Samuel Hellman

By David Hussey, MD, FASTRO, and Christopher Rose, MD, FASTRO

In 2002, ASTRO established the History Committee for the purpose of documenting and recording the history of radiation oncology in the United States. This interview took place at the 44th Annual Meeting of the American Society for Therapeutic Radiology and Oncology in New Orleans on October 8, 2002.

Question: Today is October 8; we are in New Orleans at the 44th Annual Meeting of our Society. Dr. Christopher Rose and I will be interviewing Dr. Samuel Hellman of the University of Chicago. Sam, we're glad to have you here and we're interested in hearing your history and the history of the specialty as you perceive it. So maybe you can start telling us about your background, where you were born, where you were sent to school, how you got interested in radiation oncology and so forth, and then Chris and I will fill in with questions later on.

Dr. Hellman: Well, I was born in New York City in the Bronx in 1934 and grew up there, although I graduated from high school in Long Island because my family moved there against my wishes for my senior year. Nobody wants to move their senior year in high school, and I surely didn't. I went to Long Island, but my roots are in the Bronx. I went to a high school in the Bronx—Clinton High School that had 5,000 students. They were all boys, and so I had two absolutely non-negotiable requirements for college: it should be small and co-educational. So I went to Allegheny College, which at that time had about 1,000 students. And that was a very formative time for me because my experiences were quite limited. I hadn't gone very many places. So, I went to college in the western part of Pennsylvania right next to the Ohio border. It was very illuminating, interesting and intellectually very exciting. I had intended to go to medical school in Pennsylvania, as Allegheny graduates regularly did, and there was a competitive examination, which I found out about—or my mother, more accurately, found out about from a neighbor; it was in the newspaper—in New York state where they gave out a limited number of scholarships for medical school, the requirement being that you have to go to a medical school in New York state. So she sent it to me, and I took the exam in Rochester. We were both coming back from the Wisconsin-Ohio State football game, and he dropped me off in Buffalo on his way back to New York. I took the exam and forgot all about it. I found out in December of my graduating year that I had won one of those scholarships, and they wanted to know in a month where I was going to go to medical school and I hadn't applied in New York state—small problem. Fortunately, Allegheny College had an alum who was on the admissions community at SUNY Upstate in Syracuse, and he got me a quick interview and I got admitted, so that's where I went. And that was wonderful. It was a wonderful medical school, great education; I met my wife there through a mutual friend, the sister of the same mutual friend that Chris and I know.

Question: I didn't realize you had all these good connections to Chris.

Question: These are stories you're not supposed to tell. [Laughter] Maybe that's how I got into your residency program.

Dr. Hellman: Now that was a strike against him.

Question: When I got to Harvard Medical School, I kept hearing about that I needed to meet this professor in radiation therapy and what the heck is radiation therapy? I was going to be an internist

Dr. Hellman: My first encounter with Chris was this wild-haired, angry guy complaining about the lack of married housing—I think that was it—married housing at Harvard Medical School, which I duly noted and said, yeah, it's interesting. Then I found out that he was the person that I was told about. Anyway, so we had these mutual relationships. And I took the exam, I got accepted, went to Syracuse as I said, was a great medical school, and then I went to an internship. I had no interest in radiotherapy per se, but I was very interested in cancer. I should back up to Syracuse. I had a wonderful professor of surgery, Bob Miller, who had come from Wash U just a couple years earlier—I think he came in my freshman year, so by the time I got to see him he was really quite new. Very exciting, very interested in breast cancer and just a wonderful teacher for medical students. Syracuse curiously, for a price you wouldn't have thought, had a couple of successive presidents of RSNA: Paul Riemenschneider who was very distinguished. One was the chairman of the department and they did general radiology, so they did therapy as well. And they were interested, but it was always low voltage therapy and I wasn't taken with that; I was taken with oncology. But I wasn't cut out to be a surgeon. I think that's good for both surgery and for me and, most importantly I guess, for my patients. So I took a medial internship and decided I didn't want to be an internist during the course of my internship. I figured, I didn't know what I wanted to do but I thought I would go into radiology since I thought you learn things that I didn't know a lot about, and I had these role models, Riemenschneider and his group who were very good docs so I thought. Well, I'll spend some time in radiology and figure out what I am going to do. I went to Yale. Again I was a little late in deciding that I didn't want to do medicine.

Question: Was this general radiology?

Dr. Hellman: General radiology. I went into general radiology. But I went to see Alice Ettinger who was probably the wisest. She and Felix Fleishmann are two wise radiologists in Boston, both diagnostic imagists, she in upper GI and he a pulmonary radiologist, and they both told me to leave Boston because my interests were clearly not strictly diagnostic radiology. They said there was this young man who was interesting and had just started a program at Yale—Morton Kligerman had come in '58—so I went to Yale. It was 1960 when I started my residency. I started at Yale and there was one year of therapy, two years of diagnostic. Everybody started with diagnostic radiology and you rotated out at three monthly intervals. So the first person left at nine months, the next one at 12, 15, 18 and so forth. I was the first in my year just by happenstance and I never went back. I went into radiotherapy during my first year and I loved it. I liked everything about it. It was surgical in the sense that it was proactive and anatomically-based, really changing disease. It was science-based, Klig has this great radiobiologist, Paul Flanders, and he was interested in biology and it kind of came through. It was technically-based; I loved that. Willie Scarsbuck was the chairman of physics and a first-class physicist. Very, very exciting guy. So everything was good and I realized I liked to tell my diagnostic colleagues that I had nine months and that's all you needed to learn diagnostic imaging. [Laughter] But anyway, I quite frankly think it wouldn't be a bad thing to have a concentrated block of imaging in a radiotherapy program, although mine didn't happen. I mean, mine happened that way, but it wasn't by intent.

Question: It's kind of the direction I think maybe things are going to go back to ... not pooled, mixed residencies, but maybe more time in diagnostic radiology.

Dr. Hellman: Especially with cross-sectional imaging and functional imaging. Those are really our tools and in many ways more appropriate for us than for anybody. I think we got to go with them all. So Klig then got one of the first training grants—I think Henry Kaplan had the first and Klig had the second—NIH-funded radiotherapy fellowship program. I was his first trainee in the program. With that fellowship, I spent from 1960 to January 1966 in residency, including laboratory year and a year at the Royal Marsden, financed again by this wonderful NIH grant, which was great in those days as you remember. We didn't get paid very much as residents, but this allowed you to at least make your way. I never looked back, and one of the great things that happened was I went to medical school and I took biochemistry in 1955. Watson and Crick made their discoveries and the paper was in 1953. I had three lectures on DNA. By the time it came around to my residency, it was clear there was a revolution, and Klig was very good about—and Paul, both—making sure that the kind of research I did and required that I learn this, so I took courses while I was at Yale there in what was then molecular biology and it was a very exciting time. I worked sometimes in Paul's lab on DNA repair, but then went back to what I was really interested in, which were bone marrow stem cells, how the bone marrow maintained its steady state. That turned out to be my major area of laboratory research both then and then subsequently.

