Eleanor Montague, MD, FASTRO
By David Hussey, MD, FASTRO, Moshe Maor, MD, and Luis Delclos, MD, DMSc, FASTRO
In 2003, 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 in Dr. Montague’s apartment in Houston on March 11, 2003.
Question: Good afternoon. This is Dave Hussey. I'm a member of the History Committee for ASTRO as is Moshe Maor. We're here with Dr. Delclos interviewing Dr. Montague today. It's Tuesday the 11th of March, 2003, and we're in Montague's apartment in Houston. And Eleanor, what we're trying to do today is to get an idea of two things: one, your own personal history of where you were born, more about your family, your education, why you came to work at MD Anderson and so forth, but in addition to that, in addition to your accomplishments, we're interested in your perceptions of how the field of radiation oncology and breast cancer developed during the time you were involved in that area. And the three of us will all ask questions.
Question: But I think what we might do is just start out and let you have a little bit of a soliloquy telling us about where you were born, your family, how you got into medicine, how you got into radiation oncology and how you met Monty and so forth.
Dr. Montague: I was born Eleanor Dino in Genoa, Italy, on February 11, 1926. I was an only child, and my father had served in the Italian Army during World War I and had been wounded and remained in the army. When Mussolini came to power, he decided that it was time for him to leave Italy and Mussolini and to come to the United States.
So I was in elementary school when we came and for some reason, I think for business reasons, he went to a very small coal mining town in northeastern Pennsylvania, very close to the New York border, where anthracite mining was the main industry. He started a pasta factory and, at that time, pasta apparently was not very popular, and the factory did not do well. Then he worked as a barber and then during World War II he worked at the mines.
During the war, everybody was working at several jobs, and he worked then in what was called the breaker, which was outside mining, selecting good coal versus bad coal. The bad coal became coal slag and forms coal Slag Mountains, on which nothing grows. It is an environmental disaster because as the rain comes down, the silt comes down into the rivers and creeks and destroys plant and fish life.
I remained there until I graduated from high school, and then I went to the University of Alabama in Tuscaloosa because at that time it was very inexpensive, something like $30 a month for room and board. By the time I went into college, I had determined that I wanted to go to medical school. There hadn't been a physician in the family in Italy nor here, but my parents were very supportive and it was a rather daunting prospect because they, at that time, didn't have much money and were not making very much money. It was a time, 1941/42 to 1945/46, during World War II, when my father would have a good year if he made $4,000. But they managed to scrimp and save. And then I worked in college as well as medical school.
Question: Where did you go to medical college?
Dr. Montague: I went to medical school at what was then called the Women's Medical College of Pennsylvania in Philadelphia from 1946/47 to 1949/50. It has since gone into several different names, but it still exists. However, it's no longer just a women's college. Now it's co-ed. It was founded as a women’s medical college in 1850, and I graduated in 1950. They merged with Hahnemann University in 1993 and then became Drexel University College of Medicine in 2002.
It was a wonderful medical school because it was small. We knew everybody. In fact, the faculty would have us for breakfast, lunch and dinner on the weekends, and it was a very close-knit faculty-student body.
Question: The faculty was also just women?
Dr. Montague: No, there were some men, but there were mostly women as heads of departments.
Question: At Iowa now, most of the heads of departments are women.
Dr. Montague: Well, that was a different era when there were not too many women physicians. Anyway, it was a very cloistered type of medical school where we were really sheltered. When I had finished the four years of medical school, I wanted something different. I wanted to be thrown pell-mell into a place where I would have the freedom of perhaps learning on my own and learning with other people.
I decided that I would have to go to a large city hospital for an internship, and at that time the internships were for two years: 1950/51 to 1951/52. The first year was medical, and the second year was surgical. I went to Kings County Hospital in Brooklyn, which was a 3,000-bed city hospital, much like Bellevue in Manhattan, and there we were thrown into the emergency room and the wards. It was a wonderful experience, and I learned, I think, how to take care of people and how to take care of myself in the big city environment.
One day, as I was working in the emergency room, I heard someone who was nearby say, “Oh, I would never marry a woman doctor." And I looked around the curtain and there was Monty claiming that he would never marry a woman doctor. And I looked at him and I said, "It would serve you right if I married you." He was shocked speechless, and so was I. But we developed a friendship, and three or four years later we did get married. And I think he changed his mind about women doctors.
Question: Was he at the same level as you in medical school?
Dr. Montague: Yes. I had decided to go into radiology because I was interested in it and I had thought, too, that if I were to marry, it would be very nice to have a field where I could be home some of the evenings and the nights. I applied to Columbia Presbyterian for the radiology residency for which they accepted one person every three months. My acceptance was for a position nine months ahead, and that was very good because it gave me an opportunity to do nine months of pathology at Kings County Hospital, 1952/53.
It was a wonderful experience, and I almost became a pathologist. I enjoyed the gross anatomy lab and microscopic study. I enjoyed all of pathology. It was exciting because it was the end of the clinical course of a patient, and the answers were all there if you were smart enough to find them. And we had an excellent professor of pathology, and I really had second thoughts about going into radiology.
But the reason I left pathology was that I would have had to leave Kings County to do the full pathology residency, therefore I decided to stay in radiology. So after nine months of pathology I went to Columbia and started the radiology residency, which at that time was two-and-a-third years of diagnostic and then nine months of radiotherapy. The diagnostic part of the residency was exciting, but the radiotherapy part was really fascinating, and the professor at that time was Morton Kligerman, MD.
Question: I didn't know that you trained with Dr. Kligerman.
