By Theodore Phillips, MD, FASTRO and Baldassarre Stea, MD, PhD, FASTRO
The following interview of Saul Rosenberg, MD, was conducted on January 11, 2017 by Theodore Phillips, MD, FASTRO and Baldassarre Stea, MD, PhD, FASTRO.
Theodore Phillips: This is the American Society for Therapeutic Radiology and Oncology, History Committee interview with Dr. Saul Rosenberg, honorary member and an extremely famous pioneer in lymphoma management. And we’re interviewing Saul along with Dr. Baldassarre Stea from the University of Arizona. Saul, can you tell us where you were born and where you grew up?
Saul Rosenberg: I was born in Cleveland, Ohio, and I grew up on the East Side in a Jewish district and with a poor family. That’s where I started.
Theodore Phillips: Is that in the Cleveland Heights area, or --?
Saul Rosenberg: Oh, no. I didn’t get to Cleveland Heights until my family made some money. So, I was from what you call the city, and the city weren’t the fancy people. In fact, when I was pledging a fraternity, they thought I was from the Heights and I wasn’t, and they wanted to blackball me because I came from the city. Eventually, I overcame that though.
Theodore Phillips: And you went to a Cleveland high school?
Saul Rosenberg: I went to high school in Cleveland at John Adams High School, again, in a rather poor section of the city made up primarily of Italians, Jews, and black folks. We always fought with each other.
Baldassarre Stea: Yeah. It’s almost kind of proverbial. I’m from Italy in case you’re wondering about the accent. But I heard this story all the time, how the Italians and the Jews, especially in New York and Cleveland, they all live together.
Saul Rosenberg: Yeah. We survived it.
Baldassarre Stea: Yeah.
Theodore Phillips: Where did you then go to college and what did you major in?
Saul Rosenberg: That’s a long complicated story. Some of it, I’ve told you. You’ve seen my video, I think, and I may have written it up. I was going to be 18 in 1945. I was concerned about being drafted into the Army, so I figured out how to get out of high school by the age of 16. And I went to Adelbert College of Western Reserve University in Cleveland. Nobody in my family had ever been to college. I didn’t know how to do that. But I had a Latin teacher who said I should take a scholarship exam for Western Reserve. I obtained a scholarship to Western Reserve, I think $400 a year, something like that. I started in Adelbert College in actually June, I think, of 1944.
Now, I hadn’t quite finished high school then. I needed two more units. So during the summer of 1944 I attended both high school and college. In Cleveland, there was a summer school there called John Hay High School, and it was only a mile from Adelbert College of Western Reserve. So I convinced them to let me do both at the same time so I could get in to do my premed in 1944 and get to be eligible for medical school before I became 18. So that’s what I did. I went to Adelbert College of Western Reserve and entered there for the first time in 1944.
Theodore Phillips: So how did you decide that you wanted to do medicine at that point?
Saul Rosenberg: I wanted to do medicine since as long as I can remember, Ted. I don’t know why. I think it’s because nobody in my family was a professional or wealthy, and the most respected person in our family was a general practitioner named Dr. Reeger. I used to go to him for allergy shots, and he was respected by the family, and so I thought that I should be that, and my family thought I should be a doctor. I never knew of any other plan or choice.
Theodore Phillips: So after you graduated from Western Reserve, you applied to their medical school I assume?
Saul Rosenberg: Well, that’s a long complicated story. I think you may have heard it or read about it. I tried to get into medical school then for the entering class of the fall of 1945. I went to the admission office in the spring of 1945. The war was still on. I went to the admission director, a single committee. His name was John Caughy. He said I could not get into medical school because I was Jewish. We have a quota of three Jews, and we’ve already taken the three Jews, and you are not going to be admitted. He also said I was too young. So this man, John Caughy, is very important in my history because he rejected me for medical school in 1945.
Then there is a more complicated story but part of it was that I therefore quit college. At the age of 17, I had completed two years of premed which is all you needed to get into medical school during World War II. But since I wasn’t accepted and I was very discouraged, I quit college, and I didn’t withdraw from my junior year classes. So I got four F’s in my junior year, and it’s still on my record. In fact when I was promoted to tenure at Stanford, they knew about that. They asked me why I had four F’s.
But that’s also important in my history because then I went to work for my father who became ill. His business failed, and then I was with him for one year, and then I needed a job. And I became a chemist in a lead smelting plant in the bowels of Cleveland’s industrial area. I spent two years in that lead smelting plant as a chemist, testing the lead ingots and also the workers for lead poisoning.
I went to night school during those two years taking advanced courses in Cleveland College. Finally, I got my degree. Then by that time, the war was over. I wasn’t worried about being drafted, and I went back to the same guy who rejected me in 1945. He looked at my record and thought it was strange. I had straight A’s during my first two years, and four F’s in my junior year. He said, “Well, we can’t admit you to medical school, but I’ll get you a job in a lab and see how you do.”
