects discussed. Actually, the training program was a very clinically oriented approach to medicine: the art of medicine and the art of practice. We treated from 25 to 40 patients a day. Every patient was well-utilized from a resident’s standpoint. There was one resident assigned to each machine (cobalt, kilovoltage, superficial). Everybody else was rotating on other services.
Question: Who was giving the treatments? Did you have what are now called therapists, previously referred to as technicians?
Dr. Lindberg: Yes. There were technicians.
Question: And how were they trained in those days? Were they RNs or diagnostic technologists?
Dr. Lindberg: Good question. Most of them were diagnostic technicians, as I remember. Most of them had worked there for a long time, so they knew what they were doing.
Question: And you had no pocket calculators. Did you have a physics department?
Dr. Lindberg: We had a slide rule.
Question: Did you have a physicist anywhere?
Dr. Lindberg: Yes. There was a physicist who checked the calculations and taught the residents, but basically the physicians calculated everything. In fact, there was a Friday afternoon session where every patient was reviewed and discussed in detail, just like you would at a planning clinic. There was also a weekly status check.
Question: Those were calculated using SSDs and given doses?
Dr. Lindberg: It was in given doses in roentgens.
Question: Were doses just kind of rounded out like they were at M.D. Anderson, out to the nearest 25?
Dr. Lindberg: No. If you wanted to give 200r, it was calculated at 200r.
Question: What was the type of dose schedule you might use?
Dr. Lindberg: Well, many times we were treating patients six days a week.
Question: 200 roentgens a day, six days a week.
Dr. Lindberg: Two hundred roentgens a day, six days a week was used for most inpatients. We made use of the Saturday hospitalization and treated them. We had Saturday morning inpatient rounds with Dr. del Regato and all the staff. Usually we would meet with the internists, and they would round with us to see their patients. The outpatients were only treated five days a week.
Question: How much elective regional node treatment were you doing or was it only the cancer primary that was treated?
Dr. Lindberg: There were elective areas being treated. The nodal areas and the surrounding areas were treated in addition to the primary tumor itself.
Question: I always associate del Regato with an international background. Were there a lot of foreign medical graduates there? It was hard to get American graduates interested in radiotherapy for a time.
Dr. Lindberg: No. Most of them were U.S. graduates. There were a few foreign trainees. Many of them stayed in the United States after training, but some went back to their home countries. Most of the residents with whom I trained, were United States citizens or they stayed in the United States and became citizens.
Question: It is impressive that so many Penrose graduates went into academic medicine later on.
Dr. Lindberg: Yes. Maybe that was due mainly to the fact that Dr. del Regato insisted on another year of training somewhere else, not with him. Training somewhere else exposed the residents to another viewpoint with another approach. Many residents went to a variety of different programs.
Question: Some went to France and what did you do?
Dr. Lindberg: I went to M.D. Anderson for a fellowship.
Dr. Lindberg: Well of course, not living in a vacuum, we were aware of Anderson and I thought it was a good place to train. At that time, 1963, I still intended to go back to Tucson and practice with my father.
Question: Was that your idea to go there or did del Regato suggest it?
Dr. Lindberg: No. Dr. del Regato did not suggest it. I applied for a fellowship at Anderson and was turned down.
Question: Turned down?
Dr. Lindberg: Yes, and when I told Dr. del Regato he was somewhat disturbed, to say the least. He said that he would get me in.
Question: I can imagine; I can see that because I have seen some of those letters that Dr. del Regato wrote to Dr. Fletcher recommending or NOT recommending people.
Dr. Lindberg: Dr. del Regato was upset; I don't know if Dr. Fletcher was aware I had applied. I am not sure the residency director at the time discussed the applicants with Dr. Fletcher.
Question: Would that have been Norah Tapley?
Dr. Lindberg: No. Dr. Lowell Miller was the training director.
Question: When you were still with del Regato at Penrose, did you do much in the way of brachytherapy?
Dr. Lindberg: Yes. They were doing brachytherapy. We saw a few cases suitable for intracavitary brachytherapy.
Question: What kind of applicators were you using? Do you remember? It wasn’t afterloading was it?
Dr. Lindberg: No, I don’t remember the applicators. I was not exposed to afterloading until I was at Anderson.
Question: I have just one last question about Penrose. Did the residents take a physics course?
Dr. Lindberg: Yes and no. There was a variety of lectures each week. We had lectures in diagnostic radiology, usually by the head of the diagnostic department in the hospital. We had a teacher in radiobiology and another one teaching physics; that is where I learned about "quantum mechanical tunneling.” There were whole series of lectures; four days a week every afternoon from 4:00 p.m. to 5:00 p.m.