It was traditional for people to go abroad for finishing school, and I did that, too. So I went to the Marsden and half of my time there was spent on the clinical services and half in the laboratory on stem cells. That was a rare chance to really see superb clinicians who really were wonderful doctors dealing with cancer. Manny Lederman, Julian Bloom, they were just masters. Manny Lederman, with all due respect, wasn't a good technical radiotherapist, but he knew so much about the disease and the natural history and he had so much experience.

Question: He wrote a monograph on nasopharynx.

Dr. Hellman: Right, fantastic. He used to take—Fletcher, I guess, did too—the little gentian violet sticks, a stake with a round disc on the end of it, and put it against the patient and we'd say, "We'll take care of those lymph nodes.” and he would draw with a paint brush a little circle and then have these cobalt, these millions of circles on the patient. I said to him, "We have a linear accelerator. Why don't we just treat with a rectangular field and we get all those areas and then you wouldn't miss anything in between?" And he told me, "Nothing to worry about in between. That gets treated with the penumbra. [Laughter] So I once took gentian violet and just outlined a few of the circles in red marks to see if I could show him that he wasn't doing so well. I was wrong, of course. He was doing very well. But it seemed like a cumbersome way of doing a relatively simple thing.

Question: Near the end of his life I was at the Royal Marsden setting up some patient on the fluoroscopic simulator and was struggling to get the nasopharynx, and he took the samegentian violet and paintbrush . . .

Dr. Hellman: Right.

Question: He said, "Why don't you let me set it up." He drew the nasopharynx and he laid the patient down and of course it was straight on.

Dr. Hellman: He was great. And Julian was great, and there were a lot of other people there. There were a lot of good people—Smithers, of course, who was a professor at the time. So it was very good, but it was also interesting to go elsewhere to see that, and I liked Scandinavia, France—you know I did the tours, the short tours, but my main efforts were in London. That was very good.

Question: I remember early in my fellowship. I guess a little further along, this must have been about the time I went to Anderson, so it would've been 1968, Fletcher having been with Klig and Kligerman talking about what a wonderful young resident who was just coming out of his residency. That was you at that particular time. I don't know why that stuck with me but it was interesting that it was obvious to Klig you were going to go far.

Dr. Hellman: He was a real mentor figure to me, and he promoted me. I'm sure I got the Harvard job because of Klig.

Question: It was just almost right out of your residency.

Dr. Hellman: Two years. Two years out of my residency. But you know, the Harvard job was perhaps a bit early. But you know, those days were different. There were three of us taking straight therapy boards that year. The other names are not unfamiliar to you, Ted Phillips and Gerry Hanks, and we became friends when were there. And we're friends for the rest of our lives.

Question: Your history is very similar to Gerry; I don't know about Ted, but Gerry mentioned that he started off planning to do both diagnosis and therapy and then cut it short and stayed in radiotherapy just like you did.

Dr. Hellman: Gerry was at Yale as an intern when I was an intern at the Beth Israel Hospital in Boston in medicine. When I came to Yale, Gerry had just left Yale to go to Kaplan's program and I had gone to Kligerman's and we were literally running mates in the first two programs and both did the same thing, as you say, started planning on being general radiology residents and ended up not.

Question: I think that was right after the CRTS convinced ... wasn’t it Endicott who was the head of the NCI at that time? He was the person who came up with training grants.

Dr. Samuel Hellman: Ken Endicott. Yes it was. Exactly what it was. So boards in those days were different. We were a smaller group; we used to meet, as I am sure all the other history discussions have shown, have mentioned, at RSNA on a Tuesday night. We'd have a dinner for the American club. And you got a consecutive number, and I don't remember my number but I remember that it was in the low 200s. And that was it. That was what America had.

Question: How much easier it would have been to do these videotapes. [Laughter]

Dr. Hellman: And of course you knew, you learned to greet everybody. I mean I knew Gil Fletcher then and Henry Kaplan came to an early talk I gave at RSNA and came over to me afterward and gave me a critique about it and so forth, and he didn't know me. I mean you could see the people who were interested as residents in therapy, and the major players were interested in us because we socialized together. It was a small group. I was the generation immediately after the Young Turks, but it was a very, very delightful time. Of course, you have probably heard this story and it's probably on the tape a number of times, but Fernando Bloedorn—who was a wonderful man; I am sure you knew him—he was at that time, I think, at Maryland having come from M.D. Anderson, had a panel at RSNA and was speaking. Del Regato, I believe it was Regato, interrupted him and said, "What language are you speaking?" Bloedorn having a decided accent, as did Regato, as did Fletcher, and he didn't blink an eye. He said, "I am speaking the international language of radiotherapy, broken English." [Laughter] And that was part of the excitement. You had these people with very different backgrounds, obviously very intelligent, very motivated, but they brought color and a flair to the field that is just so wonderful.

Question: Now did Bloedorn come to Boston before you became chair at Harvard, or vice versa?

Dr. Hellman: No, he was there first. He came a couple years before me and Herman Suit, as he has probably told you, was my first. I had a visiting professorship for six months and Herman came as my first one and Bloedorn was a good friend of Klig's but Herman, when he was there, said, "You should meet Bloedorn and become good friends with him. You both had the same kind of problems in Boston and you ought to work together and you could use his advice. He's a wise man."

Question: That was before Herman came.

Dr. Hellman: That was before Herman. Herman was just a visiting professor with me during that time and I did that at Herman's instigation.

Question: There's a story that I heard, and I don't know whether it's true, that when one of the important hospitals in Boston developed the new radiotherapy, then the others had to follow suit and that they then established strong programs because of that. Is there any truth to that?

Dr. Hellman: It's true, but it was not in Boston. It's a Harvard program. What happened, Bloedorn (at Tufts) didn't stimulate my job offe, but what happened—and, of course, this is to the best of my recollection of it—was that Luther Brady was asked to come to the Brigham and spent almost a year there, I believe, and then left. The person that largely recruited him was Francis Moore, the chief of surgery, who had bought a linear accelerator to be run by the radiologist to give whole-body radiation for the then new technique of kidney transplant. And so they had this linear accelerator and they needed somebody who knew something about radiotherapy and could build a therapy program and Luther came and, of course, there was no commitment, and Jim Dooley, who was then the chief of radiology, I don't think had the interest or the wherewithal to really make a program. He went back to Philadelphia in 1967. Jim Dooley retired and was replaced by Herb Abrams. Herb Abrams was the head of diagnostic radiology at Stanford and a Kaplan trainee, so he fully valued radiotherapy, he understood its importance and he went out looking to get a program. The former director of the Beth Israel Hospital, who I knew, Sidney Lee, was the Harvard vice dean for hospital affairs, and so Sid knew the area around the medical school in which Beth Israel was and Brigham was, and he championed the idea of a combined department for all those hospitals so they'd have enough resources to really get the appropriate equipment. Herb jumped on that and so, from both Sid and Herb, this idea came up and I was recruited. I could go through the history of the Joint, but to answer your question before I do that, when we became successful after a couple years, the General felt this can't happen over in the Longwood area and they set up a full academic committee and I was on that committee, the committee that eventually picked Herman. And it was very clear that they wanted to know, they wanted my advice as to who's the best, they wanted to know what we had and they were going to get the General, a charitable word would be a very confident institution. They had no doubt that they would do a very good job, and they'd have an outstanding program, which, in fact, turned out to be true. So that was the competition. But Bloedorn in his program, Harvard is somewhat arrogant. I must say that when I came from Syracuse to be a medical intern at Beth Israel Hospital at Harvard, I was somewhat intimidated. You know, here I came from this country state school and going to Harvard, I am going to have trouble. I was there but a very short period of time when I found out I had gone to the second best medical school in the country. First best was Harvard, everybody knew that, all the rest would tie for second except Tufts and BU—they were last. [Laughter] And so that's how Tufts and BU were looked at in the myopia of Harvard.