So that really started my whole career because what he did, he got me a job in the Atomic Energy Research Lab, headed by Hymer Friedell. Hymer Friedell was the medical director of the Manhattan Project and he brought the first atomic energy research program into a non-government program at the medical school in Cleveland. He was able to get isotopes and do radiation research with a good grant that lasted for years from the Atomic Energy.
So I was put into that lab. It wasn’t my choice. I became a lab tech and began to learn about radiation and radioactive isotopes. I was one of the only technicians who knew how to handle radioactivity in isotopes. In the medical school, the clinicians were beginning to want to do certain studies. They heard about labeling. Hematologists, the endocrine people, they all wanted to do some study with isotopes, but they didn’t know how to handle them. They weren’t allowed to. So I became the contact with the Atomic Energy Research Lab to do clinical studies with some of them. And I learned a lot about medicine during the two years before I got into medical school.
But I also was given the task of training radiotherapists who wanted to do lab research. I taught them how to handle and count radioactivity, and we did metabolic studies in patients who got injected with isotopes. But I also began to get into radiation effects and ways to try to counter or treat radiation damage. So the residents that wanted to do research came over to the lab. They spent one year there, and I was their research assistant. So that’s how I met some very good friends, names which are in the field, named John Storaasli, Fred Bonte, Jim Christie. Those are just three residents who came through at that time but their future careers in radiotherapy were very well known.
Theodore Phillips: Storaasli became a chief there at Western Reserve, didn’t he?
Saul Rosenberg: Yes, he did. He succeeded Hymer Friedell when Hymer Friedell retired and died. Hymer Friedell, I thought was a great radiotherapist, all I knew about radiotherapy, and I worked for him. Eventually I had my own lab even though I was still called a research associate. For example, we wanted to use beta rays to treat corneal abnormalities. I would have to take the radiostrontium and desiccate it so it could get into a small applicator which used the beta particles to treat corneal disease. So that’s just an example of the kind of work they asked me to do.
But I also did many animal studies on the distribution of radioisotopes. Some of them would be those that would come from atomic bomb exposures, but also just to study how we might use radioactivity from isotopes to study physiology or metabolism, or even to treat cancer. So I did a lot of work with various radioisotopes. But the interesting part was to meet these young radiotherapists who wanted to do research and I helped teach them. They became my colleagues, and as you know I’ve written papers with some of them. One of them, much later in life, Fred Bonte, became the head at Southwestern in Dallas, and he offered me a job. But that’s part of my later story.
Baldassarre Stea: The medical school was at the Cleveland Clinic, or at the Case Western, or both?
Saul Rosenberg: All right. Now, be careful. Case was the enemy. It was not the medical school.
Baldassarre Stea: Oh, I see.
Saul Rosenberg: Case was Case Institute of Technology. It was across the fence at Western Reserve, and they were the enemy. We were the smart guys, and they were the technicians, or the plumbers we called them. I never believed that Case and Western Reserve would get together, and now you call it Case Western. But I don’t call it that. I went to Western Reserve.
Theodore Phillips: I was an intern there in 1959, and Hymer Friedell was still there. He was the one who recommended I go look at Stanford and UCSF for radiology residency.
Saul Rosenberg: That’s good. That’s interesting. Well, later in my life, just to complete that story, after two years in the radiation lab, I was quickly accepted to medical school. And for me because all the experience that I have with medicine and clinicians, it was easy. I mean medical school was a snap for me. But I always worked part time in the lab. So I had spent six years in that lab. I wrote a number of papers, some of them which I think were interesting. That’s how I got introduced to, and I was very interested in radiation biology and radiation oncology because of the six years I spent in that lab. I would never have done that if I was admitted to medical school at the age of 17. I would have been a general practitioner in a Jewish suburb of Cleveland.
Theodore Phillips: That’s fantastic. Then you went on to intern at Western Reserve as well?
Saul Rosenberg: Well, that’s another story. My life is sort of accidents or mistakes which turned out great. I was such a good student. I was junior AOA and my advisers, especially the chief of hematology and the chief of medicine - the chief of hematology there was a great guy named Austin Weisberger. They told me I could get any internship I wanted, and they would support it. So I applied to five prominent hospitals - Mass General, Peter Bent Brigham, Columbia, Yale, and Cornell and I got turned down by all of them. So when everybody else received their envelope with where they were going for internship, I just had one - no match. So immediately the chairman of medicine offered me an internship at Cleveland, and I went there.
But that mistake turned out to be good because one of the best papers I wrote in radiation was during that year while I was an intern. It showed that short interval fractionation, how rats would recover from that. So there’s a paper you might find which shows the effects of short interval fractionation on radiation damage. At that time, it was thought that radiation was perfectly additive. There was no repair, and as you know, there is, and Elkind wrote a paper on that. But our paper showed for the first time that ten-minute intervals would allow recovery from radiation so that the LD50 for the rats doubled by the time we gave them six intervals at ten-minute breaks, and we never knew why. It wasn’t explained at that time, but in retrospect it was clear to me that there was a recovery. There was DNA repair. I think that was one of my better papers in my whole life, and it was never really published. I thought it was never published widely because at that time, the papers were circulated only within the atomic energy distribution. But I hear now that maybe some of them did get out.