Question: And then when you applied in 1963 for this fellowship at Anderson, Dr. Fletcher hadn’t been there that long. He came in to Anderson in January 1948, so he had only been there about 15 years. What kind of a program was there? Was he having a full residency or just taking fellows?
Dr. Lindberg: Well, there was a combination of groups; (a) there were fellows, like myself and Dr. Carlos Perez, who was in my year. (b) there were residents in general radiology from the military hospital in San Antonio. They were rotating to Anderson for their required year of therapy. (c) In addition, they may have had some straight therapy residents.
Question: I thought Jimmy King was the first straight therapy resident?
Dr. Lindberg: He may have been. When I started, I don't think there were any straight radiotherapy residents, but I don't remember.
Question: So tell me about your experience at Anderson Hospital. Did you have dinner with Dr. Fletcher and not be allowed to talk about the most recent patient?
Dr. Lindberg: I don't remember ever having dinner with Dr. Fletcher. That first year as a fellow was very interesting. In 1963, Anderson had probably some of the best equipment in the United States. In the basement there was an Allis-Chalmers 22 MeV betatron, and the 18 MeV Siemens betatron which was staffed by Dr. Norah Tapley . The Grimmett cobalt unit, a rotating Therac cobalt unit and a short SSD cesium unit were on the ground floor. On the second floor there were four to six 250 kV units. The equipment was unchanged for a many years.
The residents rotated machine assignments every three months and the faculty rotated from one machine to another every six months. My first faculty supervisor was Dr. Eleanor Montague, for five months because we rotated together. At the time Dr. Montague was, retrospectively, probably a little hyperthyroid, and she ran my “ass” off. She was so good; it was unbelievable. When I was assigned certain work, for example drawing the isodose curves for the vocal cord patients, if I didn’t complete the task expeditiously, she had already completed the curves. Dr. Montague was an excellent teacher and I was very fortunate to have her on my first rotation.
Question: The faculty at that time—you mentioned Lowell Miller and you mentioned Eleanor Montague.
Dr. Lindberg: Right. Others included Dr. Lillian Fuller, Dr. Norah Tapley, and Dr. Herman Suit.
Question: Herman was there already?
Dr. Lindberg: Yes. Dr. Suit was there for quite awhile before I came. Dr. Suit was from Houston and returned after completing a Rhodes Scholar in England, where he earned a doctorate.
Question: And how many patients a day were they treating on the average in 1963-1964?
Dr. Lindberg: They must have been treating 125-130 patients. There were the four megavoltage units: two betatrons and two cobalts, plus the cesium unit and four to six 250 kV machines.
Question: Were there about the same number of residents as at Penrose? About nine? You had such a mixed bag; it is probably hard to say.
Dr. Lindberg: Yes. There were nine or ten residents and/or fellows.
Question: So how did the day go?
Dr. Lindberg: The morning started with an 8:30 AM planning clinic. Of course, planning clinic was not where it is now. Rita Harris ran planning clinic, and Dr. Fletcher examined the head and neck patients. After planning clinic, you went to your assigned machine, that hasn’t changed much. Basically there were usually two faculty for an individual patient. There was the faculty actually treating the patient on a particular machine and then another faculty in charge of the tumor area. For example, Dr. Herman Suit would see the all the sarcoma patients, but somebody else treated them. Dr. Eleanor Montague would see all the breast patients as they were being treated on various machines. And of course, Dr. Fletcher always saw all the head and neck patients on Monday morning.
Question: Did Dr. Fletcher ever mention that this system was copied from somewhere else or that it was his idea? There were very few clinics that size that had that kind of faculty that allowed you to do that.
Dr. Lindberg: I don't remember him ever mentioning anything one way or the other.
Question: And the actual treatments were given by techs or nurses?
Dr. Lindberg: At that time they were all nurses. None of them were certified techs. They were all nurses trained to treat the patients.
Question: I heard two stories about that. One is that Dr. Fletcher thought it was easier to teach the technical details to nurses. And another one was that he could pay nurses more, in that era, than he could pay techs. Therefore, he could get better quality people. I don't know if either of those is true, but those are the stories I heard.
Dr. Lindberg: The story I heard was the first. In other words, he wanted the people that were treating the patients to be clinically aware of the patient’s well-being and the patient’s performance status. Dr. Fletcher believed that a nurse who was already trained from the nursing standpoint could be trained to be a technician and use the machine, but it was more difficult to take a technician and train her to be a nurse. They looked after the patients. The nurses would call a physician if there was something wrong, and they were attuned to that.