Question: Your intern mix, by the way, was a stellar group too, wasn't it?

Dr. Hellman: Well, yeah. Two deans ... well, not two deans. You're thinking of Sam Thier too? Sam wasn't an intern with me. Sam was in medical school with me. Sam was a year behind me in medical school and lived next door to me when we both were married, and Sam and I worked in a lab in medical school together. But the intern, my closest friend as an intern, was Richard Nissen, who eventually became the president of the Brigham and Women's Hospital and then the first founding president of Partners, the combined Brigham/MGH. When he became the president of the Brigham, at the start of Partners, his equivalent at Mass General was Sam Thier, this fellow who was at medical school. I had introduced them when I was an intern and Sam stayed with me while he took his internship interviews. So yeah, this was a stellar group. But of my 12 interns, there was another dean, the dean of the School of Public Health at Columbia, the current dean of the School of Public Health at Columbia, Allan Rosenfield, who was also an intern with us. So Dick, Allan and I had similar careers and remain close friends for the rest of our lives.

Question: So how did you find things when you got to Boston? How were the facilities that had been prepared? What happened after that?

Dr. Hellman: There were a couple of things that I wanted in my negotiations. You know, I didn't want the Harvard job; I mean, it was too soon. I mean, I was very honored and flattered, and I would like to take the Harvard job but not enough to just jump in. I knew it was going to be a difficult thing; I had a lot of self-confidence, which mostly is due to ignorance at the time. But there were two things I thought were important: that the department should be separate and that radiotherapy had to have admitting privileges, almost more for the notion of us not being handmaidens of the surgeons or other people and able to control the destiny of our patients. When I was selected, there were members on the committee from all the hospitals and, of course, the major player was Sidney Farber, who represented the Children's Hospital at the time, and my relationships shortly after I came with Sidney were the most defining ones. But the first time, right at the beginning, Herb said, "I will make it; you have my absolute guarantee I will fight for a separate department, but we can't do it now. You're too young; you're too new; you haven't been proven." And that's what Bobby said. And by 1970, two years later, they made it a separate department, so that was never an issue. They made it a separate department—I am going ahead of my story, but I'll come back—before I wanted it to be a separate department because, I mean, it was Herb's suggestion, I said, "Well, don't rush; we're doing fine. I got a lot to do building the Joint and handling the department. The medical schools can wait." Herb said "No, no. We've got to do it now," and I said, "Why?" and he said, "I want two votes." [Laughter] He expected me to vote with him, which I did in the beginning. It was a long time before I would vote differently than Herb.

Getting admitting privileges was a more formidable issue. After I'd accepted the job and came and called the admitting office for my first implant, I was told I didn't have admitting privileges. I said, "That can't be," and I explained everything to the woman. So I called the director of the hospital and the hospital was run by four people: the chairman of medicine, the chairman of surgery, the chairman of radiology and the chairman of pathology. The most equal of them was the chairman of surgery, and so I called Frannie and Frannie said, "You can admit any time them to surgery; the surgical house office will take care of them. You know, you don't have house officers; you let us take care of you. We'll be delighted." I said, "Frannie, that's wonderful, but I really don't think that's what I want." And so we had our first disagreement. He, I think, was more right than I was which is, I didn't have house officers and so they gave me admitting privileges. But, in fact, for the first few years we didn't admit many patients and when we did, well, they took care of them. But the surgical officers took care of them at night. It was called radiotherapy service, but in actual fact, we had no beds assigned as radiotherapy beds. And I think I was, again, being very young and very rigid, I didn't need the beds that way. Frannie's solution was a good solution. I had surgical house officers to care for them, I admitted them, I made the decisions in the department and they got good care. When we did tongue implants or neck implants that way in those days, but we didn't do gynecology cases there. We did them at the Women's Hospital, where I did have a separate arrangement. The big problem came once with Dr. Farber. Sidney Farber was a major player in American medicine. At the time, he was greatly respected and feared at the Harvard Medical School by people who were not in his position and not beloved by the people who were his equals. But he was very powerful. He had to go to Washington; he'd get this and he wanted me to do what he wanted me to do. And I didn't want to do that. I wanted to develop our program and so he pulled out; the Children's Hospital pulled out after I had been there less than a year. I came in March and he pulled out during the summer. I remember I was on summer vacation, and I got a call from Sid Lee, the associate dean, telling I had better come back and we had this big brouhaha. So I had four hospitals: Deaconess, Brigham, BI and the Women's. That was enough at that time. By 1970 the Children's Hospital eventually decided to come in. So this was fine. But what he tried to do, which I will never forget, he asked me for advice and I said there are defining moments that occur in your early times when you are being tested and how you answer them often decides everything in your future, and I think for me that was true. Sidney Farber one day came in and wanted to appoint his own radiotherapist, Mel Tefft who was with him for a long time, and I said no. I said I'd be willing to give Mel Tefft the pediatric job in the radiation oncology department, but he would be in the department. It couldn't be done. He said, "I can put anybody I want on my service." And so it came to the Board of Trustees at Children's Hospital. Not the chairman. The Board of Trustees at the Children's Hospital could pass the chairman, that was too hot to handle by them, and I said that it would be terrible if they allowed me to appoint the surgeon to my department who wasn't a surgeon in the department of surgery, and the same thing for any other department. It would be chaos and recited just what I said about now and so forth. So I won.

Question: It's the exact same thing that was tried in Florida two or three years ago.

Dr. Hellman: Is that right?

Question: In terms of neurosurgery and wanting stereotactic to be there, and Nancy Mendenhall also was quite strong about that and held her ground.

Question: Right. It's the defining point because it determines your status, you know. And you are rig

Dr. Hellman: She's right. I was right. I mean, it's not a matter of whether you were right, it just a strength question. A control question. So anyway, those years were very exciting years. Do you want me to talk about the beginning of the Joint?

Question: Sure.

Dr. Hellman: So we had this accelerator – oh, I misspoke. I said linear accelerator and it wasn't a linear accelerator, it was a Van de Graff generator. We had a resonance transformer, two resonance transformers, a GE monster machine at the Deaconess. Those were our super-voltage units.