Theodore Phillips: That search I did was only when lymphoma relative. That paper with Storaasli was on lymphoma in rats. That’s how I found it.
Saul Rosenberg: The other one is hidden somewhere. But it’s a good paper.
Theodore Phillips: I’ll find it. So at that point, you finished your internship. Were you planning to go on to medical residency then, or why not radiology?
Saul Rosenberg: No. I was going to go into radiology, radiotherapy. Everybody had to do an internship so I did that. But then I was curious enough about radiation that I got a post doc. I was going to get a PhD in radiation biology, and I got accepted at Cambridge. That was a major center. I forgot the name of the professor, but it will come to me. So after one year of internship, I was going to go to Britain, at Cambridge, and get a PhD in radiation oncology. But I wanted to do another year of residency. That’s where my luck happened when I called around. The Peter Bent Brigham Hospital remembered me as an intern applicant. They said that I was high on their list and they had an opening. So I was accepted for a junior residency at the Peter Bent Brigham Hospital in Boston. That was quite a coup.
But then that was in 1954, and the Korean War exposed all of the doctors to the draft who did not serve during World War II. So after three months at the Peter Bent Brigham Hospital I received my orders that I was going to be drafted. Well, Hymer Friedell said that there was a great radiation program in San Francisco, and that he would get the Navy to assign me there. So I should join the Navy, and he would speak to the assignment officer in Washington to send me there.
Theodore Phillips: Was that RDL?
Saul Rosenberg: Yes. I thought that was great. That’s what I expected. Then I got my orders and they said Fleet Marine Force, Korea, medical battalion surgeon. So whoever was supposed to assign me to San Francisco either ignored that request or screwed up, but whatever it was instead I’m going to San Francisco to do further research, I went to Camp Lejeune, North Carolina, and took Marine Basic Training along with 25 other doctors. That was an experience in itself. But then I was sent to Korea. I was a battalion surgeon in a tent camp in the winter of 1954 - 1955, and I was supposed to take care of the Marines there. We were on the frontline that were facing the Chinese. This was during the truce, and we were just looking at each other waiting for the first one to attack the other. I spent an interesting winter then in Korea.
Theodore Phillips: It was like MASH.
Saul Rosenberg: Well, no, MASH was where the real doctors were, and they did surgery. I didn’t have anything more than sulfa and aspirin in a tent camp. What I took care of were guys who would fall down drunk or occasionally they’d stepped on a mine, or even more interesting they got gonorrhea. I would treat gonorrhea. I was a venereal disease control officer. So that was my experience in Korea. I used to have to get up at 5:00 in the morning to thaw the water that was in basins in the tent and use it for some bathing. There were no facilities there except for a pot stove. So that was interesting. But then fortunately my unit was transferred back to Japan, and I spent the rest of that year on the side of Mt. Fuji with a Marine battalion sort of in the reserve.
That was a fascinating year because I really enjoyed Japan, traveled all over the country, and was on the side of Mt. Fuji up 5,000 feet. Again, one of my major jobs was as venereal disease control officer. So, I had to check out all the brothels and the working ladies to make sure that they didn’t have gonorrhea, syphilis, or tuberculosis. So that was my job during the rest of that year. I’ve got a lot of stories to tell about that if we have time.
Theodore Phillips: Did you get transferred back to another Navy hospital then after that?
Saul Rosenberg: Yeah. Because I had bad training, I mean bad luck with where I was sent, so the Navy then let me to pick what hospital I wanted to go to, or what I wanted to do next. So I decided to go to a hospital rather than some other unit, and they sent me -- I went to Corona Naval Hospital. That’s in Southern California, that’s east of Riverside, a very small town. It used to be a polio hospital and in fact we had quite a few polio patients there. But it was a very nice hospital, and I spent a year there.
That year was very important to me in two ways. I was put in charge of a medical ward, and there were no residents. We only had a corpsman. But the hospital was full of young doctors like me who had been drafted out of academic programs, and we had a wonderful interaction, the young doctors. We didn’t pay attention to any of the regular naval officers, and they let us do our thing. I enjoyed clinical medicine so much there that I decided I would not go into radiation therapy and I would not get my PhD, and I’d go back to the Brigham and finish my training in medicine.
The other thing that happened there was I met my wife. My wife was a social worker with the Red Cross, and we spent a lot of time together there for a year. Eventually, she came East and got married when I went to my fellowship in New York. So that was it. It turned out that being drafted and such a disappointment of where I was sent, it all influenced my whole life from then on. Because I decided not to be a radiation therapist so I would never forget my radiation oncology or biology. But I also found my wife and that was a major, important turn in my life.
So I went back to the Peter Bent Brigham. They took me right back where I left my rotation. I did well there during my junior year and I finished my first year of residency. Then, I can tell you more that happened after that if you want to hear the next.