Dr. Montague: Yes. The combination of Kligerman and the clinical part of radiation oncology convinced me that I would be happier in radiotherapy rather than diagnosis. We didn't have much equipment. At that time it was only orthovoltage. We never saw any gynecological patients. They were taken care of by the gynecologist.
Question: What year was this?
Dr. Montague: This was in 1953.
Question: Over 50 years ago!
Dr. Montague: We did see patients with lymphomas, Hodgkin’s disease, skin and thyroid cancer and an odd assortment of solid tumors.
As I recall, we didn't see too many patients prior to surgery. I never saw a breast patient who hadn't had a mastectomy. We saw them after the mastectomy and generally the surgeons would have said, “Well, we got it all, but just in case, you need a little bit of radiation therapy.”
Question: It hasn’t changed.
Dr. Montague: It hasn't changed. (Laugh) That's why MD Anderson was such an eye-opener. We actually saw some patients ahead of time. But in any event, I was at Columbia for two-and-a-half years (1953-1956) when my husband was inducted into the Air Force. Now, if he hadn't been a physician, he would not have been drafted, as he was classified as 4f because he'd had tuberculosis of the spine and spent all of his childhood in hospitals. But because he was an MD, he was taken into the Air Force and sent to Japan. So I had the choice of finishing the residency or going to Japan, and I decided to go to Japan. And it was a wonderful two years—a wonderful time, 1956-1958. And our first child was born in Japan.
Question: Did you practice at all while you were in Japan?
Dr. Montague: Yes, I did. I was a civil service employee, and I did diagnostic radiology, but no therapy, at the tactical hospital in Fukuoka.
Question: For the Air Force?
Dr. Montague: Yes. I worked for a year. It was an interesting time. The only radiotherapy that I came in contact with was in the Japanese School of Medicine in the city of Fukuoka. The head of therapy was a very nice gentleman, Dr. Irie, and I visited with him several times.
He demonstrated his treatment for tuberculosis using orthovoltage radiation and several other interesting things that they had been doing during and after the war.
I went to a couple of his clinics, and I enjoyed talking to him and to his subservients, and at that time they were really subservient. One didn't argue or discuss much with Professor Irie, but he was really very sweet, very nice and very kind to me.
My husband was very happy to have me working because he was the head of medicine. As the head of medicine, he was also the head of diagnostic radiology, and he was very uncomfortable in that particular chair. So when I got there he said, “I’m glad you're here. Now we can diagnose skull fractures with a reasonable certainty," because all those sutures were very confusing.
It was interesting work, and I enjoyed the Air Force and got paid for it and for the first time in our married life we made some money. As interns we got $50 a month, and as residents we each got $300 a month. That's $600 a month total. Our apartment was $250, and so all the rest was for food, which we bought very quickly on getting our checks. Then at the end of the month when we ran out of food and money, we would go to his mother's to eat dinner. But we enjoyed New York, and it was really a very interesting time.
Upon returning from Japan, we had decided to leave New York City, and we took a trip through the United States looking for a place to settle. The medical center here in Houston was really just beginning (1958), and we were excited by it and decided to come here. I talked to Kligerman about Houston because I still required six months of residency and he said, "There's only one place in Houston for you to finish your residency; that would be with Gilbert Fletcher, MD" So when we moved down, I talked to Dr. Fletcher—this was in 1958—and Fletcher accepted me.
Question: Who was on the staff at that time?
Dr. Montague: There was Lowell Miller, Gordon Johnson, Paul Chau, and I think that Lillian Fuller had just come. Rauol Herrera came shortly afterwards.
Question: Fernando Bloedorn wasn't there?
Dr. Montague: No, he was gone.
Question: When I came in 1960, there were the same people: Lowell Miller, Paul Chao, Hererra, Lillian Fuller and Johnson.
Dr. Montague: Yes. I talked to Fletcher in 1958 when I first came. I hadn't passed the Texas Boards yet. And I had to settle my child and family.
Question: Had you decided you were going to devote your practice to radiation therapy?
Dr. Montague: Yes, I thought so. But I still required three months of diagnosis to complete my residency, and I thought that I would be able to finish that at Anderson, too, which I did with Gerald Dodd.
Question: Dodd was already there?
Dr. Montague: Yes.
Question: But Dr. Fletcher, I think, was the chairman of the whole department, including diagnosis.
Dr. Montague: Yes, that's right, chairman of the entire Radiology department. By that time I was an American Cancer Fellow, and I think they required a year of residency in therapy, and that was fine with me. I had to settle my family. I did have trouble getting household help. I think I drove Fletcher crazy for six months because I kept saying, “Well, I'm probably ready to begin in three months,” and then three months would pass and I would say, “Well, I still haven't passed the Boards, and I'm not quite ready. Another three months.” And he said he had lost some hair because of my inability to make up my mind as to when I was going to finish this residency. But in the long run he was quite patient, and eventually I did finish the year of therapy.
Jerry Dodd, MD, did let me complete the diagnostic part, and interestingly enough, Jerry Dodd asked me if I wanted to be on the diagnostic staff. And somehow facing him, I couldn’t say no. I said, "Well, I'll think about it." But in the meantime Fletcher had asked me also. So they had talked to each other and Fletcher stopped me in the hall one day and said, "What's this? You haven't told Jerry Dodd that you're going to do therapy?" And I said, "Well, I just didn't have the courage to come right out and say it," and he said, "Go back in there and say it." (Laugh) And I said, "All right."
