By Nancy Mendenhall, MD
The following interview of Theodore Phillips, MD, was conducted at ASTRO's 43rd Annual Meeting in San Francisco by Nancy Mendenhall, MD.
Question: I am Dr. Nancy Mendenhall from the University of Florida, and I am privileged to interview Dr. Ted Phillips from the University of California, San Francisco, as part of a project for the History Committee of ASTRO to compile an oral history of our specialty. Dr. Phillips, you are one of the giants in our field. You have done everything in terms of research and teaching and you have had an illustrious career so it is going to be delightful to talk with you today. I would like to begin with the very beginning - when and where were you born?
Dr. Phillips: I was born in 1933 in Philadelphia at the Pennsylvania Hospital, and grew up just outside Philadelphia in a small suburb called Springfield, Pa. After high school, it was the Korean War, so they suggested that I start college early. So I did, and went to Dickinson College in Carlisle, Pa., where I majored in chemistry.
After graduating from Dickinson, I went to the University of Pennsylvania to medical school. While there, I became interested in research. I had an NCI research training fellowship that supported me to work summers and nights in pathology, where I became interested in electron microscopy and learned how to do it. Only one paper came out of that work on mast cells. But it was a technique that I could pursue later.
After that, I went on to Cleveland for a categorical internship, which included medicine, surgery, pediatrics and OB/GYN. I had intended to go into pathology, but at that time pathology was very remote from the clinic. I had been impressed by radiology because it was interesting and I had some friends that went into radiology, so I thought that was a better alternative than pathology. I looked around the country and asked, ‘What are the best residencies?’ And they said, ‘Well, look at Michigan, Stanford and UCSF.’
So I went and looked in those three places, and UCSF was the best because it was in San Francisco. Stanford had just moved down the peninsula, and I was afraid there would not be enough patients. So I eventually went to UCSF in general radiology. I spent the first year doing six months of diagnosis and three of nuclear medicine. But the last three months were in therapy. Dr. Buschke was the chair and Jerry Vaeth was the other faculty member, and he was very persuasive in convincing people that you do not want to try to do general radiology anymore, that you really need to do one or the other. That same thing was happening in my group of residents. Many of them, particularly the ones that were interested in academics, realized that they had to do one or the other. So in my class, beginning in 1960, there were several who went into straight diagnosis, and I went into straight therapy.
When I came to UC in 1960, Dr. Buschke had been recruited to come and head radiation oncology. At that time, radiotherapy was a section of diagnostic radiology. Jerry Vaeth had just spent a year in Europe and brought back some new brachytherapy techniques. So it was a very interesting residency, but very much clinically oriented. Dr. Buschke insisted that you had to look at the slides of every patient you would treat, so we always had the slides first, and there was a lot of pathology orientation. We all spent four months in pathology as part of our training, and I found that very useful ever since.
When I was in diagnosis the first two months, you had to be a technician. You had to learn to take all the films. In those days, and I think this is true in most academic departments, the residents did all the work nights and weekends. So any films that were taken over the weekend or at night, a resident had to come and take. So you had to know how to take the films, and that has been very useful. When our simulator films do not come out, I know what to do to make sure they come out right. So I think that six months in diagnostics and three months in nuclear medicine were very valuable. You do not do it anymore. But now with tremendous new emphasis on imaging in radiotherapy it is valuable to have a fundamental background in radiology. It has probably influenced what I did. Following my residency, I spent two years in the Navy doing radiobiologic research at NRDL. That experience and laboratory training launched my research career.
Question: What was radiation oncology like, in your view, in 1965?
Dr. Phillips: Compared to today's standards, it was very crude. There were a couple of linear accelerators in the world. Stanford had one. There were some betatrons. We had the 70 MeV synchrotron. But very much of it was all cobalt, and had just emerged from the orthovoltage era when everybody treated with 250 or 400 kVp. We were lucky at UCSF because we had had a one million-volt machine that was built by the people in Berkeley, designed by Sloane and installed in 1933. But that was not working anymore, and I think it went out of commission in the early 1950s.
Then in 1955, we got a one million-volt GE resonant transformer. So mega voltage was there and cobalt was there. But the delivery techniques were extremely crude. I remember all we had was one blocking bar. You could mount that bar on an arm that held it out so you could put in a mid-line bar or one corner block, but that was it. There was no way to shape the beam in any more complex fashion than that. The major changes I remember from the 1960s were first of all getting better machines, moving up to cobalt, and then in the 1970s moving to linear accelerators.
Parallel with that were three things that became extremely important. One was the ability to create complex field shapes. It came through developments, at Stanford and elsewhere, where they would cut blocks from lead blocks using a band saw, or fill plastic boxes with bb shots to make shaping blocks. Finally there was the development, at Washington University, of cerrobend blocks, where you could pour a low melting point alloy into molds and mount the resulting blocks on trays that really revolutionized our ability to take the first steps toward conformal therapy rather than using square fields on everything.
The second thing that happened, between 1965 and 1970, was the development of the simulator. The third was the early introduction of computerized treatment planning. This was being pioneered in St. Louis and in England. I remember that our first computer, which we got about 1968, had 34 KB of memory. Can you imagine that?