Theodore Phillips: I think you next went to Sloan-Kettering for a year. That’s extremely interesting. Could you tell us about that?
Saul Rosenberg: All right. Let me tell you about the other mistake.
Theodore Phillips: Okay.
Saul Rosenberg: At the Peter Bent Brigham, they had an unusual training program. They would take 12 junior residents and they would only promote six of them to senior residency. But they wanted you to get your specialty training or your lab research training after junior residency, and then they would select you for senior residency depending upon what you did during the first year, but then during your research training.
So I wanted to study to treat cancer. I wanted to use radiation to treat patients with cancer, but also there was a beginning field of chemotherapy. There were no oncology programs for medicine. In fact the name oncology wasn’t even coined at that time. There was a fellowship offered at the Memorial Sloan Kettering in medical neoplasia. I applied for that and I got it. Because I went there, my wife and I got married, and we lived off Park Avenue in New York.
I went into the Memorial Sloan Kettering with my fellowship, and I knocked on David Karnofsky’s office which is that’s where I thought I would be. And they told me, “No, you’re not with David Karnofsky. You’re assigned to a man named Lloyd Craver.” I didn’t know who Lloyd Craver was. But he and Henry Diamond, but especially Lloyd Craver, had the biggest lymphoma practice in the country. So I spent a year with him, and I saw hundreds of patients with lymphoma, and I wanted to do some research with him. Someone else had decided to study Hodgkin’s disease, so I picked up the non-Hodgkin lymphoma. But we didn’t call it that; we called them lymphosarcoma. I analyzed all his experience over a period of about 25 years, and I analyzed 1269 cases of lymphoma.
But the big advance that I had, and some of this I’ve told you before in my interviews - we had no computers. But the IBM sorting machine just was built and Memorial Sloan Kettering had one. If you know what the IBM sorting machine was, it was the size of a refrigerator. And you had cards which would have 80 slots on them, and you punched in numbers. So you could take these cards and put them in the sorting machine, and the IBM machine would arrange them. You could order anything you want - the age, the sites of involvement, the treatment - so I was able to get data that nobody ever had from those 1269 cases.
Now that led to two things. I became extremely experienced or learned a lot about lymphoma there. But also I wrote a paper on those 1269 cases which appeared in Medicine eventually in 1961 which was an epic, quoted for many years about lymphoma. In retrospect, it’s totally outdated and useless right now, but it was my major accomplishment during that year.
I wrote two other papers about the effects of radiation on lymphoma. We didn’t call it lymphoma. We called them lymphosarcoma. And then I wrote a good paper on children with lymphoma. It was published in the New England Journal. All that data really established my interest and my reputation and knowledge about lymphomas. But at that time there were only three non-Hodgkin’s lymphomas. They were lymphosarcoma, reticulum cell sarcoma, and giant follicular lymphoma. Those were the only three types. Now, there must be 50 at least. It’s totally irrelevant right now what we know about lymphoma except that it taught me about it.
Theodore Phillips: I read it when it first came out. It gave me my whole foundation. I was a resident then in lymphoma, it was a great paper.
Saul Rosenberg: At that time it was pretty good. I gave talks in Boston and a couple elsewhere while I was still in residency because I knew more about lymphoma than anybody in Boston at the time. But there are two interesting things about my time at Memorial. We used radiation for palliation of patients with Hodgkin’s and non-Hodgkin’s lymphoma. Lloyd Craver and I went on rounds, and sometimes Henry Diamond was there, and we would write a prescription for radiotherapy. We’d take a red crayon or a marker and we mark on the patient’s body where the radiation should be given. Then we would send it down to radiotherapy with the prescription of what to treat, for how long, and what dose, and that’s how we gave radiation during that year while I was there.
Theodore Phillips: Dr. Bushde used to comment on that being the technique at Memorial. He was appalled by it. That’s what he told me back when I was a resident.
Saul Rosenberg: Yeah. So, isn’t that interesting? The other thing is I learned a lot about radiation there because I took a course with Edith Quimby. Now, you may remember that name.
Theodore Phillips: Oh yes.
Baldassarre Stea: Yes.
Saul Rosenberg: Edith Quimby was famous because no radiation resident wanted to take the oral exam with Edith Quimby because she was tough. So there was a course there on radiation physics which I attended and completed and have a certificate signed by Edith Quimby. So I learned a lot about radiation physics during that year at Memorial as well.
Theodore Phillips: I’m sure you could take your radiology oncology board and pass.
Saul Rosenberg: No. I didn’t take the radio oncology board. I’ve never been certified. A lot of people think I’m a radiotherapist. I mean I never got paid like a radiotherapist.
Baldassarre Stea: Yeah.
Saul Rosenberg: But I’ve never forgotten my radiotherapy. So then is a long story in my career after that.
Baldassarre Stea: How long were you at Memorial?