Question: It was a great two stories tall, right?

Dr. Hellman: Right.

Question: Was it there when you were there?

Question: Yeah, they were taking it out when I came did my medical school rotation in 1973.

Dr. Hellman: So because it was designed for whole body radiation, the room was very long because the patient obviously had to be at the other end, and so we broke the room in half and put in a linac in half the room and kept the Vande Graff in the beginning at the Brigham. So we had two machines at the Brigham. We had this big resonance transformer and then we set about getting a department for the BI, which we did and put another linac there. The idea was we would treat patients wherever they needed treatment on the machine best for them. They were outpatients; the only restrictions would be on inpatients. So patients were treated on the first available machine that was appropriate for them. By the time the Joint was in its full maturity, there was equipment everywhere, so most patients got treated in their hospital of origin, but for special things they got moved. In the beginning that wasn't true because the BI had portable, so all the BI patients got treated elsewhere and isocentric mounting only existed in the linac at the Brigham. So things that needed to be treated by rotation were done there. We had two rotational chairs. Do you remember upright rotational chairs?

Question: What year are we talking about now? Approximately?

Dr. Hellman: 1968 to 1971, something like that.

Question: That's about the time I went to Anderson. I've heard this story—and I don't know if it's true—that you had conceived of computer controlled therapy really and were shaping your department, and this was in the early 1970s with what I did later perceive was the beginnings of conformal therapy.

Question: That came later.

Dr. Hellman: It came later, but it started then. Did you ever go to a talk that really impressed you and you would say, "This is wonderful"? OK. There was a fellow by the name of Green, I think Anthony Green, at the Royal Marsden Hospital in London who visited Klig and he had an orthovoltage machine, which he guided mechanically on a bar. The bar was shaped like the spine and his idea was that you would rotate the orthovoltage machine and follow the para-aortic nodal distribution. That was to bend the bar and I heard that and he showed some pictures of this.

Question: And they would watch it during fluoroscopy?

Dr. Hellman: Yeah.

Question: I remember that. I'm pretty sure that that's one of the things that Herman talked about during his stay in England that had impressed him.

Dr. Hellman: It was very impressive! It wasn't while I was in England. It was still while I was at Yale when Klig had this fellow come through and there was this paper by this Japanese man by the name of Takahashi who wrote a very interesting thesis, and it appeared in it, or an excerpt of it did, with multileaved color bands. And it was clear that isocentrically mounted cobalt machines were available. We could do what Green was talking about and more and use the conformal treatment that would be available in a dynamic way. I went to Varian, from whom I bought my first machines, and asked them for two things: a multileaf collimator, but sure, if they could not give me a multileaf collimator, at least give me independent jaws with one of the jaws being able to cross the midline.

Question: I think Dr. Takahashi designed that for the cyclotron that they were planning to utilize there.

Dr. Hellman: Absolutely. Yeah, so Varian wouldn't do either. You know, the company...

Question: You've had to show that it was marketable...

Dr. Hellman: Well, you know, they looked at me and said, "We're building the machines." They were arrogant. They were sort of like Harvard in that sense. Siemens, which was ARRCO at that time, that's right, were eager to get something in. They were in Boston originally.

Question: And builders of your first linear accelerator at the Brigham.

Dr. Hellman: Oh, was that an ARRCO machine?

Question: That was an ARRCO machine.

Dr. Hellman: You're right. You're right.

Question: That was I believe either their first or second linear accelerator.

Dr. Hellman: Chris remembers more than I do.

Question: You were involved in that technology too, or they were when you changed over.

Dr. Hellman: Right, right. That's correct. That's absolutely correct. I had forgotten that that was the case. Anyway, they were much more responsive, and so we couldn't do multileaves but they would give me independent jaws. And with independent jaws using the technique, which is quite similar to what is now being sold as tomotherapy, we conceived of the idea and it was known somewhat inelegantly by those who criticized it as the "Hellman screw.” We would move the couch moving it up and down and so forth and have the machine go round like this. We got a number of grants combined with MIT to actually try to develop the software for doing this. We did do dynamic wedge, we published on the dynamic wedge, we did complete para-aortic and pelvic scoop approach. We never treated anybody with that. We did treat with the dynamic wedge. Put quite frankly, we were ahead of the computer software for it. And it was ongoing when I left to go to New York.

To jump ahead to New York, when we redid the radiotherapy department in New York, Zvi Fuks's department, the one thing that I really pushed for that he wasn't crazy about was a microtron. The only reason I wanted the microtron is they would give us a multileaf collimator for it, and nobody would give us a collimator so that's how we got it in New York. To some extent, I believe that's really how the New York program got literally started on intensity modulated therapy or conformal therapy. But, so we had it. In fact, there was a meeting on charged particles. I was in Los Alamos and I was asked to speak with a contrary view whether you think you could do with charged particles is just like revisiting protons today.

Question: It was almost 30 years ago to the day, and I will tell you later on why I know.

Dr. Hellman: You were at that meeting. Do you remember that meeting?

Question: I left from my honeymoon to go to that meeting. [Laughter]

Dr. Hellman: So at that meeting I spoke on our experiences with this and why I thought that those distributions would be good enough, and unless charged particles had a biologic advantage, they weren't going to go. So, yes, so I think I was early on in. You know, success has many authors, so I will take some credit. There are a lot of other people that contributed though. Anyway, that's how it began.

Question: Tell us about the Joint Center.

Dr. Hellman: The most exciting part of the Joint was the camaraderie, the sense of building, the initial people that came and the residents. The residents were interesting because they joined this program, which was sort of a traveling circus. Monday we met at the BI and Tuesday at the Brigham and Wednesday at the Children's, and we did it every morning every day and went around.

Question: All the residents?

Dr. Hellman: All the residents. Everybody went to morning conference, no excuses.

Question: I knew that there was a morning conference, but I didn't dream that it was held at different places.

Dr. Hellman: Different place every day and everybody went. The only excuses were the people who had to do implants or to be in the OR, and they were rare. People didn't schedule the day of the conference that was in their institution unless something came up.

Question: Talk about the teaching method. That was something that you were veryinterested in. You tried to model that after the Harvard Business School, the case method.

Dr. Hellman: Well, I tried to use the case method, but going back to your question—the most exciting part of the Joint—the camaraderie of the faculty, the dedication to teaching and the very close relationship we had with the residents. I mean, it was hard going for them sometimes, but there was a system that was based on interaction, always about a case where we would expect them to know the pertinent literature. But that wasn't the question. That was the base of the question. The question was what would, how would they manage the patient? What were the essential issues? How would they manage the patient and why and what was the rationale for each of those. It was a very interactive program, Chris says it came from the Harvard Business School case study method, and it did partially. It also came from Kligerman. Kligerman used to have a morning conference, which was more about getting the port films done and everybody would make a brief presentation about the patient and then they would put up the port films and Klig would comment on the adequacy of that treatment and so forth. But you know, there was more to the general discussion that I was interested in, so we did port films in the beginning but then we stopped doing them. Later on we did them only in chart rounds. But morning conference was not every case presented like Klig had it, but a few cases—usually three—right?