So I told Dr. Dodd that I was going to stay with Fletcher and Dodd was very kind and he said, "Well, I thought that was how it was going to go. So that's how I stayed on the staff, and the rest of my professional life was in radiotherapy.
Question: Were you assigned from the beginning to breast cancer, or was it general?
Dr. Montague: It was general and we rotated around, as I recall, every six months. Fletcher saw every breast cancer patient, including those treated with orthovoltage by the baclesse technique and those who were treated with cobalt.
The postop mastectomy patients were then treated with cesium. I saw the breast patients when I rotated to those machines. Then Herman Suit, MD, arrived and needed some help with his patients; I think he was doing 5FU adjuvant therapy.
Question: There was a 5FU protocol.
Dr. Montague: Yes. Also hyperthermia. Anyway, Fletcher asked if I would like to work with Dr. Suit in those areas and I said, "Well, I'll do anything that you think I should do." About three or four months later, Fletcher said, "Maybe you'd rather do the breast patients.” He didn't say it would be better for Herman too, but I rather thought that it would be. “And then you could help me,” that’s when I began looking at all the breast patients with Fletcher, and I did that for about a year.
Question: This was about 1962?
Dr. Montague: Yes, in 1963, Norah Tapley, MD, came. We started to do chest wall irradiation with the electron beam. Fletcher did a tremendous amount of work in this area. He was always interested in the breast, the head and neck and the GYN patients.
So that was the beginning of the breast program, and the rotation of the staff began to solidify. I think it was Fletcher's idea that every staff member should have an area of interest/expertise. But in the meantime every staff member should rotate every six months to the various machines so that at the end of a couple of years you've rotated through the major sites of cancer. I think it worked very well. While you were rotating you were still expected to see your patients in your specific area once a week, but you didn't lose contact with the other areas.
Question: That's the same way it was all the time when I was there. I imagine it’s different now.
Dr. Montague: Yes, it changed with Peters, MD. At that time we stopped rotating, and we dealt only with the area in which we were involved.
Question: I think it was particularly good for the junior staff because they kept up in all areas. Many of those would go on elsewhere, and they were able to stay in touch and yet gain special expertise.
Dr. Montague: It was wonderful. In the beginning before the staff was given a specific assignment around 1963, the junior staff was left quite alone, and we didn't have much supervision. I do remember that for quite a while we were each doing the radiums by ourselves. Paul Chau, MD, would look at the films, but by the time he looked at the films, the die was cast. Gradually each staff member had a specific site and began to develop good supervision with the other staff. I think that system worked quite well until Fletcher retired.
Question: When did you start seeing all the patients in planning clinic?
Dr. Montague: We were doing it from the beginning. The planning clinic was up on the second floor, and we didn't have much room; maybe ten seats. But the patients would come in, and Fletcher would examine them. Then there would be a discussion and a decision.
Fletcher would also look at the interstitial work, which was quite voluminous at the time. I mean, they were doing a lot of head and neck interstitial treatments, and he would look at every one. So he kept very close tabs in the areas of interest. And that's how the department developed and how we developed.
Question: Now you left them for a while in '68?
Dr. Montague: Yes.
Question: That's just the time I came in, July 1968. I remember going to a party at your house just before you left. We met the first week that I was there.
Dr. Montague: Yes, I went to Baylor because I had to work part-time. I had a particular problem with a child. So I worked part-time at Baylor beginning in 1968 and then returned to Anderson in 1972.
Question: And I think that you were gone about that time also?
Question: Yes, we more or less left about the same time and came back about the same time.
Dr. Montague: And by that time my problems had greatly improved, and I could return to full-time work.
Question: Were you able to cut back much while you were over there?
Dr. Montague: Yes, because for a year I was at Ben Taub Hospital and the VA where we never saw patients pre-operatively. After everybody else got through with whatever treatment they thought the patient should have, then eventually they would come to radiation therapy. So you could manage to do it on a part-time basis. Now, when I went to Methodist on rotation, it was a little bit more difficult because you couldn't leave patients without a supervising physician. And that's ultimately what made me decide to go back to Anderson because I was working longer and longer hours at Methodist, and I thought if I'm going to work these hours, I might just as well go back to Anderson where I enjoyed the practice of radiation oncology more.
At that time we were beginning to see patients with the surgeons prior to the surgery. I'm talking now about the era when we had a number of surgeons who were very willing to have consultation with the radiotherapist before they even biopsied the lesion.
The other thing that interested me was that I had done some work for the NSABP and Bernie Fisher, MD, prior to going to Baylor, and it was a very interesting study.
That was the BO4 protocol, which randomized operable patients to either radical mastectomy, simple mastectomy or simple mastectomy and radiation. And we were just beginning to develop the protocol, and I was hoping that MD Anderson could join that protocol. Baylor would not join. I had talked to Fletcher about joining the NSABP.
Question: Were the surgeons interested?
Dr. Montague: There was no interest in randomizing patients.
Now, George Brown, MD, who had been at Anderson working in the breast area, had done good work discussing the protocol with Dr. Fisher, and they had already outlined the simple mastectomy - radiation therapy protocols.
Then he left, and I went back to Anderson trying to develop the protocol and interest our surgeons into joining it. They were not interested. Since the 1960s they were already doing simple mastectomy and radiation therapy for patients with more advanced disease; stage III.
Also included in this group were the patients who were TxNx because of unknown stage. They had been biopsied before they were referred to us.
Our surgeons were already accepting the locally advanced patients for simple mastectomy (which became extended simply if they had clinically positive nodes) and radiation therapy. So we never did get any interest amongst our surgeons to join into the protocol. By that time it didn't matter because there were 27 other institutions that were participating.