Question: So that was a major difference between the two hospitals at the time, between Penrose and Anderson?
Dr. Lindberg: Yes.
Question: How about physics? How did that differ?
Dr. Lindberg: Well, physics was tremendously different. Anderson was always well-staffed from the physics standpoint. As a resident, you took not only a physics course, but you had physics lectures. In January, there was a full physics course for about six weeks, eight hours a day. It was given in three two-week sections. Dr. Shalek ran the Physics Department when I was there.
Question: Leonard Grimmett was the first head of physics at Anderson from 1949-1951?
Dr. Lindberg: Yes, I never met him.
Question: And then Dr. Fletcher himself, who was trained in physics and engineering, took over the Physics Department from 1951-1954. And Warren Sinclair was head of Physics from 1954-1960.
Dr. Lindberg: I was there after Dr. Shalek took over Physics in 1961. Vince Sampiere basically ran all the dosimetry, did most of the dosimetry for the department.
Question: Tell us about your career and how that you made your name in head and neck cancer and with sarcomas. And any other areas I’m missing. Hyperbaric?
Dr. Lindberg: Yes. Originally I had intended to go back to Tucson in 1964, but I decided that to stay in academic medicine. Dr. Fletcher made me an offer I couldn’t refuse. At that time the RSNA (in December) was the meeting that everyone went to in order to find a job. One thing I can say is that Dr. Fletcher was really nice because he offered me a faculty position before the RSNA meeting.
Question: Smart guy.
Dr. Lindberg: That’s right. So when I went to RSNA, I already had the offer in hand. Some of the other offers were less than one-third of what Dr. Fletcher offered.
Question: This was after you had been there only three or four months, having started in July 1963.
Dr. Lindberg: It was a one-year fellowship (1963-1964). Dr. Fletcher had pet names for some of the residents. Some of them were appropriate and some weren't.
Question: And what was your pet name?
Dr. Lindberg: It wasn’t used very long, only at the beginning of my fellowship. Coming from Dr. del Regato, during patient conferences, Dr. Fletcher would turn to me and say, “Okay, professor, what would del Regato do?” So I was known as the “professor”. Like most new faculty, my first rotation for six months started on the Allis-Chalmers betatron treating mainly patients with cervical cancer. Dr. Fletcher was the backup faculty. Dr. Fletcher saw all cervix patients and ran the “fitting clinics” along with everything else.
Question: Was Delclos there at that time?
Dr. Lindberg: Dr. Delclos and Dr. Paul Chau were there. Dr. Paul Chau was the one that was doing most of the GYN therapy with Dr. Fletcher, and the new faculty started with that GYN group. During my first six months on the faculty, since I was assigned to the betatron; Drs. Chau, Fletcher, and I saw the patients almost every day.
Question: I had heard that a lot of the Anderson GYN therapy technique was primarily developed by Paul Chau and/or Fernando Bloedorn.
Dr. Lindberg: I think it was probably Dr. Bloedorn who was there and left before I came. Dr. Herman Suit developed the afterloading applicator. He took the French applicators and made them afterloading before I came. Dr. Suit was into that part of it, the mechanical part of designing the afterloading applicator.
Question: But they were a little different than now, weren’t they?
Dr. Lindberg: They underwent some revisions. The first applicators at Anderson had just a pop open top on the ovoids so you could slip the radium in and close them. They weren't afterloading. Dr. Suit designed the applicators with hollow handles so the radium could loaded after insertion and packing. That was done before I arrived in 1963. In the OR there were microgram sources that duplicated the milligram sources. In a typical system used for cervical cancer, such as 15-10-10, 15-15, you loaded microgram sources in the OR. With a probe in the bladder and then the rectum, doses were recorded on every patient as actual measurements by using microgram sources.
Question: You put the probe through the Foley?
Dr. Lindberg: We took the Foley out and put the probe through the urethra. The bladder and rectal measurements were analyzed to determine which doses were important and which were not. An obvious point of inaccuracy was that how you held the probe made all the difference in the world as to what kind of a dose you would measure.
Question: Tell us about head and neck cancer and how the Anderson technique evolved while you were there. I suspect this was just as the concept of “subclinical disease” was evolving.