Two or three cases. It started with more and then slowed down and there was a little bit of a game because the residents used to ask the other residents over at the hospital what cases would be presented just so they would know the literature and we didn't know that, but of course we knew that and that was good because that meant they had all read. They were all frightened of being called on but so that meant they had a motive for reading about that disease and so what could be better than that? So since we knew that, we didn't quiz them on that unless they were falling on their faces, but we expected it and then we went on and pushed and pushed, and I think it was a good method. It required, I think, the residents to understand that it was in good nature and for the faculty to understand that it was in good nature, and when someone was having trouble not to make a fool of them and, you know, move on. And so you tended to pick the hardest—the best—because they could tolerate it and you would have a dialog, "Why would you do that Dr. Rose?"

Question: That's the most fun. It's more fun if you can banter back and forth.

Dr. Hellman: Exactly. And that's what it was, so I would say of the Joint, the excitement that was there was building something new, building this multihospital thing, having a small very cohesive group of attendance and everything focused around resident education. We met every day, twice a day with the residents—mornings for that and then different things in the afternoons. One day seminar, one day chart rounds, one day lab meeting. Am I right? It was very exciting.

Question: Before you move on to New York, I think that the other thing that it seems to me was one of your contributions had to do with the development of conservative management of breast cancer. I mean, it certainly started at Yale, but it really took off when you were in Boston. Maybe you could talk about your memories of that. I recall that when I went off to Britain, maybe 30 percent of the patients were being treated conservatively, and when I came back one year later it was above 50, so the inflection point occurred in the mid-1970s. How did that start?

Dr. Hellman: Well, first of all, I think I made a real contribution to breast cancer treatment, but it was more politicalby engaging in the academic debate than it was in making a discovery or inventing the treatment. The treatment experience, which we all grew upon, was originated by the French. They were clearly out in front; it was in the literature, and it wasn't a great mystery. As you said, we were interested in it at Yale. There was a surgeon who was interested in doing some of this and so we all had a little experience with it. I treated some patients; Lenny Prosnitz, who was two or three years behind me, picked up what I did and continued with this surgeon. So when I came to Boston, I had some confidence in it. Martin Levine, who was my close colleague and dear friend, had a similar experience with inoperable patients but also some experience with breast conservation.

So, the two of us had a few patients, and we started to try to get some more patients—especially from the Boston Hospital for Women—where the gynecologists there considered themselves women's doctors. So they would do mastectomies, just like they would do gallbladders on women. The Brigham hated them for that. Frannie Moore despised them, and that was the biggest issue in the joining of the two. But they lived with these women, in a sense. They delivered their babies, they saw them and then they saw them get breast cancer and I think the feelings about body image, preservation of the breast grew more important to these people and they were less enamored of having to do radical breast operations. So they were more open to it. So they offered me a special opportunity. There were three or four of them there who were wonderful in sending patients. We had a bunch of patients very early on and one of our early residents—I think our first resident—Eric Weber urged me to write the cases up. He was the resident and he was the first author with Marty Levine and me and we wrote up a series of the first hundred cases. And like all series, with a short follow-up we did very well. We published this in the Journal of the American Medical Association in, I think, 1974 or 1975. When did you go to Europe?

Question: I went off to Europe in 1978.

Dr. Hellman: Yeah, so that was really the beginning of getting people who were offered and came from the outside, and so we got a lot of patients from New York. We got patients from Cleveland who wanted it and couldn't even refuse mastectomy. I had a couple of people from Memorial. One woman who worked at Memorial who I still see, and she's fine. She's got another breast cancer in the other breast and that was taken care of. Corman treated her, and she's fine on that side, too. So that's how I got started. But what I did, if I had a contribution to it, was that I published the cases, followed them very carefully, recruited very aggressively and made my rounds of all the meetings, taking on the major surgeons I think a little bit because it was Harvard. I had more access to the meetings perhaps but, I mean, I was accused of malpractice, I was pilloried but I was used to it and it got us a lot of activity and we studied very carefully, as you know, M.D. Anderson.

Question: Now this must have been about the time that the National Surgical Breast Adjuvant Breast Program was forming for post-op treatment at B-04.

Dr. Hellman: B-04 and in fact I was invited to an NSABP meeting to talk about this experience by Bernie Fisher very early on, so...

Question: This probably led to...

Dr. Hellman: I don't know if he had that in mind or not, but he clearly was influenced by the idea of doing radiation treatment because Bernie's background, you know, was with Barney Crile at the Cleveland Clinic and so...again, nothing was new…

Question: I didn't know Bernie was from the Cleveland...

Dr. Hellman: No, no. But he was influenced by Crile. No, Bernie was from Pittsburgh, but he was trained at the University of Pennsylvania, but he was from Pittsburgh. So anyway, that was a big issue, which was important and before that, though, we were very actively involved in Hodgkin’s Disease. Those two areas—Hodgkin's disease and the breast—were the big areas in our department.

Question: Signature things for your department...

Dr. Hellman: We built the first linear accelerator devoted to stereotactic radiosurgery due to, in fact, due to a neurosurgeon. One of my neurosurgical friends came to me and said he had seen and heard this Gamma Knife, could we do this with our machines. I said I am sure we could and he then became the professor, which is kind of interesting because radiosurgery really came from neurosurgery.

Question: Even the Gamma Knife.

Dr. Hellman: Right.

Question: I remember the discussion about the difference between radioablation and radiotherapy, I guess, and that stemmed from your experience with the pituitary gland and whether or not it should be treated with multiple fractions or the way that Sjelberg was doing it with protons at the MGH with the single fraction.

Dr. Hellman: That's right. So, I mean, there is more to the Joint. You know, I've been a lot of places, but I think if you asked me where was the seminal part of my career, the part that I feel the most acutely was the Joint.

Question: That's what we always ask at the end.

Dr. Hellman: Fifteen years went by and I had this real feeling about biology, that there was a new biology that was going to be put into practical use and working in a multi-hospital setting. I can't say that I was looking for something, but when Memorial came along and Paul Marks asked me to consider the job, that's the thing that really excited me. I would be physician in chief; I wouldn't be the Chief of Radiotherapy, but I could deal with this interaction between what was coming out in the laboratory and put in the clinic.

Question: Did you have a particular notion about how oncologists should be educated, which hasn't come to pass but that you wanted to try and do at Memorial?

Dr. Hellman: Chris is reminding me ... my fundamental disagreement with our specialty and surgery and medical oncology was the trade union venture. That we were competitive with each other, when it is clear our best work usually was collaborative. And, I mean, it's not always that you always used every modality, but the collaborative way was very effective. And the enemy wasn't surgeons or the medical oncologists—it was the disease.

Question: It seems interesting to me that a lot of those specialties or most of the specialists have felt that the multidisciplinary approach is the best approach to patient management. But there still is this trade union attitude, isn't there?