Saul Rosenberg: Only one year because it wasn’t the fellowship that I wanted. I could have stayed longer, but they accepted me back for the six senior residents of the Peter Bent Brigham, and they asked whether I wanted to come back so I did. So I went back to Boston for three more years, and I eventually became the chief resident in medicine at the Peter Bent Brigham which is an extremely honorable, honored position.
At that time, I was a Henry Christian fellow. I was chief resident of a great program. That helped to establish my reputation as an internist and a teacher, because I learned an awful lot about clinical medicine there, and I did well there. They picked me as chief resident. So my teaching credentials in medicine were established there but also my habits, and what I know about internal medicine. You may all know me as a lymphoma doctor but other people know me as a clinician-teacher.
Theodore Phillips: You’re a great internist besides all the oncology stuff.
Saul Rosenberg: I hope so. Yes, that’s what I’m much proud of, both of it, but I never forgot radiation. Then, I finished my total four years at the Brigham, and I had all this lymphoma and radiation background. But I always promised and planned to return to Cleveland because Hymer Friedell and the chairman of medicine named Hyman said that I could come back. I could have a joint appointment both in radiotherapy and in internal medicine and treat cancer patients.
Friedell promised to support me both - salary and in the laboratory. So a couple of months before I left the Brigham, I went to Cleveland and said, where’s my office? Hymer Friedell showed me what I would get. I went to see the chairman of medicine and he had changed. The chairman of medicine resigned, and a new chairman of medicine was there and he didn’t know who I was.
Austin Weisberger and he talked, and Friedell, and the guy said I needed two more years of research in biochemistry. I said I’m not going to do that. I’ve had enough lab experience. I want a combined appointment. He wouldn’t give it to me. But also, Austin Weisberger, I think, told him that I was too much like him, and we only needed one of them. So I had to apply for a job somewhere. I got a job offer at Harvard from Farber, and I would be at the Peter Bent Brigham and at the new Jimmy Fund. But he said I could not treat lymphoma or leukemia. I could treat cancer but not lymphoma. He also showed me an office that was about a clothes closet, and pay me $6,000 a year. I’m not going to do that.
So I asked around. Then Fred Bonte from Dallas offered me a job. It would pay me $15,000. And he would get me a job in both medicine and radiotherapy, and he gave me a lab. So I went there with my wife, pretty much assuming I would go there. The chief of medicine there was a guy named Don Seldin. But you know Don Seldin. He was a very tough, prominent internist who came from Yale. We met with him and we went out to dinner, and he was nasty to me and my wife. He said he didn’t see any reason for internists to treat cancer. He wasn’t going to set up a program in eventually what’s called oncology. So I wouldn’t go there.
So then I had to look around. I had a job offer at a couple of other places. But I had met Henry Kaplan because I gave a paper on the radiation of these lymphoma patients in San Juan, Puerto Rico at the American Radium Society meeting. I think that year was, I don’t know, 1959 or ‘60. Henry Kaplan remembered me. I met him there. I also had a contact with Stanford with medicine because a great cardiologist liked me named Bernie Lown. Lown became famous for the Nobel Prize, but he was a very controversial person because he was blackballed by McCarthy. But he had a friend named Hal Holman who was as left-wing as he was. So I called Henry Kaplan, and my friend Bernie Lown called Hal Holman, and they said they’d offer me a job. So I came out and Henry welcomed me. He gave me a lab and he gave me an office and he supported my position. Hal Holman eventually asked me to head the teaching program in internal medicine so I headed the house staff teaching program for ten years. That’s how I got to the West Coast. I thought I’d go to Cleveland. It never happened.
Theodore Phillips: Your first meeting with Henry was actually at the Radium Society in Puerto Rico, right?
Saul Rosenberg: I think I also met him in Oberlin. There’s a new society called the Radiation Research Society. When I was in Cleveland, I went to their meeting there. Actually, I think their founding meeting of the Radiation Research Society. I’ve been a member of that for all that time. But I think Hymer introduced me to Henry Kaplan, but at that time there was no connection with lymphoma. I just was introduced to him. But then when I gave the lymphoma program at the American Radium Society meeting he was impressed, and so that got me into Stanford.
Theodore Phillips: He was already interested in you because of your lymphoma expertise.
Saul Rosenberg: Yes.
Baldassarre Stea: How did your friendship with Glatstein develop? Tell us.
Saul Rosenberg: Well, Eli Glatstein was just a resident in radiotherapy at Stanford. I taught a lot of radiotherapists at Stanford. They’re as much my students as my internists. I’ve got friends in radiotherapy all over. But Eli became a very close friend. Eli was interested in lymphoma. He helped us with trials and then eventually he was junior faculty, and we wrote some papers together. Eli has always been a close friend.
Baldassarre Stea: And collaborator.
Theodore Phillips: I was at Stanford in 1969. The three of you - Kaplan, Bagshaw, and Rosenberg - were known as the trinity. Were you aware of that though?
Saul Rosenberg: No. I wasn’t aware of that.
Theodore Phillips: You were the father, son and holy spirit.
Saul Rosenberg: What was I? I don’t know which was one.