Dr. Lindberg: The philosophy started before I came there. Dr. Rod Million was a year ahead of me and he left before I came. He had done a node-mapping for nasopharynx cancer, showing where the nodes were that drained the nasopharynx. He made some of the original diagrams for the nasopharynx showing the node mapping. They were already treating the posterior cervical and low neck and the full fields when I came. Since the treatment of head and neck cancer was so different at Anderson, I put together a manual using the Anderson anatomy stamps. I drew the typical treatment fields on the stamp diagrams just for my own benefit. Basically, the fields and those outlines did not change very much from the time when I first came there. Now, the ease of treatment has changed significantly. Many of the head and neck patients were treated on the old Grimmett cobalt unit, where you had to mechanically change the collimator. It was not a moveable collimator system, so you had to put in a fixed collimator. Then there was the blocking. A plastic table was placed over the patients, and blocks were set on the table to shape the fields. Dr. Fletcher used to have a “fit” when they built that “wedding cake,” which was more than two layers of blocks stacked up to shape the treatment field.
Question: Well, Fletcher, he was pretty derogatory about cerrobend when it first became available.
Dr. Lindberg: Well, yes. It was very interesting. You know, Dr. Bill Powers developed cerrobend and Dr. Fletcher didn’t like him.
Question: Actually, Fletcher did not dislike Powers per se, but Powers had just joined the Committee of Radiation Oncology Studies (CRTS). CRTS had been organized by the head of the NCI; a guy by the name of Endicott. Fletcher had been chairman of that committee for a number of years – a large number of years. They decided that democracy should serve and that maybe somebody else should be chairman for a change. That was because Regato and Fletcher and Kaplan were all sending mixed signals about the way radiation oncology research should be done by/at the NCI. Norah Tapley, from Anderson, was the first secretary. Anyway, Powers had been the one who had been delegated to be the one to tell Fletcher that he should step down as chairman.
Dr. Lindberg: It was interesting when the Physics Department tried to set up the first cerrobend blocking at Anderson. The way they went about it almost doomed it to failure the first time. I won't say it was malice of forethought, but there sure was an underlying prejudice.
Question: So Dr. Fletcher preferred to treat patients in the lateral position with stacked blocks?
Dr. Lindberg: That’s the only way he could do it at that time. It took him a long time to accept the cerrobend blocking. Of course, now it is standard.
Question: But, actually, you know, I think he had a point even though we all use cerrobend now. But you can’t change it on the spur of the moment. And Fletcher would come into those clinics, and he would change a centimeter, millimeter here and so forth.
Dr. Lindberg: That is one of the problems with cerrobend, since you cannot change the fields instantly (more like an hour or two), and the patients may suffer.
Question: Before I forget it, let’s talk about your sentinal node-distribution paper in 1972. That was such a landmark, and even today at 2002, I am still making copies of it for various clinicians. I give it to pathologists and all variety of physicians.
Dr. Lindberg: Actually, I got into the head and neck area by default due to my interest in the statistics of the area. For years I did all of the coding. We designed new code sheets. Dr. Rod Million designed the earlier code sheets; there were three code sheets for different head and neck sites. I put them all together into one code sheet with the various major sites and all of the sub-sites so all of the head and neck cases could be coded on one sheet. We developed a database for all the head and neck sites and published a number of papers from this data, which was all on IBM punch cards. The meeting scheduled for Phoenix (ASTR in 1971), and they wanted papers for a head and neck symposium. Dr. Fletcher called me, and Dr. Richard Jesse was involved. Dr. Fletcher wanted a neck node distribution paper, a head and neck node paper. So, okay – I did a neck node paper (CANCER 29: 1446, 1972).
If you remember, every head and neck patient that was initially seen at Anderson was seen by head and neck faculty. Not only the fellows, but the faculty saw them in addition to the fellow, and a stamp was made showing the disease in the neck. The areas involved were drawn in as well as dictated. The initial notes were always dictated by the faculty, so it was relatively simple to go through the Anderson charts. I made a special code sheet showing where the nodes were and the areas that were involved. I reviewed and coded many thousand charts and put the data on IBM punch cards and out came the paper.
Question: That was very innovative. That was the first paper on nodes for any site. And since then you see node papers for a lot of sites. The next ones that I noticed coming out of Anderson was GYN and then breast. It is such a key, such an important paper, especially in head and neck. Did you do that as a resident?
Dr. Lindberg: No. I was on the staff. I was on the faculty for six years before I did that paper.
Question: I guess you would have to say that Dr. Fletcher’s organization of the department and the principles involved when he started the department allowed the faculty to be able to do clinical research.