Dr. Hellman: Yeah, I mean...

Question: ... We still have that today.

Dr. Hellman: Oh, absolutely.

Question: I even do it myself.

Dr. Hellman: But we all do. I do too, I'm sure. But what I wanted to do, and this happened while I was in Boston and I thought I would be able to do it more in New York, but I went to Tom Frye, they then had medical oncology at the Dana Farber Center, with the idea that we would set up a combined training program—two years combined, exactly the same. They would all get basic training and they would be taken, now, with the idea of what the branching tree would be so and then they'd go into medicine and do medical. I mean, go into medical oncology or they would do radiation oncology. And he would have done it, I would have done it, I had preliminary feelers to the board who said it would work for them. One year of medical oncology because I was giving two years of radiotherapy that would be the three years, that was all right. But the American Board of Internal Medicine wouldn't do it. And so we never did it. And it is still my feeling that we should be educating our oncologists. I don't think you can be a complete oncologist. I am not suggesting that you should be able to do radiotherapy and surgery or radiotherapy and medical oncology. But you should have a common base. I think it's more true even for the medical oncologists because they don't see cancer. They spend so much of their time taking care of the adjuvant complications of aggressive chemotherapy or adjuvant therapy patients that they don't see the primary disease. I mean, earlier when I was in Yale, one of my closest professional friendships was made when Kligerman came to me and said this fellow, Joe Bertino, he wants to use methotrexate to see if it would work in solid tumors, and I told him I thought head and neck would be a good one because you can see and feel them. And he didn't know how to examine a larynx. "Would you go in with him..." and I was a resident at the time and, "You do the evaluations and ..." and I did. And we became good friends and methotrexate was tested in solid tumors. Well, we were the people that actually did know what tumors looked like early in the disease and late in the disease. The medical oncologists, because of the way they practice and what they do, don't except for lymphomas.

Question: We hardly know late-stage disease...

Dr. Hellman: We don't know about widespread metastatic disease as much as we did when I started because we did not have many chemotherapies then. Most metastatic disease then was treated by radiation to bony mets, pain medications and hormone treatment.

Question: Yes, that's true. Yeah, you're right. We did that. I know when I was on the American College of Surgeons Cancer Center Accrediting Committee, they commented that as far as staging is concerned, when they wanted to determine the true stage of a patient, they went to radiotherapy charts. The radiotherapists staged them accurately. Medical oncologists, for just the reason that you say, they couldn't assess the disease, so they didn't have any staging. And the surgeon didn't care about staging. They were going to operate anyway. [Laughter]

Dr. Hellman: So it was a way to think about it. Anyway, New York was very exciting for that. It was fun to go there—especially since on the faculty at Memorial were three people that I had argued with regularly on those breast cancer rounds.

Question: So that was why you went? Was because of the interest in biology or broadening your involvement in the education of oncologists in general? Is that it?

Dr. Hellman: Yeah, I think mostly the broadening to be able to control more than what happened in radiotherapy and really have a multidisciplinary team effort, and I picked my three chairmen. One of them was sort of picked for me, but he wouldn't take the job and Paul would not offer him the job, although they were dancing together. No doubt my coming, because he wanted to know who he was going to work for, which was reasonable, and Paul because he knew he was going to get somebody and he might as well like this appointment.

Question: I don't know whether you remember when you and I went to Poland and we were walking in the streets of Krakow. It was snowing and I asked you what you were going to do, what you planned to do ultimately. And I don't remember actually how it came up. And you told me you don't know, maybe you would be interested in being, eyeing the administration of Memorial, or maybe a dean.

Dr. Hellman: Did I really say that? [Laughter]

Question: I think I told that story. It was fascinating.

Dr. Hellman: I don't remember that. I remember going to Poland with you, but I don't remember that. So it was an exciting time and of course, John Mendelsohn and I brought in medicine and Murray Brennan in surgery, and Zvi as I said. They were all multidisciplinary and we still are and it was a great...it's a great hospital. I mean, if you have a malignant disease, you can't do better than Memorial. There are other places you can do well—I am not saying it's the only place—but it was terrific.

Question: I don't know though, before you came though, wasn't it known for not being multidisciplinary?

Dr. Hellman: It was completely run by the surgeons. That's why everybody was shocked that I went there, and also, the Memorial people were shocked they picked a radiotherapist.

Question: A true masochist. [Laughter]

Dr. Hellman: Well, I went there and, of course, in those days we were still doing implants as a boost for breasts. And I hate to say this, but it's not that hard to do. I mean people like to make a big deal, but it's harder to implant the tongue. It's not hard to implant the breast. You do agree with that, don't you?

Question: Yes.

Dr. Hellman: So I went there and the first day that I was scheduled for an implant, and I scrubbed to do a case, I turned around and it was like one of those amphitheatres that you see in the old pictures by Thomas Aiken. There were all those people staring; they were all there. "Okay." Well, I was skewering those breasts with the needles and after my patients did well a little bit, they accepted me. The turnaround was so complete. They didn't necessarily agree with primary breast treatment by radiation, but they agreed that I was a doc like they were, that radiotherapists were serious people who could do something. I had never had any non-collegial relations when I was there, and I had had very non-collegial relations with some of them when I was on panels with them before then. In fact, Dave Kinne was then the head of the breast service, and he I were on a panel at ASCO, I think, I can't remember where, or maybe not ASCO, maybe just a separate panel when I was appointed but I hadn't gone to Memorial yet, and this new arrangement for the program was made long before anybody knew that I was being considered. They asked me how patients would be treated now that I was going to Memorial, how breast cancer patients would be treated and I said ... and I said, "Very carefully." [Laughter]

Question: You also brought Steve Leibel there and IMRT, I guess, that was something which was started at Memorial under your and Steve's leadership.

Dr. Hellman: Well, IMRT radiotherapy was Steve's contribution; I don't want to try to take credit for that. Steve, yes. I surely supported it and I facilitated it. The big thing that Zvi and I did together was to get a first-class physical plan and to recruit Steve. Those two things were very important. But it was first class. In those days, $32 million for a department was a lot of money.

Question: It still is.

Dr. Hellman: I remember making this presentation, Zvi and I making this presentation, and I knew the trustees—Zvi didn't—and I had a good sense of them and rehearsing him and going in there and it was Lawrence Rockefeller, Benno Schmidt, Louis Gerstner who was the chairman of the Long Range Planning Committee…

Question: To those guys $32 million was probably peanuts.

Dr. Hellman: Yeah, well, they had tough questions and so forth, but we had it down and we conceived it, it was very exciting. I wanted very much to not be the head of radiotherapy, not because Zvi wouldn't let me even if I wanted to be, but I didn't want to. so what happened IMRT, yeah, it came from my thoughts in the past, but it was really all done by that department and not by me and really all done by Steve, Clif Ling, Radhe Mohan and Gerry Kutcher. Radiotherapy changed completely at Memorial. But then as you said, I had this other notion of being a dean. I missed universities. I loved Harvard and I loved Yale. Memorial was a cancer center, which was great, very exciting, but it wasn't a University. It didn't have certain things that universities have, not only university medical centers but universities. So that one came out of the blue, but when it came I took it and it was interesting, too. It was a different kind of job and I enjoyed it. The constraints on being a dean are very difficult.