Theodore Phillips: You were the Holy Spirit.
Saul Rosenberg: Okay, thanks.
Theodore Phillips: I think that’s really true. You were the impetus behind the honesty of what went on at Stanford.
Saul Rosenberg: Well, you know, Henry and I we’re both fascinated by lymphoma but especially Hodgkin’s disease. We were provoked that you might cure Hodgkin’s disease. Some papers came out, “The Cure of Hodgkin’s Disease” by Easson and Russell, and their data was not convincing. They never had a flat curve. But Henry felt that with high dose radiotherapy which he could give with the new linear accelerator, which he helped invent, that he could make great strides in treating of all cancers, but certainly including Hodgkin’s disease. And as you know, pseudomonas has made a tremendous difference in what we could do in terms of the depth and margins and size of fields.
So we had a lot of studies initially trying to use maximal tolerated radiotherapy to control Hodgkin’s disease and even other lymphomas. But Henry wanted to use more radiotherapy than I did. He wanted to extend the field all the way to the groin from neck disease; and I wanted to use more limited fields. We argued a bit and agreed to compare and randomize studies, these various forms of treatment. Those studies went on then for, you know, they’re still going on. But they went on with him for at least 30, 35 years.
We constantly debated where we would go next. I would take a conservative role, and he would take the radical role. We ended up hardly ever showing differences. The only difference we showed was that our patients gradually improved. We began to see patients that never recurred after not only 5, 10, even 15, 20 years. So we established flat, disease free survival curves with Hodgkin’s disease that go back to our studies that started in 1962. That really established that Hodgkin’s disease could be cured. Now, there are many other leaders in the field especially Vera Peters, and some people, Gioberti and a few others who have been using bigger fields and got better results. But none of them were able to show flat survival curves like we did.
Theodore Phillips: Last year, you wrote a paper for the 50th anniversary of the Paris meeting in 1965. Will you reflect a little bit about that 1965 meeting and what it meant to the field of lymphoma and Hodgkin’s disease?
Saul Rosenberg: Well, it meant a great deal. There were two meetings actually. But Paris was the first one, and Jean Bernard, a great hematologist. What’s the other man’s name? I have to remember it. He is from Morocco, the radiotherapist in Paris. I’ll remember it. But they decided to have a meeting because chemotherapy was beginning to be accepted, nitrogen mustard, a few others, and the pathologists were beginning to sort out the different forms of Hodgkin’s disease - Bob Lukes and Henry Rappaport. Our results would have been from the NIH. The French organized a meeting of multiple leaders in the field from around the world but mostly from Europe and the U.S., Vera Peters, Henry, and --
Theodore Phillips: Tubiana, right?
Saul Rosenberg: Yeah, right.
Theodore Phillips: Tubiana was the Frenchman from Morocco.
Saul Rosenberg: Yeah. He was terrific. I was very fond of him. He and his son-in-law had been friends. But Tubiana, we traveled together a lot. We gave joint teaching conferences. I will never forget the time that he and I were escorted through Israel after a meeting we had. He was a wonderful man.
But this meeting, we brought up what might be done for Hodgkin’s disease in pathology, chemotherapy, radiotherapy, and staging, and virtually, at the same time Paris was six months ahead of it. We organized a similar conference in Rye, New York. Kaplan was trying to compete with the Europeans. So we had a similar conference. It’s better known in the English literature as the Rye Conference, but the Paris and the Europeans wanted to emphasize that they were first. The guy named Mathé was the immunologist there, and Jean Bernard was the hematologist there, and Tubiana was the radiotherapist. It was a great group. It was really stimulating to be able to be in a group of 25 investigators who would argue with each other, and talk to each other. It’s a kind of conference which has been expanded in many ways. But they didn’t do that before. We did the same thing at the Rye Conference. And then when there were other developments. About five years later, we had the Ann Arbor Conference. It was a similar time in terms of trying to bring together the pathologists, radiotherapists, the chemotherapists and statisticians. We made great advances in those meetings.
Theodore Phillips: Looking back on the whole career in Hodgkin’s disease, can you tell us some conclusion about what the disease really is?
Saul Rosenberg: I don’t know. You know I know more about it than most people but it’s a unique disease. I’m very upset with the pathologist that changed the name to Hodgkin’s lymphoma. That doesn’t make any sense. Hodgkin’s disease is a unique disease. There’s nothing like it. There’s no animal model. You can’t transplant it. There really is no cell line but the Germans think they have one, but I don’t believe it. Henry Kaplan thought he had cells, Hodgkin cells or Reed-Sternberg cells, and they’d turn out to be diffused large cells. These lines are now known for non-Hodgkin’s lymphoma, but not Hodgkin cells.