Dr. Lindberg: The department was organized in such a way that actually the clinical research opportunities were unlimited. The set up allowed you plenty of time to do research, and you had the wherewithal to do it. Anderson had probably the best tools that were available at the time, so there was no reason not to do it. Besides, Dr. Fletcher made sure that you did research.
Question: What about research at Penrose?
Dr. Lindberg: The charts were top quality. The residents at Penrose all did research papers based on the work that was done at Penrose. In fact, one of the projects I did at Penrose was reviewing the incisional biopsies of skin lesions, which were done just to make the diagnosis. Actually, many of them turned out to have clear margins. The outcomes of patients with positive margins were compared, whether they were further treated or not, versus those that had clear margins. So there was a clinical approach, reviewing charts, at Penrose also.
Question: The hyperbaric oxygen story wasn’t quite a happy ending. How did that all come about?
Dr. Lindberg: It started because there was a lot of interest in use of hyperbaric oxygen, obviously from the radiobiology standpoint. If you look back, a number of “radiobiology principles” of that time have led the clinicians down the merry path to the point of no return. There are quite a few and that was basically one of them. Before we started, Dr. van den Brenk in Australia, Dr. Plenk in Salt Lake City and Dr. Johnson in Manitoba had used hyperbaric oxygen for quite awhile while treating cervical cancer. Dr. Fletcher decided that he was going to get into the hyperbaric business, and I was to check it out.
Question: An oxygenated tumor was going to be more responsive to irradiation, the OER, oxygen enhancement ratio.
Dr. Lindberg: Right. You can increase the blood oxygen level to 2,000 mm of Hg, the partial pressure is 2,000 rather than 120 or 100. It was fantastic; you get a 20 times increase. With that increase, the argument being that there should be increased profusion of oxygen into the tumor. So I got “tabbed” for the hyperbaric study. I went to see Dr. Plenk’s operation in Salt Lake City and Dr. Johnson’s in Manitoba, and then came back to start it up at Anderson. They had been using a hyperbaric tank that was actually a steel tank with just one four foot section that was 180 degrees of plastic. Dr. Dan Tobin had been doing hyperbaric treatment in Madison and we got the same tank. As we were ready to use it on the first patient, we got a telegram: Tobin had an explosion. The tank plastic blew as Dr. Tobin was standing by the tank. It threw him across the room into a steel cabinet. Fortunately he recovered. The patient had a bilateral pneumothorax but survived. Therefore we got a different tank. We used the Vickers Tank, which has the double full plastic cylinders. Dr. Jess Caderao was the resident at the time, and thus we started on the hyperbaric business.
Question: You and Caderao published about this in 1973 and 1977?
Dr. Lindberg: I don’t remember the dates.
Question: And you used the cobalt E machine?
Dr. Lindberg: Yes, at that time there was a cobalt unit that was located in a basement room that was big enough to handle the hyperbaric unit. The room was built for the hyperbaric treatments. There were some head and neck patients. The main group had cervical cancer,sincewe had enough patients to do a prospective randomized trial. In those days you only talked to the patients who were randomized to receive the oxygen. The patients who were randomized to receive the standard treatment never knew they were in a study. Actually some statisticians believe that is a sound way of handling trials. So we talked to the patients, but we never told them they were in a randomized study. We just told them they were in a study and that we thought it was best to treat this way (hyperbaric). We got a signed consent. One of the big problems that almost shut the program down was when the astronauts burned up on the launch pad. They had an oxygen fire that almost put the hyperbaric treatments out of business, but we survived that and got the patients treated.
Question: Did it look promising as you went along with it?
Dr. Lindberg: Could you imagine what would have happened if that hyperbaric treatment would have been statistically significant and improved survival? Improved results with hyperbaric oxygen coming out of Anderson at the time? Every patient now would be treated with hyperbaric oxygen. But, no, it didn’t show any benefit.
Question: And how many years did you study it?
Dr. Lindberg: We ran until we got quite a few patients; there were over 300 patients.
Question: There were a lot of positive studies. There had to be a negative one sometime. If you don't do it, you don't get the answer. So it took a lot of guts to do it.
Dr. Lindberg: One of the problems was that we were comparing cobalt to the standard form of treatment, 25 MV photons, and just that alone would make the results not significant. So, in retrospect, the study design was loaded against the hyperbaric, not intentionally, but in retrospect.
Question: Somewhat related, I think, would be the Anderson experience with the “extended field for cervix.”