Question: I was fascinated by your editorial after you stopped being a dean. That was interesting. Maybe you can tell us about what it's like to be a dean and be a radiation oncologist and a dean.

Dr. Hellman: Oh, I don't think being a radiation oncologist was any detrimental; it was much harder being a physician in chief as a radiation oncologist at Memorial than being a radiation oncologist and being a dean. Deans are looked on, not with awe, but with disdain. So radiotherapists have been looked on with disdain before, so it was familiar territory. [Laughter.] You know, if you ever think about it, the people that run businesses are called executives. The people that run universities or medical schools are called administrators. And that's a derogatory connotation where executive has the reverse connotation. So if you do everything right and everybody likes it, you are doing what you should do; you are doing your job. If you don't do something right, it's the damn administration and of course the damn administration stops at the dean.

It's a great opportunity to affect programs, and I was very interested in changing programs and in getting recruits and building physical plans. But I was a dean at the time when health care was changing. Its whole economic base and the opportunities that were provided for my first three years were disappearing rapidly in my institution., So I was in it for five years and all of medicine but especially, I think, well no, I wouldn't say especially radiotherapy, maybe more surgery is a use-it-or-lose-it business. As dean I was not doing radiotherapy. I'd say I was down there once a week and I did some when I had this meeting or that meeting or something else. My mind was not on it and I wasn't reading the literature. So when I was asked to take another five-year term as dean, I decided that if I did that that's all I'd do. If I did that, I'd never go back to oncology because I didn't have the wherewithal. I had lost it or I’d just take one term. And I chose the latter. So I left and spent six months retraining myself.

Question: But during that time you taught college students and you engaged in discussions of public policy and also ethics. I mean, I think the paper that you and your daughter wrote on clinical trials is not read as much as it should be.

Question: Yes, I missed that. What was that?

Dr. Hellman: Oh, that's my most quoted paper and, particularly in my daughter Debbie's view, even worse, it's her most quoted paper. She is a professor of law at the University of Maryland. I wrote a paper on the ethics of randomized clinical trials, which was critical of them, and I sent it to the New England Journal of Medicine. When I wrote it I had these feelings, and Debbie was a philosophy graduate student and then a law student, and I talked to her about it and in the course of those discussions she helped formalize the criticisms I had into appropriate, rigid, rigorous philosophical argument. So we wrote this paper and I sent it to the New England Journal of Medicine and they accepted it but said they wouldn't take it unless they could have a counter view also there. So they had a pro and a con and I wrote mine and they said they couldn't really have a con unless the con could see what I said. So we wrote ours, Debbie and I, with no idea of what the other person was going to do, but he had our paper, which was fine with me. I mean, the arguments are the arguments and so forth. I had people call me traitor and people who wouldn't talk to me. A lot of people very, very, very angry with me, and I think a lot of people misunderstood the paper or didn't pay attention to what the real points were.

Question: Which were?

Dr. Hellman: That...well, there's a whole series of points. One, that you wear two hats and they are not the same hat. That you are a doctor for the patient – the patient comes to you, you have a white coat and you have a piece of rubber tubing sticking out of your pocket, you read their image and they think you are their doctor and you are going to recommend what you think is best. And then you have the scientist hat, which is that you are going to be rigorous, you are going to be careful, you are not going to accept things as true unless they are proven. You are going to be skeptical and those aren't the same thing. So we use some devices to help us separate them. One is that you don't know if improvement is in a rigorous fashion, as though there is a dichotomy between knowledge, knowing something, and ignorance, not having any view that one thing is better than the other when, in fact, life isn't that way. We all have opinions along that spectrum and that's what the patient wants you to share with them. Otherwise, they wouldn't be interested in you as the doctor versus someone else as the doctor. That's what they want to know. And in fact, that's what you want to do. Secondly, that patients are not homogeneous. You can make a protocol that I feel very comfortable with for stage I breast cancer but I might not feel comfortable with Mrs. Jones or Mrs. Smith. I might recommend different alternatives for them because one is 43 years old and has an aggressive-looking tumor, which is poorly differentiated and almost 2 centimeters. The other has a well-differentiated tumor. She is 65 has some underlying morbidity. So while I have a protocol, I can't put Mrs. Smith and Mrs. Jones and give them the same recommendation that you could have either treatment; we don't know which one is better. I know for Mrs. Jones I am going to want to treat aggressively and I know that for Mrs. Smith I am going to want to treat conservatively and I need to impart that. Now I have to impart that to them in the context of saying there are certain things we don't know. But we have opinions on them and this is what I think for you.

Question: But just for the sake of posterity, as I understand your arguments, when there is clinical equipoise, when you really don't know which treatment is better, you think controlled clinical trials are great.

Dr. Hellman: Oh yeah, I do. But I think clinical equipoise is very difficult to have and even more difficult to maintain. Let's say you start the trial and we are doing conservative management for breast or adjuvant therapy for breast or any of the ones that really have been tested, you get into it for six months or a year, and you get to have a feeling. All those patients that got "treatment A," I mean they're not double blind; it is not possible to double blind most cancer therapeutic treatment. So you get an opinion. Now you're no longer in clinical equipoise. But if you stop doing the trial, those patients you have treated so far...

Question: Yeah, it's a waste.

Dr. Hellman: Right, and so it is an ethical dilemma

Question: It was a problem with the neutron trial.

Dr. Hellman: It's the ethical problem of trials. You're right. You are absolutely right. I have no problem with the idea of clinical equipoise, but I don't believe in reality it lasts.

Question: So then you went back to the department of radiation oncology and the other seminal contribution that I think that you contributed, which must have been something that's been bubbling in your head for decades, is the idea of oligometastases.

Dr. Hellman: Well, yes, it has been bubbling. I mean, I've always been struck with, again it is this Dichotomy, I believe very strongly that there are paradigms that underlie what we do, but we don't talk about the paradigms very often. And if we would talk about them we would realize the extent to which there are exceptions to them.