It’s unique in that it is curable. When you look at it under the microscope, you see mostly reaction or inflammation and a lot of fibrosis. So it is some kind of a host reaction. But it has many other features which I could go on and on and tell you about. It’s a very unique disease. I mean there are paraneoplastic syndromes like nephrotic syndrome and Guillain-Barré, and we don’t know the reason for them. Also, there is a unique immunity of Hodgkin’s disease and it looks like sarcoid. It’s more like sarcoid than any other cancer. I mean the cellular immunity is gone almost from the very beginning of the disease. We don’t know why, and there is so much --
Baldassarre Stea: Dr. Rosenberg, I was wondering, could we talk about the future of oncology? Like what do you envision for the future of radiation oncology? You’re being somewhat inside and outside. You have your feet in both camps.
Saul Rosenberg: Yeah. I don’t know how long you want me to talk.
Baldassarre Stea: That’s up to you.
Theodore Phillips: As long as your voice lasts.
Saul Rosenberg: Well, for Hodgkin’s disease, it’s gradually, interventionally, dramatically changed so we’re using less and less radiation. I have been part of that. It took us 20 years to really identify the toxicity of the big fields and the curative doses of radiation. So we showed that we caused a lot of breast cancer, of many other cancers. We damaged the heart and muscles. But we didn’t know all those things unless patients survived more than ten years. The breast cancer incidence was dramatic, and we didn’t recognize it until we had 15 years of follow-up. The heart damage and valvular heart disease we didn’t know until 20 years later. So then we began to change it.
That’s about the time that Henry Kaplan passed away and I was in charge. We were able to reduce our fields, and begin to use chemotherapy which also had some major advances during that same period. The first dramatic program was called MOPP which was a very difficult treatment, very toxic in itself. But it was able to control early stage -- I mean limited amounts of disease especially when you combine it with radiotherapy.
Now, again, my and our major contribution was to really combine the two of them. That when you use chemotherapy, you could reduce the radiotherapy fields and doses considerably. Now that progress has continued to date so dramatically. There are many Hodgkin’s physicians in the world who think we don’t need radiotherapy at all anymore. Now that’s true of quite a few patients of certain stages and where the treatment would not be tolerable.
But I haven’t given up on radiotherapy. I use it for bulky disease. I think our results are better. The radiation techniques now are so focused and so much better that tolerance is great. We can reduce the dose so we don’t have to give 44 gray. We reduce it to 30, sometimes 20, for children - even less. So we get less and less toxicity now but our cure rates are superb.
Our chemotherapy, we abandoned MOPP long ago, too toxic, causes sterility, neuropathy. There are new chemotherapy programs and even newer. I mean in the past few years, you know, some of the immune markers, I mean the CAR inhibitors and nivolumab is very effective for Hodgkin’s disease that has relapsed after multiple treatments. So the treatment is going to continue to evolve and be better and better, and radiotherapy will be used less and less. One of my major students, who I’m proud of, Joe Connors in Canada, says we shouldn’t use radiotherapy at all. He’s one of my students.
Theodore Phillips: I could agree with that. Saul, you came up before there was actually a specialty of medical oncology, and before radiation oncology. What do you see the future of those two, whether they’re now a specialty, whether they’re on separate training? How do you see them developing in the future?
Saul Rosenberg: Well, that’s some of my disappointment. First of all, as far as medical oncology, when I came to Stanford in 1961, there was no fields, no divisions, no departments of medical oncology. The word was just introduced. There were four of us, Paul Carbone, B.J. Kennedy, Al Owens – who is at Wisconsin, Minnesota and Hopkins - and I, convinced our chairs of medicine that there was enough evidence that we should have to treat patients with cancer with drugs and chemotherapy and even radiotherapy, and treat them as internists, and have divisions of medical oncology.
But the hematologists in the country, Wintrobe, Harrington, many of them greatly opposed that. They tried to prevent it from happening in their hospitals at Wash U and Cleveland. So we were the first ones. We developed divisions of medical oncology against the opposition of hematologists. So at Stanford for example we were very separate. They wouldn’t let me treat breast cancer or ovarian cancer in the medical clinic, so I had to set up an oncology clinic. We tried to have an American board or a specialty board for oncology which was opposed by the hematologists for ten years. Eventually, they agreed and I was one of the first board members. They didn’t want to combine hematology and oncology. They had to have separate boards. Now, they’re almost always combined. You can’t practice hematology without doing oncology, and most of the hematology is laboratory based and is not treated.
But also getting back to radiation and medical oncology, I was always upset that the training was separate. We always had rotation of our oncology fellows to radiotherapy clinics, and we always had radiotherapists serve on the medical wards. So Henry and I combined our training, and there’s a whole group of trainees who have been through both. I saw that in Europe, whether it be Sweden or England, even some Canadians. They trained in both radiotherapy and medical oncology. I think that’s a great advantage. I’m sorry it hasn’t developed in this country. It never will be now. But if you come through my program, our fellows always knew how to respect and use radiotherapy much more than most other trainees.
Theodore Phillips: You know that died out at UCSF which I felt was a grave mistake.
Saul Rosenberg: Yeah.
Theodore Phillips: Do you have any more comments about your family, Saul? You mentioned that you got married, but did you have kids? What’s happened with the family?