Dr. Lindberg: The “extended field for cervix” was interesting. We got started mapping the nodal areas involved in cervix cancer and it was decided that we needed to treat one echelon above the nodes involved. That concept also came about the same time as hyperbaric. So there was an extended field with the hyperbaric; at times we treated up to T-12. It came about because the Anderson could well pinpoint very well the level of nodal involvement because of our lymphangiograms. The lymphangiographers at Anderson were excellent. They could pinpoint the involved nodes and map them out, and the idea was to treat one level beyond. Subsequently, there were a number of papers published.
Question: That turned out to be a pretty negative study, too?
Dr. Lindberg: The toxicity was horrendous; therefore, the dose you could deliver was limited.
Question: So, you ended up with greater complications and poor central local control.
Dr. Lindberg: That’s right.
Question: I would also be interested—and this was kind of at the time you took over the sarcomas from Herman Suit—in a little bit of the history of how we started treating sarcomas. When I was a resident, before I came to Anderson, it was thought you could never treat sarcomas. They were radio-resistant cancers. So nobody ever did that. It kind of came out of Anderson. Could you elaborate?
Dr. Lindberg: That change was due to two people: Dr. Richard Martin, chief of surgery at Anderson, and Dr. Herman Suit. Dr. Suit showed in the laboratory that the sarcomas were responsive to high doses. Now it has always been known that sarcomas responded, but they couldn’t be “cured.” Dr. Suit experimented by putting sarcomas in the mice. He placed the tumors in the leg and clamped off the blood supply and then treated the mouse tumors.
Question: What about the tourniquet?
Dr. Lindberg: From the clamp in the mice, Dr. Suit used a tourniquet in the patients, and these were obviously selected patients. The first patients had tumors located around the joints, since a sarcoma around a knee joint can't be treated by a wide excision. A wide excision in those cases is an amputation, or if it is higher it is a disarticulation. Therefore, most of the patients selected had lower extremity lesions. A tourniquet was placed as proximal as possible on the extremity and pumped it up to 550 mm of Hg, which cut off all the blood supply. A plastic bag was placed over the limb first and then the tourniquet over the bag. Nitrogen was pumped through the bag so that the skin of the leg wouldn’t absorb any oxygen from the air. The pressure was on for 30 minutes before the patient was treated. Now, stop and think about that, very painful. Even a pressure cuff at 200 mm of Hg around your arm can be uncomfortable. An IV line was inserted, and we had syringes loaded with 100 mg of Demerol and 100 mg of Nembutal. Every time the patient “twitched” we “hit” them with sedation. The patients were set up and treated on Therac A (cobalt), 1,000 rads single shot, two days in a row (2,000 TD in one week). The patients would have never tolerated daily treatment.
Dr. Suit treated both osteogenic sarcomas and soft tissue sarcomas. He increased the dose to the patients with osteogenic sarcoma up to 16,000 rads in 16 fractions in eight weeks and one day, and the sarcomas kept on growing. The osteogenic sarcomas kept on growing in the midst of the radio-necrosis, so we exceeded the normal tissue tolerance. Normal tissue will tolerate up to 14,000 rads with the tourniquet technique, but it didn’t do any good with the osteogenic sarcomas, no matter what we did, it didn’t work.
The soft tissue sarcomas responded and you didn’t have to take them to 16,000 rads, at 14,000 rads Dr. Suit got cures. So then he decided to try treating sarcomas with just conventional treatment (no tourniquet), but with higher doses (7,000+ rads).
Question: Was it a random study? Wasn’t it randomized?
Dr. Lindberg: There was a random study later. Dr. Martin was very intuitive about the approach and believed in radiation therapy. Also he was tired of “chopping off” legs and extremities. So, that is how the soft tissue sarcoma group started.
Question: And the group that got only the 7,000 or more conventional fractionation did well, too.
Dr. Lindberg: Yes. And there was no difference between the tourniquet technique with hypoxia and 14,000 rads and the 7,000 to 9,000 rads under the regular schedule. When you look back at the published data, whenever you think you found something new, just check the literature. In 1951, Sir Stanford Cade in England published a paper on post-operative radiotherapy in soft tissue sarcomas with a similar technique, and the results then were just as good as they were in the 1970s.
Question: So that took Herman on to Mass General?
Dr. Lindberg: I don't think so, but he showed that it could be done, and that early work evolved into routine post-operative treatment. Most patients at that time were coming to Anderson either (a) post-op, after an unexpected diagnosis of soft tissue sarcoma of the leg, or (b) they had recurred after a local incision, or (c) they were sent to Anderson and were re-excised and then irradiated. Later we started (d) pre-op radiation for gross tumors. So there were a whole series of evolutionary steps.