Question: What about the famous white paper that Fletcher wrote? I think he had a big confrontation with the surgeons.
Dr. Montague: He had several. In fact, I talked to Fisher last week, and he still remembers some of the arguments that he had with Fletcher. (Laugh) They never saw eye-to-eye on the use of postoperative radiation. And there were arguments on both sides.
Of course, Fletcher by that time had a lot of data on patients with negative nodes, one to three positive nodes or four or more positive nodes. He demonstrated that in the MD Anderson patients with four or more positive nodes; the local regional recurrence rate was about one-third of what the NSABP had with simple mastectomy alone. But they never really completely agreed that postoperative radiotherapy was necessary.
This was the era before the tylectomy or segmental/partial mastectomy. This was the radical mastectomy versus simple mastectomy versus simple mastectomy and radiation therapy. Interestingly enough, the 30-year results were in the New England Journal of Medicine about four or five months ago. And in all three groups the local regional recurrences are different, certainly, but all three survival curves are superimposed on each other.
Question: One of the residents where I am now just presented that paper in one of our conferences.
Dr. Montague: Yes, it's an interesting study. I think Fletcher was disappointed that we didn't join the study because we could have contributed a great many patients. But he was not happy with the fact that some of the simple mastectomies were done without any radiation therapy. But of course that was the biologic interest of Fisher and his committee. They figured that they would learn something about the biology of breast cancer if one-third of the patients who were treated with simple mastectomy were left unirradiated.
Question: As I recall, there was concern that the radiation therapy would not have been adequate.
Dr. Montague: Yes.
Question: That's why you and George Brown did a lot of traveling. To make sure that every place did the irradiation correctly.
Dr. Montague: We did, and one thing you have to say about Fisher was that he agreed that when we found some egregious problem than those institutions would be eliminated from the study. I think he was very brave.
He was courageous because he agreed to do this. For instance, we had someone who was treating all breast cancer patients standingup. There was no way that we could corroborate some of the fields that were used, so the NSABP Board said that for problems like this (where we were really up a creek,) they would be eliminated from the study.
So that made it a little bit more manageable, but Brown and I and the outreach physics staff went everywhere. We looked at every institution that had joined that study. So by the time the study ended, I do think that the treatment technique had gelled a bit.
The only problem was in the axilla as I recall. The internal mammary chain didn't bother us much because two-thirds of the patients weren't getting treatment to it anyway, and we figured that we'd never know how important it was (laugh), and we still don't know. But the axilla was the big question mark. Is the axilla being adequately treated?
Because if there were positive nodes in the axilla, one was supposed to give a boost. So there were some questions relating to the axilla. But all in all, it was a good study, and it was the first really good, I think, randomized study of patients with breast cancer. The earlier study with postop therapy didn't have any kind of radiotherapy control, nor did we know exactly who was getting the postop therapy. In some of that early data, only the people who had the more advanced disease got the postop therapy, so the results as far as survival is concerned would be expected to be very poor in that group. In fact, Fisher had reported on the increased mortality in patients who had received postop therapy. That made Fletcher and most radiotherapists really rabid because there was no control on who was given the postop irradiation. The postop therapy was not controlled.
But I think the simple mastectomy study was good. Anyway, the BO4 study, showed that radiation therapy could control disease on the chest wall in a great majority of patients, even in the axilla, where the recurrence was six percent, and the superclav area. We never got any recurrences there, and more interest began to develop in saving the breast amongst this same group. And that's how the BO6 study got started.
Question: Was that generated in the United States, or was it just because of the data that was coming in from France?
Dr. Montague: It was also generated by what was going on in the United States. And it was to a large degree what was happening in the BO4 study. I mean, for the first time, surgeons who might have been skeptical about the use of radiation could see that the irradiated patients had very few recurrences even in a positive axilla.
And it was a gradual development from the BO4 to get to the BO6 study, and then I do think that the data coming from other institutions, including ours, was beginning to demonstrate that you didn't have to remove everybody's breast. And, of course, the Italians already had a randomized trial. Their surgery was a bit more radical but nevertheless of interest.
Question: Did you want to go ahead and talk about the conservative treatment. Did you finish that?
Dr. Montague: I think so. You know, by 1972, '76, '78 we already had accumulated a number of patients treated with radiotherapy without removing the breast, and the NSABP was interested in developing a protocol.
Question: I'd be somewhat interested in the Baclesse technique - how that came about - and your impressions of its efficacy and so forth.
Dr. Montague: Of course, Fletcher was very interested because he had actually seen patients treated by Baclesse in France when he visited there. He often made the statement that Baclesse told him that the most important thing in radiotherapy was to stay in one place. He said that was the only way that you're going to find out how you're doing and what complications you're going to have. And this resulted in Fletcher's famous statement that “a good way to avoid complications is to move from place to place” because you never saw them. And apparently Baclesse had his share of some complications, but it was the only way of treating these patients with very far advanced breast cancer.
So Fletcher brought back from France Baclesse’s treatment, which was done with orthovoltage over a twelve-week period of time. We used to say that one good way of staging patients was that if they survived their treatment, they were an earlier stage than what you had postulated. Because so many of them were disturbed breasts that had already been biopsied, we really didn't know what stage they were. But twelve weeks of treatment plus another two or three weeks of a boost was a long treatment.
Question: I remember once Kligerman telling me that if you're a radiotherapist you had to be a rugged individualist. You really had to be able to put up with those complications.