But CT revolutionized the whole field. The head scanners came in 1973, and body scans in 1975. Then GE and Siemens and Phillips all got into the business and rapidly improved it. So in 1984, we had excellent body scanners, high speed. The new era began with the ability to image the tumor at its location. And then the beginning of MR in 1980, and its rapid advance, made that even better because at most sites now, particularly in head, neck, brain and pelvis, you can really tell where the tumor is.
Question: What are some of the significant events that took place in your early years as a radiation oncologist?
Dr. Phillips: One of the important things that happened between when I started in 1965 and now, I think, was the development of and the ability to do good clinical trials. That began with Dr. del Regato putting together a group to do clinical trials in prostate cancer. I do not think they were ever finished or published, but it sort of floated the idea among the radiation oncologists that they could get together and do things the same way and pool the cases.
That was followed by Simon Kramer's decision to create a group to study methotrexate in head and neck cancer. A lot of institutions got together, and they transformed into the RTOG, the Radiation Therapy Oncology Group, which has been extremely important to the specialty. There are a lot of important trials that come out every year from RTOG, and it is extremely successful. I thought it was a pleasure and an honor to participate in RTOG. I was head of the chemical modifiers committee and then became vice chair for modalities and then later vice chair for the site oriented studies.
Question: There is so much to talk about. You had such a rich experience. Why don't you tell me who the heroes were for you in your early years? The people who helped you most in the development of your career, if you could just talk a little bit more about them.
Dr. Phillips: Sure. I would say Dr. Buschke was a hero. I had two great professors in my career: one in college, and Dr. Buschke, both of whom were Germans raised in the old education system, where they were total academicians - played the violin, spoke many languages, had a lot of training in philosophy. Buschke was a person like that, and he played the viola. The other person was my German professor at Dickinson, who was the same kind of person, very influential on me.
I think the person that I tried to use as my role model most was Herman Suit. He was a little bit older than I, and he had already been doing both clinical work and animal modeling of the clinical situation. And I thought this was the thing that one really should do. He was the first to do all the elegant experiments, such as fractionated treatment of mouse tumors that explained many of the things that we did empirically in the clinic, and he figured out why they worked. So I wanted to be like Herman.
Harvey Patt was a major influence, and so was Henry Kaplan. I was fortunate enough to do a six-month sabbatical at Stanford in 1969, and working with him was a great pleasure. He was very active in the clinic then treating Hodgkin's disease, and he had an outstanding department in 1969. It epitomized, I think, what a department should be like, and that is they had great biology and physics and a bunch of great clinicians and were pushing high technology as far as you could push it in those days, but they were pushing it.
Question: During those years, it sounds like a radiation oncologist played a very strong role in the multidisciplinary management or the evolving multidisciplinary management of the patients. Can you talk a little bit about what responsibility the radiation oncologist took for treatment decisions and management of the overall patient?
Dr. Phillips: Well, I think over the last 40 years that I have experience with that. It has differed in different parts of the country. On the West Coast, we have been fortunate to have strong radiation oncology departments in a number of universities, and fairly weak medical oncology departments in the sense that they never dominated at UC or Stanford or even up at the University of Washington or UCLA. This allowed the radiation oncology department to continue with a strong role. We always decided that we wanted to be the best.
My feeling was that we needed to have a big enough faculty and good people and developed people who were experts in one or two areas that would be the expert on our campus along with the surgeon in that area. We had Glenn Sheline and then Dave Larson in CNS tumors, and we had Karen Fu in head and neck and so forth. That happened at Stanford, too, and several other places. So we never were in a position of being weak or second-class citizens, so I have never felt that paranoia. We also always had an in-patient service and a presence on the floor, and I think that is important. Before they came in with DRGs, we used to run a service - usually 15 to 20 people in-house because you could hospitalize people for their external beam plus the brachytherapy patients. Of course, now we cannot do that. I think the experience was different in some other parts of the country.
Question: What of your many accomplishments are you most satisfied with?
Dr. Phillips: Well, I think if we looked at the whole career, it is my interest in chemical modification and the success of chemoradiation. That, I think, has been the most successful thing. I think the other thing is the approach I used to develop our department by trying to be good at as many of the new technologies as possible. As an academic department, you are continually challenged and competing with the people in private practice for patients. That was a big problem 10 years ago. It is not so much a problem now because nobody wants the patients because they do not get paid enough to treat them. But when it was, I felt the field could be advanced and it could help our department to prosper if we were good at the new things. So we made a conscious effort to develop radiosurgery, to develop isotopic immunotherapy, to develop IMRT, to expand brachytherapy and do HDR, to get into 3D conformal and IMRT early. And we did all those things, and it has really paid off.
My advice to new, budding department chairs would be to look out there and see what are the new things that are going to be mainstream in 10 years, and start doing them now. We did that with 3D conformal, and we became leaders in that. We have done that with IMRT, and we have become leaders in that, too. And so I think that is the secret, not just going along with "standard radiotherapy." But look at what is developing in the industry, and what is developing in physics and biology and molecular biology, and say, ‘Where could we be, where is the place to be, in five years from now in that area?’
Question: I would like to thank you for sharing your recollections of your career, the developments in our specialty, and just thank you for being such a leader in our field. You have mentored so many people. You have been a leader in research, a leader in residency training programs and you have brought on many new leaders in our field. We are very grateful for all you have done.
Dr. Phillips: I think that you brought out the most important thing that I am proud of - the people we have trained.
Question: And they are all so appreciative of your role in their development.
Dr. Phillips: Thank you for having me here.