Question: Tell us about the next phase of your life, the University of Louisville.
Dr. Lindberg: A number of us had been at Anderson for quite a few years when Dr. Fletcher decided to step down from chairmanship. About that time, I had decided it might be in my best interest to look for another position, and the University of Louisville made me an offer I couldn’t refuse. People in Louisville had built a freestanding cancer center with the idea of giving it to the university. When I moved there it was still freestanding and controlled by Brown Cancer Corporation. Dr. Ralph Scott has been chairman at the university for many years and the director of the cancer center. Finally he decided to move on, so they were looking for a new chairman. The opportunity was unique at the time because the dean of the medical school was a pathologist and a pediatric oncologist. The head of OB GYN was a gynecological oncologist. Dr. Tom Day was there as head of OBGYN oncology, and he was Anderson-trained. The chief of diagnostic radiology was actually mainly interested in tumor localization and he had spent a year in therapy. In addition, the head of medicine was a medical oncologist. So there were a lot of pluses.
Question: Did you mention Condit Moore?
Dr. Lindberg: No. Dr. Condit Moore was there. He wasn’t chairman of the department. Head and neck was not a department; it was under general surgery. Dr, Moore was there, as was Dr. Mike Flynn. Dr. Flynn had trained at Anderson and returned to his home in Louisville. So, there were a number of good people.
Question: Was Hiram Polk still there?
Dr. Lindberg: Dr. Polk was still there, working hard. When I moved there, the radiotherapy department didn’t even have a memory typewriter for the office staff. By contrast, the physics section had treatment planning computers, but they didn’t even have an electric memory typewriter.
Question: I was going to ask you about the culture shock of leaving a place like M.D. Anderson, where for years and years they had the leading technology and infrastructure to help out. Then you get out in the real world and you don't find that available. It really explains to some extent why places like Anderson are what they are.
Dr. Lindberg: There was little infrastructure at Louisville. In fact, most of the radiation therapy faculty had left. Dr. Ann Chu was on the faculty, but she left. Dr. Baby Jose was the only one remaining, and the university was hiring locum tenens to help out. So, it seemed like there was an ideal opportunity to build a new program since they had good equipment and a nice physical plant; a good set up.
Question: It sounds like a challenge.
Dr. Lindberg: Yes. There was a lot of animosity between the private hospitals and the physicians in the university. Basically, the university hospital took care of the patients who couldn’t afford to go to the private hospital.
Question: Sounds familiar.
Dr. Lindberg: Yes. So it was a golden opportunity.
Question: Bob, I have a couple of things I wondered if you have any thoughts about. Your father was not in academic medicine but in private practice, and your original idea was to go into private practice. Was it because you were exposed to some real good people that you decided on an academic career?
Dr. Lindberg: Right.
Question: And what all went into that decision?
Dr. Lindberg: I realized that my father should have been in academic medicine because basically he was an academician.
Question: He sounds like he was.
Dr. Lindberg: Yes, he really was. The circumstances were such that he was out of academic medicine, but he should not have been. After going through three years with Dr. del Regato and one year of fellowship with Dr .Fletcher at Anderson, I realized that I was “spoiled.” I mean, I had the best of the training at that time. One was the art (Penrose), and the other was the science (Anderson), and I just couldn’t see myself going back to Tucson into private practice.
Question: And if you hadn't gone into clinical research, the world would be a lot worse off.
Dr. Lindberg: The circumstances were very beneficial.
Question: One other question about chemotherapy. We have been talking about sarcomas and cervix cancer, and the trials at Anderson to make things better. Now we are faced with concurrent chemotherapy. It is helping us with many of these problems and getting better results but also causing lots of toxicity during irradiation. At Anderson under Dr. Fletcher, there was not much cooperation with medical oncology. But now it is hard to find a tumor that we don't share with the medical oncologist. Did you begin to see that when you were at Louisville – more and more participation with medical oncology? Or did you have any feelings about that?
Dr. Lindberg: Actually it was stated before Louisville. By the time I got to Louisville in the early 1980s, there were a few things that helped establish medical oncology in the radiotherapy setting. One was the RTOG and the other was the pediatric oncology group, POG. There were certain areas that really showed benefits, and early pediatric tumors were one area. In a number of these tumors the cure rates rose from 10-25 percent up to 80-90 percent. So chemotherapy was hard to ignore. There were many changes that went into effect before I moved to Louisville. At Anderson, there were numerous combined treatments. For example, Dr. Julian Smith used intra-arterial pelvic infusion therapy and radiotherapy in patients with stage IIIB and IVA cervical cancer in the 1960’s. That’s when I found out that chemotherapy could affect the end-arterials that supply the skin over the buttocks.