Dr. Montague: Yes, the complications were severe. After you follow patients for a long period of time, you get to know them and suffer the complications. I still remember the chest wall necroses and the fact that nobody would touch them. Nowadays I think there are things that we could have done.
We had McMurtry, MD, who was a very good chest surgeon. When he came, he did tackle some of the necroses, and he would do chest wall eradication and then put in a mesh or pedicle, and some of them we did get to heal. But it was an era of attempting to see how much dose you could get by with, how much dose would control the tumor.
It was only after looking at some of the complications that we decided that by far the best effort would be to try to surgically remove the gross disease at the primary site, and even in the axilla first, and then treat with radiotherapy because you could then limit the radiation therapy to 5,000 plus a boost. That was a reasonable approach. I've forgotten when we stopped the Baclesse technique.
Question: It seemed that it was supplanted, I guess, by the simple (toilet) mastectomy.
Dr. Montague: Yes, exactly. Our surgeons were told not to make the flaps too thin and never to use a skin graft. I mean, this was far advanced disease. They were to leave thick flaps that would heal in two or three weeks and then could be followed by moderate doses of radiation. And in the beginning, we would leave the positive nodes and then at the end of 5,000 rads to the chest wall we'd give more boosts into the axilla. We had a couple of axillary necroses, and they are hard to deal with.
So after a few years we decided to do a low axillary dissection, removing the big nodes, and then we'll add radiation therapy.
And the advantage, of course, is that the results are good as far as local regional control, and the cosmetic results were good. The necroses were then very rare.
We also began to do interstitial implants of the scar because it was the scar that required the boost. Of course, by that time we had electron beam too, and so we used whatever we could and was appropriate.
Question: You didn't seem to be as much a champion of implants, though, as Sam Hellman was?
Dr. Montague: No. And of course this treatment was for far advanced disease.
The results were excellent and local-regional control was really very good. As I recall we had less than 10 percent failure on the chest wall which, when you consider that you're getting by with 5,000 rads plus a boost, is good.
And the axilla was well controlled and with the superclav areas we very rarely had any recurrences. And we actually had only one internal mammary chain recurrence in this patient group. We put all of this data into the computer. When did we start? I guess in the 1970s.
Norah Tapley did all the post radical mastectomy patients, and I did all the other ones. So we entered an era where we could actually look back and pick out any group of patients we wanted to. And that's when we also started to analyze the excision biopsies.
Question: Do you have any thoughts or comments you want to make about the internal mammary area and the controversies regarding the need for treating the internal mammary nodes? I'm thinking now about Jay Harris who wrote an editorial called "Let's put the hockey stick on ice.” I know there was some controversy when Fletcher was a visiting professor at Harvard and pointed out to Sam Hellman that at Anderson they were covering internal mammary nodes as well.
Dr. Montague: Right. Fletcher always felt that you either had to angle the medial tangent inferiorly (towards the floor) 10 degrees in order to get the internal mammary chain. Or better yet, have a separate internal mammary chain (IMC) field because then he said you could not miss it. We did a lot with cobalt and then with the electron beam or a combination of both.
Question: Fletcher thought it was the key to improved survival as I recall.
Dr. Montague: Yes, that's right. And the results at MD Anderson were excellent, even with four or more positive nodes. One other advantage in treating the IMC is for the opposite axilla- a very common failure site in patients with heavy lymphatic infestation in the chest wall that’s very frequent, and when I looked it up, I found that 30 percent of the first failures were in the opposite axilla in patients who did not get internal mammary chain irradiation.
And I think the lymphatic’s become increasingly important in patients with heavy tumor infestation. I think that would be an interesting thing to review again now that there would be more patients. When Norah and I looked at it, the opposite axilla was rarely a failure site as the first failure in patients who had internal mammary chain irradiation in stage III cancer. Now, whether that was also due to the fact that these patients were treated to the chest wall (so that you were treating the lymphatic’s of the chest wall), we could never tell because we never treated just the chest wall alone. We always treated the internal mammary and the chest wall. It's an interesting speculation, but I know that Fletcher felt that it was the internal mammary chain that was the important site.
Question: You had a group that you treated only the first couple of interspaces.
Dr. Montague: Yes, the more recent ones were treated to only the first three interspaces. And I don't think we've answered that question yet. But the time for doing this is probably gone. There are more urgent questions than going back and treating the internal mammary chain. I think we could have done a good study in the late '60s and early '70s, but we didn't, and nobody else did it. I just don't think we can answer that question. It remains a mystery.
Question: Would you comment about your appearance on “Nightline” with Ted Koppel and Jerry Urban, MD, from MSK?
Dr. Montague: It was in 1985, I think. Well, that was about the time that the early studies on BO6, the segmental mastectomy protocol, were coming out. The important part of that interview was disseminating information that the study was accomplished. This was a very hard study to get the surgeons to do, even in the NSABP. It took a lot of arguing. It took Bernie Fisher a number of years of trying to convince his surgeons to do this very conservative surgery. The surgery in that study was much more conservative than Veronesi’s study. I mean, Veronesi removed a whole quadrant of the breast. Bernie Fisher just wanted negative margins, so it took a lot of effort for him to get them to agree to do minimal surgery, a lumpectomy. And the fact that the study was even accomplished, I thought, was a major success.