Saul Rosenberg: Well, my daughter, my oldest, Ann, went to Stanford. I think she wanted to be a physician. I wanted her to be a physician. She became a human biology major which is no premed at Stanford, and she did two years of human biology, and she didn’t like organic chemistry. She did like the tennis team, however. So she was really diverted from her premed development, and she never became a physician.
However, she has worked in the cancer field most of her life. After she got married, she moved to Salt Lake City with one of her husbands, and she worked with the development of the Huntsman Cancer Center. She raised money for them and did educational programs. She eventually got a master’s degree and then worked with a big cancer clinic that I introduced her to. She still works in cancer clinics. She knows a lot about medicine and oncology. But she never became a physician and that disappointed me.
My son, a long story, a dyslexic, could hardly get out of high school, was a poor student, can’t spell, can’t multiply, and finally was able to get out of high school with a lot of help. He got off his marijuana and his beer. He decided he wanted to be a skier, so he went to Utah after he went to junior college here. The long story short is now he is the president, one of the presidents of Polo Ralph Lauren. He’s a very creative guy, a very good manager. Though the company had a downturn this past year, he is looked upon like a son of Ralph Lauren. He worked for them for 35 years and he’s extremely successful, and still dyslexic. He still can’t spell, can’t multiply. So that’s my son.
He works in Manhattan and has houses in Connecticut and has twin granddaughters of mine. They are only 6-years-old. My daughter has one child. She’s been married three times. The first two were not good. The third one is with an oncologist that she met in the cancer clinic, and he does primary palliative care and hospice care, but he’s a good medical oncologist as well. So she’s finally connected with someone that I trust and they’re doing well.
Theodore Phillips: You had your retirement gala a couple of years ago, and I know at that time you were still seeing patients. Are you still now?
Saul Rosenberg: This Monday I saw patients with Hodgkin’s disease, this past Monday. I see follow-ups. I don’t see new patients because they require more care and attention that I could give them. I don’t even know all the new drugs and the new protocols. But I still go to conferences. I go to Hodgkin’s staging conference every Monday morning. We’ve done it for 55 years. And we had one or two patients this past Monday that were fascinating. The radiotherapist, Richard Hoppe, and my colleague Ranjana Advani, who happens to be the Saul Rosenberg Professor of Lymphoma, we have an endowed chair in my name but she has it. So we have a staging conference for Hodgkin’s. We have pathologists, radiotherapists, nuclear medicine, and we meet every Monday morning with all of the new Hodgkin’s patients. But we’re getting fewer and fewer of them because referral patterns are not good, and the community doctors think they can treat Hodgkin’s disease. But every patient is seen and staged on Monday morning. We give them follow-up when we declare them finished with treatment and/or if they recur.
I go to other conferences. I go to oncology conference every Tuesday morning, and I went to grand rounds this morning. I try to keep up. I’ve got to see young people. I can’t be in this old folk’s home that I live in. I got to see young people. But many people at the medical center remember me and they say hello. Doc, they call on you, I walk down the corridor and somebody come at me and says, “Oh, you treated my dad, and he’s still doing well,” or, “You treated my wife. She’s gone. We appreciated what you did.” I live off that.
As my wife passed away a year ago, I’m very lonely. I live in an old folk’s home. I don’t like old folks like myself. Then I broke my hip. I have a new hip that was put in six months ago. I’m finally getting around on my own reasonably well.
Theodore Phillips: I think Karen told me about that. Karen Fu lives where you live.
Saul Rosenberg: Yes. Karen Fu’s here. She’s very active, I mean, physically active. She plays piano and is an artist. I see her often. I go to the pool to do exercises, and she goes there to swim.
Theodore Phillips: Dino, do you have any more questions?
Baldassarre Stea: Yeah, one final question, Dr. Rosenberg, if I may? What advice would you give young academic radiation oncologists who want to achieve a global impact?
Saul Rosenberg: Well, you know, I’ve always told my fellows, I told the radiotherapists as well - take one disease, rare or not, know more about that than anybody else, and then you can teach the rest of the world. So, somebody take a rare disease, whether it be used with radiotherapy or chemotherapy or both, but concentrate on one. I mean you got to know about all the others, but you don’t have to do your research about all the others. And now you can do the same thing with the technique or drug, or a particular disease. But I find that the ones that are most successful narrow down. Then they can travel around the world.
Baldassarre Stea: Wonderful. That’s very good advice, and we appreciate the time you gave us. I hope to meet you in person on my trip there in the San Francisco area one day. I was there just a couple of months ago, but I was just in the radiation department.
Saul Rosenberg: I’m often there but not the last six months. I’ve been off because of my hip fracture. But I’m in staging conferences in radiotherapy every Monday morning, and any visitor there should be there, should come to that conference. It’s still very good.
Baldassarre Stea: Yeah.
Theodore Phillips: Okay, Saul. We’d like to thank you very much. It was a very wonderful piece of history. They’ll be transcribing it and sending it to you for your editing.