One of them is that you either have local-regional disease or you have widespread distant metastasis. But the idea that you could have regionally defined limited metastasis is one that wasn't accepted as in any way common, except rarely in soft tissue sarcomas, melanomas and renal cancer. And those are the ones, I've always been interested in this being a self-fulfilling prophecy. if you believe that and you don't treat them for a cure, then they will develop distant metastases. So the nidus of that argument started in those diseases and wherein the data are the most compelling, but the disease that interested me maybe the most was colon cancer, where I was becoming aware that 25 percent of patients with colon cancer had liver mets and they were liver only. That was a large number. I saw them at Memorial, not only when they presented, but when they recurred; they recurred in the liver only and nowhere else. And so this was occurring in a common disease and it was commonly an isolated metastasis. And so we got the idea. And I think that, just to jump way ahead out of history but to today, I went to look at the CyberKnife today because I think that's something you could do bone mets and a variety of mets in a variety of locations sequentially in a radiosurgery or a hypofractionated way in patients who were found early in the course of their disease and by mammography or PSA or whatever and have the benefit of adjuvant disease, maybe getting rid of what that old paradigm predicted that is small microscopic foci in multiple places. The argument was that we should re-think this in the day of early diagnosis, which is today, and of adjuvant chemotherapy, which is today. With the technologic abilities, the technological abilities are imaging, functional imaging and MR. I think MR is the best tumor imager. I mean it's fabulous; it's just fabulous. And the ability to deliver the kinds of treatment that we now have with IMRT, I am not advertising the CyberKnife. I went to look at it to see how it would fit in, but I am interested in IMRT. And then we've got all these technical ... you go over that floor and it's full of opportunities to do this kind of thing. So, yeah, I am very interested in that.

Question: So I guess another question that we need to ask you, and maybe this kind of brings it to the closing, is what about the future? For us? For you? What's happening?

Dr. Hellman: Well, the thing you didn't ask me about, which has been a very great interest of mine in recent years, is understanding the natural history of breast cancer. I would say that we have to be very careful that we don't train people to be professional treaters and who don't understand the natural history and knowledge of the disease and that natural history can change with new diagnostic techniques and circumstances. I still don't know why esophageal cancer has now become more adeno and more distal. [Laughter.] I mean, what's that all about? [Laughter.]

Question: That's what was going through my mind; they were all squamous when I was in training.

Dr. Hellman: Right, and they were all mid-third or uppers, but they weren't way down at the cardia.

Question: We all have agita. Maybe that's...


Dr. Hellman: True, but, so we have to emphasize understanding the natural history of the disease and understanding it will prepare us for varying the therapies. It gets back to this business of what's the right treatment and not being competitive. I walked around today and I saw people at all the big company exhibits—Varian, IMPAC, Elekta, Siemens—nobody was around the radioimmunotherapy programs, nobody. Why aren't we doing that as radiation treatment with monoclonal antibodies directed at lymphomas? Why is that not radiotherapy? It's not medical oncology, I'll tell you that. And we need to embrace the new biology. I think that's the hard part for me to get across. See, we've embraced the technology, but we need to embrace the new biology and accept it as part of the evolution of our specialty just like IMRT or radiosurgery is an evolution of our specialty, so should this. We embrace cardiology, which is ridiculous. The idea of putting radioactive stents and being an interest of a radiation oncologist to me is wasting our time. But not doing radioactive monoclonal antibodies is wrong. We should be doing that.

Question: It should be in our own knowledge base, but we're not willing to learn it

Dr. Hellman: But we know we have a much better chance at it. We really know the isotopes. They don't know isotopes. They don't know how to handle radioactive materials. We know the lymphomas. It's not like we don't know the lymphomas. These are diseases we handle. So the knowledge base needs to get with the new biology. And we need to. We need to. We must do that or we'll fall by the wayside.

Question: You are absolutely right.

Dr. Hellman: In 1995 I spoke at this meeting when Jay Harris was president, you might remember I gave that keynote lecture and that was my point—either get on, or we're going to get passed. We're going to get passed and that would be a terrible thing. We'll be those guys in the basement again who get patients when people want to send them rather than part of the cutting edge.

Question: I think that the sense that we all wrestle with is how to excite people about precisely that, how to be investigative scientists rather than technologists and maybe that's easier to be a technologist than a biologist—again, you don't want to dichotomize things but physics is easier than biology. That's too simplified but clearly, to learn immunology, to learn all these biochemical pathways requires everybody going back to school .

Question: I think that's it. If you look at the conformal therapy, IMRT, all of that, it's really just refinements of what we've always done.

Dr. Hellman: It's clearly a paradigm shift and that's the hardest. But it's a paradigm shift for everybody. It's a paradigm shift for medical oncologists. It's a paradigm shift for anybody who embraces it. The nuclear medicine people don't know anything about cancer. It's a paradigm shift for them. So I would argue that if we are oncologists primarily and that's what we understand, then this should be our turf.

Question: Then it might be less of a paradigm shift for us?

Dr. Hellman: That's my view.

Question: That's a good point.

Question: The only thing that kind of got missed in this narrative of time had to do with your fundamental laboratory work back in England and in Boston before you stopped doing it. You spoke about it briefly—the stem cell and proliferating stem cell, proliferating compartment, the people that you met along the way in that area—and clearly, you know, I remember going back to all those conferences at the Joint and these people who came through who ultimately found the CD34 cell that you and Leslie Botnick were playing with for all those years and I don't know if there's anything that you want to say, going back to the late 1960s and early 1970s, and then forward from there?

Dr. Hellman: Well, the only point I would make about it was that I was studying normal tissues. There were others doing this; Rod Withers, clearly studying normal tissues because we were interested in cancer as a disease of the normal cell renewal process. And if you wanted to understand the abnormal, you had to understand the normal and how it worked. It's a little bit of the same thing that I am talking about the treatment of disease: You have to understand the disease. That was why I was very interested in it. I still am interested in it and, of course, that field has had a wonderful blossoming. I mean, it may well be that those stem cells that you call CD34 and we call them now, they may be or there may be ones earlier than them that are so plastic that they'll make the gut as well as the marrow and we'll have, they will really truly be stem cells. It's already clear that the bone marrow stem cells provide the new cells for proliferating endothelium. That's a very interesting concept when one thinks about radiation because we destroy both the tumor and the infrastructure and that infrastructure is repopulating. That may well be that that's one of the reasons for fractionation that it allows that repopulation. I don't know, but I think it's all part of the notion that it's a legitimate and appropriate thing for radiotherapists to be studying, so in all systems. Those things that are changed in the process of becoming malignant and half of the tumor is the normal tissue in which it embeds itself.

Question: Well, Sam, is there anything else you want to add?

Dr. Hellman: He's been fishing for me and he's done a good job picking out the things that I think about. I guess I would, maybe this is an old guy saying it: I'm worried that we are getting spectacularly good residents but I do not see the fire of trying to do laboratory work and clinical work. Circumstances are difficult now. Clearly the economic circumstances are requiring more activities, but I don't think that they're as difficult as people, I mean as different as people say. Radiotherapists still are very well compensated—maybe better compensated than private guys in our day, and people in universities make a living. They make a pretty good living. I mean, they may not make what the private docs make, but they make a good living. We need to refocus this. I see more M.D./Ph.D. graduates of good places go to good programs and end up not doing the things they were trained to do and therefore depriving us, a people with a special viewpoint and a people who can understand both sides. I will end with a quote from Judah Folkman, and I may be paraphrasing it, but Judah says that clinicians know the problems, they just don't know the answers. Basic scientists know the answers. They just don't know which problems they apply to their answers. [Laughter]

Question: That's great! Thank you, Sam. Thank you, Chris.