Because then you could follow the patients and really learn how many of them needed radiation, which subgroup did not need it and which ones required it. And then, of course, by that time we were also looking at the noninvasive intraductal (IN SITU) patients. We already had some patients treated with radiotherapy to just the breast and not the peripheral lymphatics. So as an offshoot of the segmental mastectomy protocol, we were already looking into what happens if you treat patients with noninvasive (IN SITU) cancer with radiation therapy. How many of those would recur after irradiation, and how many would recur without the radiation therapy?
These are interesting biological questions. It was not so much that you're a radiotherapist so you want to use radiotherapy but rather that you are a breast cancer researcher and you want to know some of the answers. So that was the pitch that I was trying to make with Jerry Urban, MD. The fact was that he could continue doing his radical mastectomies forever, and he'd never learn anything about breast cancer. It took him 25 years to find out he could save the pectoralis muscle. He was really an advocate of the really radical mastectomy.
Question: Didn't he split the sternum?
Dr. Montague: Yes, that too, although he had stopped doing it by 1985. But it was a basic question; are you interested in breast cancer or are you interested in promulgating your own specialty? It seemed to me that the BO6 study was a very important study.
And I think that, in retrospect, so will the intraductal study be important. You know, the intraductal carcinoma has a very low recurrence rate with radiotherapy, whereas without radiotherapy it was about a quarter of the patients. I don't know where it is now. Anyway, so the pitch wasn't so much you've got to stop doing a radical mastectomy on everybody; the pitch was do something that's scientifically interesting by which you will learn something about the biology of breast cancer. And I think that the NSABP studies have done that.
Question: Bernie Fisher was given honorary membership in ASTRO two years ago. I know that in his acceptance speech he commented about working with you in those earlier years.
Dr. Montague: I talk to him occasionally every few weeks or so because I'm very fond of his wife, Shirley, and of Bernie, too, and they've been very dear friends. I give him all the credit for convincing many surgeons and presenting them with the protocol and saying to them, 'This is the protocol that we're going to follow.' That takes guts. (Laugh)
Question: What of the people that he was battling at that time?
Dr. Montague: As you know he suffered a great deal because it was discovered that one of the Canadian surgeons didn't follow the protocol. Then Dr. Fisher was actually fired from the University of Pittsburgh, and the NCI didn't back him up.
Question: That was one of the reasons, I think, for ASTRO giving him the honorary membership. Radiation oncologists have appreciated what he has done and his contributions in breast cancer management. What about the future? What do you see? Any directions? I'd be interested in your thoughts and questions as well about the “mammosite:” a balloon that they fill up and put a source in the center of to irradiate the surgical bed after lumpectomy.
Question: As an adjuvant to a conservative resection?
Dr. Montague: Yes, and some therapists want to do that as the only treatment.
Question: I worry a little bit about disease elsewhere in the breast and the length of time for follow up. Do you use the “mammosite,” Dr. Maor?
Question: We haven't done it yet. Actually the company is pushing this technique also for use in the brain of all places.
Question: They market it heavily in San Antonio.
Dr. Montague: Do they really?
Question: And I just worry about the dose distribution. It doesn't seem to me that the physics is too good with this technique.
Question: You know, I haven't been enchanted by balloons because I can see so many problems with balloons. I mean, a balloon is efficient if you have a source right in the center of a spherical or hemispherical geometric center. They have tried that in the bladder. I recall in Manchester that they did try to treat the bladder with a balloon.
Question: Well, a lot of people are pushing it for a quick fix, and you don't have to have six weeks of treatment and so forth.
Question: Is there any more you want to add, or is there anything you want to ask?
Dr. Montague: No, I have talked too much.
Question: I think it was superb.
Dr. Montague: Well, it was an interesting time. You know, in retrospect I'm so grateful to Fletcher because I think he could see in his mind the development of radiation and radiotherapists.
Question: He saw the big picture.
Dr. Montague: He certainly did.
Question: That is one thing that has come out on all these tapes. I've interviewed Luis Delclos, Bob Lindberg, Sey Levitt and you. I would expect all of you to be very positive on Fletcher. But then others that have been interviewed, Sam Hellman and Herman Suit, were also very complimentary of Fletcher.
Dr. Montague: Fletcher had an uncanny way of making complex problems look simple. In the beginning you would think, 'Oh my God, we'll never get through this,' but then as you worked it down, you saw that his message really was a simple one, but he had a very intricate mind.
Question: When did chemotherapy start to be a player in the initial or in preoperative . . . in the initial treatment of breast cancer? Rather than in an adjuvant . . .
Dr. Montague: I think at Anderson it came very quickly. It started primarily with the advanced disease because they were trying to make advanced disease more operable, and that was a worthy thing to do. But then, of course, with Dr. Bonadonna, adjuvant chemotherapy took on a life of its own.
The chemotherapy came on very quickly, and I can't remember exactly, but it seems to me as though it was in the early ’80s that they really began to push the chemotherapy. And then gradually they began to give it earlier and earlier, and now they're giving the chemotherapy after the surgery and then adding the radiation therapy later.
Question: Although the trial between when to give what in terms of radiation and chemotherapy was a toss-up. I mean, the results were equal both in terms of distant mets and in terms of local control.
Question: Well, Eleanor, thank you.
Dr. Montague: Oh, my pleasure.
In 2003, 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 in Dr. Montague’s apartment in Houston on March 11, 2003.
Question: Good afternoon. This is Dave Hussey. I'm a member of the History Committee for ASTRO as is Moshe Maor. We're here with Dr. Delclos interviewing Dr. Montague today. It's Tuesday the 11th of March, 2003, and we're in Montague's apartment in Houston. And Eleanor, what we're trying to do today is to get an idea of two things: one, your own personal history of where you were born, more about your family, your education, why you came to work at MD Anderson and so forth, but in addition to that, in addition to your accomplishments, we're interested in your perceptions of how the field of radiation oncology and breast cancer developed during the time you were involved in that area. And the three of us will all ask questions.
