I wish u knew… My lessons learned in oncology

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Tim Hampshire

In 1895, it was discovered that X-rays carry enough energy to kill malignant cells. In the early half of the twentieth century, European doctors started making radiotherapy a part of cancer treatment. The field was underdeveloped in America until after World War II, when European specialists and their linear accelerators washed up on our shores. By the 1960s, Dr. Henry Kaplan of Stanford and Dr. Morton Kligerman of Yale switched from their previous specializations to become full-time radiation oncologists. They became the role models for every young trainee in the field.

One of those young trainees was a medical student at Stanford in 1964. He was a bright young man from a small river town in Iowa. His name was Eli Glatstein.

“I was happy to share the same planet as those guys,” Dr. Glatstein said about Dr. Kaplan and Dr. Kligerman, who were his mentors. He was saying it not as a fresh-faced intern, but as the foremost cancer guru in Penn’s department of radiation oncology, after 45 years of experience, in the year 2012, to a 20-year-old blogger who was mostly just listening closely

Dr. Glatstein shares some of the important lessons he has conveyed upon the many oncology professionals he has trained.

“My particular view is that we’re doctors before we’re oncologists, and we’re oncologists before we’re radiation oncologists,” he said. Dr. Glatstein spoke every part of that statement as if he was counting the rings of a tree, with the observational certainty that comes from seeing many years of a particular thing.

There’s a way to go about learning how to treat cancer, and there’s a way to teach it. Dr. Glatstein learned from the best and went on to train 26 heads of academic radiation oncology departments throughout the country (a country which only has about 80 such departments.) Learning and teaching, even more than curing cancer, are his areas of expertise. He’s like the Aristotle of oncology: leading and being led, teaching and being taught, questioning and answering, and doubting the truth of every word and datum he sees are the trademarks of his practical philosophy. “You encourage them to think for themselves…” he said when asked about what he tries to impart to the doctors he trains. “…which sometimes leads to disagreements, but that’s healthy.”

According to him, we need experienced doctors who think on their feet, and bring a breadth of experience to the table, if we are to battle cancer correctly. The good radiation oncologist is the one who intuits rather than obeys. Dr. Glatstein does not have a great amount of trust in the changing tides of oncology dogma: “Now and then it’s fashionable to talk about the role of the immune system in treating cancer. Well, most of these cancer cells have PhDs in immunology. They’re very bright, and they’ll get around whatever we do…Each tumor is unique—molecularly unique,” he said. That heterogeneity is what makes cancer so insidious. The people who treat it with radiation are people who enroll in a risky and highly technical practice. In order to do it effectively, they need to learn to be intellectually flexible. They also need to learn to sift through all that is inexpedient. Not just flexibility, but also rigor, are the marks of a worthy radiation oncologist. “You need reliable data. That’s the most important thing,” said Dr. Glatstein, adding, “We’re not selling used cars.” He smiled the crooked smile of a seasoned officer telling privates to jump out of a plane: “Put your chutes on; we’re not playing dolls here, boys.” He shrank the room with his gravitas. (Dr. Glatstein actually does have a bronze star for his military service in Vietnam. If you’re keeping track of my metaphors, that makes him the militaristic Aristotelian botanist of the cancer jungle. He is many things indeed.)

There is a special need for mentors like Dr. Glatstein because medical schools do not usually teach oncology in depth. Only a fraction of physicians will go on to treat cancer. The ones that do will need to pick up the requisite skills from somebody who has learned, as Dr. Glatstein puts it, “The Devil in all his disguises.” Like so many things, the only way to do that is to do it. It cannot be learned exclusively through studying. Dr. Glatstein brings that element of experience to all the apprentices he decides to take on.

So is every patient of a radiation oncologist under the age of 70 just some guinea pig? How are we supposed to trust anybody who hasn’t been radiating tumors for decades? How does any of this help?

People like Dr. Glatstein know that cancer is not something to play with. In treating life-threatening diseases, you don’t just put the rookie on the mound despite the fact that you know he’ll cost you a few outs. It’s not like that. Like he said, the progress of a radiation oncologist should be threefold: First, a very bright person becomes a doctor. Then, that doctor (who knows a lot about the human body,) becomes an oncologist. Then, that oncologist (who knows a lot about curing cancer,) becomes a radiation oncologist. So ideally, before anyone sends you to the cyclotron, they’ve already shown that they’re very bright, know a lot about the body, and know a lot about curing cancer. Plus, keep in mind that a third of the department heads in the nation learned everything they know from Dr. Glatstein. There’s actually a good statistical chance that you’re being treated according to his exacting tenets.

Dr. Glatstein thinks in the long-term. He has seen cancers return after twenty years of remission. However, such relapses and outliers like that one don’t make him less hopeful that one day there will be a cure. “I think the seeds are there to ultimately give long-term solutions,” he said, but not without adding his catch phrase:

“But it takes time.”