Question: RTOG actually got started with the Methotrexate study.
Dr. Lindberg: We used Methotrexate with head and neck tumors. At that time it was oral Methotrexate given as an out-patient. The head and neck group at Anderson also studied inter-arterial infusions through the superficial temporal artery using Methotrexate. So there were selected areas all the way along.
Question: Tell us about where you think radiotherapy is going. Are we going in the right direction with chemotherapy and other drug therapies?
Dr. Lindberg: There have been a number of technological advances in the last 30 years. When you stop to think about them, there are certain ones that have really been important, not only in radiation oncology but also in other fields. Probably one of the first advances was the Xerox machine. Others were the electric typewriter and the computer. (I forgot to mention the fax machine). One of the things that people under appreciate is flexible endoscopy; all the different types of endoscopies that can be done. The CT scans, including the spiral CT and the MRI as well as the different P.E.T. scans are gradual improvements. The problem with the improvement is the cost. If I’m sick, I want the best that is available which is going to be expensive.
From the radiotherapy side, you have the same type of tools, but they have become more and more sophisticated and expensive. Now, does the IMRT really do anything? Well, if you listen to what Dr. Karen Fu showed us today [2002 GHF Society annual meeting] with head and neck tumors, you can use IMRT in nasopharynx cancer. It may not cure any more patients, but you may cut down on the morbidity. Dr. Fletcher used to say that any program that will improve survival or decrease morbidity is worthwhile. If you happen to find one that does both, you have a magic bullet. Now, some of these programs are obviously going to eventually find their proper use, but it is going to take awhile.
Question: There are two camps regarding IMRT. Virtual reality is not reality and the implication being that if you really don't know the extent of the tumor and imagining that you think you do and then treating there to that area, may not pan out. On the other hand, it seems like we are getting enough experience at IMRT, but we are not really doing any randomized studies on them. But eventually practice seems to go in directions like that. We really never did much in the way of random studies for 25 MeV X-rays either.
Dr. Lindberg: We never did a randomized study on the small pox vaccine either. So a lot of it becomes self evident.
Question: That’s right. And it may be that we are going to reach that. I don't think we know for sure. The cost of these new technologies, of course, is more easily achieved in large institutions or major medical centers. Twenty years ago when I was out looking for a job, every department I visited seemed like it had 40-50 patients. I didn’t see any small departments. And shortly after I got out, in the 1980s, I heard of California people running departments with 10 or 12 patients.
Dr. Lindberg: Unfortunately, they found out that radiotherapy makes money, and not only for the physicians, but in those days for the hospitals too. That is one of the problems, but there are other problems. Because of the money generated, you may do things you wouldn’t do otherwise. So, it is a double-edged sword. A lot of this “stuff” (new technology) is used in marketing. Nowadays with the Internet, the patients get on the Internet and if you don't do things the same as what they found on the Internet, you are suspect. So the patients are “pseudo-knowledgeable.” They're knowledgeable, but they don't really understand what they know and that drives a lot of these problems.
Question: Radiotherapy has lent itself to commercialization. And large corporations hire you as an employee. They will put you in Tennessee or put you in southern Indiana.
Dr. Lindberg: There are corporations that are owned by lay people and there are also corporations that are owned by physicians that will do that. Texas has quite a few.
Question: If you look back, do you have something that you are proudest of? You have done so many good things that I hate to narrow it down. But I just wanted to know if there is anything specifically or in particular that you are most proud of or that you most enjoyed participating in.
Dr. Lindberg: Well, after my wife and family, I can think of a few things I enjoyed participating in. I think that the approach of actually looking at statistics and looking at your results, and not just treating a particular way just because everybody does it, is one. Actually looking at the results you are getting, good and bad. Being able to publish the bad results is, I think, probably more important from the future patient’s standpoint than publishing the good results (in many cases). I think that probably is the most important thing that I have done is to look at the data. Look at what has happened to the patients.
Question: I see that also as one of your strongest points. You have always had great insight into studies, great critical analysis and constructive comments that get to the heart of the matter and in a courteous way, without being offensive about it. I certainly would like to back that up, too. And with that I think we have pretty well covered the waterfront. Thank you, Bob.