Question: But I think what we might do is just start out and let you have a little bit of a soliloquy telling us about where you were born, your family, how you got into medicine, how you got into radiation oncology and how you met Monty and so forth.
Dr. Montague: I was born Eleanor Dino in Genoa, Italy, on February 11, 1926. I was an only child, and my father had served in the Italian Army during World War I and had been wounded and remained in the army. When Mussolini came to power, he decided that it was time for him to leave Italy and Mussolini and to come to the United States.
So I was in elementary school when we came and for some reason, I think for business reasons, he went to a very small coal mining town in northeastern Pennsylvania, very close to the New York border, where anthracite mining was the main industry. He started a pasta factory and, at that time, pasta apparently was not very popular, and the factory did not do well. Then he worked as a barber and then during World War II he worked at the mines.
During the war, everybody was working at several jobs, and he worked then in what was called the breaker, which was outside mining, selecting good coal versus bad coal. The bad coal became coal slag and forms coal Slag Mountains, on which nothing grows. It is an environmental disaster because as the rain comes down, the silt comes down into the rivers and creeks and destroys plant and fish life.
I remained there until I graduated from high school, and then I went to the University of Alabama in Tuscaloosa because at that time it was very inexpensive, something like $30 a month for room and board. By the time I went into college, I had determined that I wanted to go to medical school. There hadn't been a physician in the family in Italy nor here, but my parents were very supportive and it was a rather daunting prospect because they, at that time, didn't have much money and were not making very much money. It was a time, 1941/42 to 1945/46, during World War II, when my father would have a good year if he made $4,000. But they managed to scrimp and save. And then I worked in college as well as medical school.
Question: Where did you go to medical college?
Dr. Montague: I went to medical school at what was then called the Women's Medical College of Pennsylvania in Philadelphia from 1946/47 to 1949/50. It has since gone into several different names, but it still exists. However, it's no longer just a women's college. Now it's co-ed. It was founded as a women’s medical college in 1850, and I graduated in 1950. They merged with Hahnemann University in 1993 and then became Drexel University College of Medicine in 2002.
It was a wonderful medical school because it was small. We knew everybody. In fact, the faculty would have us for breakfast, lunch and dinner on the weekends, and it was a very close-knit faculty-student body.
Question: The faculty was also just women?
Dr. Montague: No, there were some men, but there were mostly women as heads of departments.
Question: At Iowa now, most of the heads of departments are women.
Dr. Montague: Well, that was a different era when there were not too many women physicians. Anyway, it was a very cloistered type of medical school where we were really sheltered. When I had finished the four years of medical school, I wanted something different. I wanted to be thrown pell-mell into a place where I would have the freedom of perhaps learning on my own and learning with other people.
I decided that I would have to go to a large city hospital for an internship, and at that time the internships were for two years: 1950/51 to 1951/52. The first year was medical, and the second year was surgical. I went to Kings County Hospital in Brooklyn, which was a 3,000-bed city hospital, much like Bellevue in Manhattan, and there we were thrown into the emergency room and the wards. It was a wonderful experience, and I learned, I think, how to take care of people and how to take care of myself in the big city environment.
One day, as I was working in the emergency room, I heard someone who was nearby say, “Oh, I would never marry a woman doctor." And I looked around the curtain and there was Monty claiming that he would never marry a woman doctor. And I looked at him and I said, "It would serve you right if I married you." He was shocked speechless, and so was I. But we developed a friendship, and three or four years later we did get married. And I think he changed his mind about women doctors.
Question: Was he at the same level as you in medical school?
Dr. Montague: Yes. I had decided to go into radiology because I was interested in it and I had thought, too, that if I were to marry, it would be very nice to have a field where I could be home some of the evenings and the nights. I applied to Columbia Presbyterian for the radiology residency for which they accepted one person every three months. My acceptance was for a position nine months ahead, and that was very good because it gave me an opportunity to do nine months of pathology at Kings County Hospital, 1952/53.
It was a wonderful experience, and I almost became a pathologist. I enjoyed the gross anatomy lab and microscopic study. I enjoyed all of pathology. It was exciting because it was the end of the clinical course of a patient, and the answers were all there if you were smart enough to find them. And we had an excellent professor of pathology, and I really had second thoughts about going into radiology.
But the reason I left pathology was that I would have had to leave Kings County to do the full pathology residency, therefore I decided to stay in radiology. So after nine months of pathology I went to Columbia and started the radiology residency, which at that time was two-and-a-third years of diagnostic and then nine months of radiotherapy. The diagnostic part of the residency was exciting, but the radiotherapy part was really fascinating, and the professor at that time was Morton Kligerman, MD.
Question: I didn't know that you trained with Dr. Kligerman.
Dr. Montague: Yes. The combination of Kligerman and the clinical part of radiation oncology convinced me that I would be happier in radiotherapy rather than diagnosis. We didn't have much equipment. At that time it was only orthovoltage. We never saw any gynecological patients. They were taken care of by the gynecologist.
Question: What year was this?
Dr. Montague: This was in 1953.
Question: Over 50 years ago!
Dr. Montague: We did see patients with lymphomas, Hodgkin’s disease, skin and thyroid cancer and an odd assortment of solid tumors.
As I recall, we didn't see too many patients prior to surgery. I never saw a breast patient who hadn't had a mastectomy. We saw them after the mastectomy and generally the surgeons would have said, “Well, we got it all, but just in case, you need a little bit of radiation therapy.”
Question: It hasn’t changed.
Dr. Montague: It hasn't changed. (Laugh) That's why MD Anderson was such an eye-opener. We actually saw some patients ahead of time. But in any event, I was at Columbia for two-and-a-half years (1953-1956) when my husband was inducted into the Air Force. Now, if he hadn't been a physician, he would not have been drafted, as he was classified as 4f because he'd had tuberculosis of the spine and spent all of his childhood in hospitals. But because he was an MD, he was taken into the Air Force and sent to Japan. So I had the choice of finishing the residency or going to Japan, and I decided to go to Japan. And it was a wonderful two years—a wonderful time, 1956-1958. And our first child was born in Japan.
Question: Did you practice at all while you were in Japan?
Dr. Montague: Yes, I did. I was a civil service employee, and I did diagnostic radiology, but no therapy, at the tactical hospital in Fukuoka.
Question: For the Air Force?
Dr. Montague: Yes. I worked for a year. It was an interesting time. The only radiotherapy that I came in contact with was in the Japanese School of Medicine in the city of Fukuoka. The head of therapy was a very nice gentleman, Dr. Irie, and I visited with him several times.
He demonstrated his treatment for tuberculosis using orthovoltage radiation and several other interesting things that they had been doing during and after the war.
I went to a couple of his clinics, and I enjoyed talking to him and to his subservients, and at that time they were really subservient. One didn't argue or discuss much with Professor Irie, but he was really very sweet, very nice and very kind to me.
My husband was very happy to have me working because he was the head of medicine. As the head of medicine, he was also the head of diagnostic radiology, and he was very uncomfortable in that particular chair. So when I got there he said, “I’m glad you're here. Now we can diagnose skull fractures with a reasonable certainty," because all those sutures were very confusing.
It was interesting work, and I enjoyed the Air Force and got paid for it and for the first time in our married life we made some money. As interns we got $50 a month, and as residents we each got $300 a month. That's $600 a month total. Our apartment was $250, and so all the rest was for food, which we bought very quickly on getting our checks. Then at the end of the month when we ran out of food and money, we would go to his mother's to eat dinner. But we enjoyed New York, and it was really a very interesting time.
Upon returning from Japan, we had decided to leave New York City, and we took a trip through the United States looking for a place to settle. The medical center here in Houston was really just beginning (1958), and we were excited by it and decided to come here. I talked to Kligerman about Houston because I still required six months of residency and he said, "There's only one place in Houston for you to finish your residency; that would be with Gilbert Fletcher, MD" So when we moved down, I talked to Dr. Fletcher—this was in 1958—and Fletcher accepted me.
Question: Who was on the staff at that time?
Dr. Montague: There was Lowell Miller, Gordon Johnson, Paul Chau, and I think that Lillian Fuller had just come. Rauol Herrera came shortly afterwards.
Question: Fernando Bloedorn wasn't there?
Dr. Montague: No, he was gone.
Question: When I came in 1960, there were the same people: Lowell Miller, Paul Chao, Hererra, Lillian Fuller and Johnson.
Dr. Montague: Yes. I talked to Fletcher in 1958 when I first came. I hadn't passed the Texas Boards yet. And I had to settle my child and family.
Question: Had you decided you were going to devote your practice to radiation therapy?
Dr. Montague: Yes, I thought so. But I still required three months of diagnosis to complete my residency, and I thought that I would be able to finish that at Anderson, too, which I did with Gerald Dodd.
Question: Dodd was already there?
Dr. Montague: Yes.
Question: But Dr. Fletcher, I think, was the chairman of the whole department, including diagnosis.
Dr. Montague: Yes, that's right, chairman of the entire Radiology department. By that time I was an American Cancer Fellow, and I think they required a year of residency in therapy, and that was fine with me. I had to settle my family. I did have trouble getting household help. I think I drove Fletcher crazy for six months because I kept saying, “Well, I'm probably ready to begin in three months,” and then three months would pass and I would say, “Well, I still haven't passed the Boards, and I'm not quite ready. Another three months.” And he said he had lost some hair because of my inability to make up my mind as to when I was going to finish this residency. But in the long run he was quite patient, and eventually I did finish the year of therapy.
Jerry Dodd, MD, did let me complete the diagnostic part, and interestingly enough, Jerry Dodd asked me if I wanted to be on the diagnostic staff. And somehow facing him, I couldn’t say no. I said, "Well, I'll think about it." But in the meantime Fletcher had asked me also. So they had talked to each other and Fletcher stopped me in the hall one day and said, "What's this? You haven't told Jerry Dodd that you're going to do therapy?" And I said, "Well, I just didn't have the courage to come right out and say it," and he said, "Go back in there and say it." (Laugh) And I said, "All right."
So I told Dr. Dodd that I was going to stay with Fletcher and Dodd was very kind and he said, "Well, I thought that was how it was going to go. So that's how I stayed on the staff, and the rest of my professional life was in radiotherapy.
Question: Were you assigned from the beginning to breast cancer, or was it general?
Dr. Montague: It was general and we rotated around, as I recall, every six months. Fletcher saw every breast cancer patient, including those treated with orthovoltage by the baclesse technique and those who were treated with cobalt.
The postop mastectomy patients were then treated with cesium. I saw the breast patients when I rotated to those machines. Then Herman Suit, MD, arrived and needed some help with his patients; I think he was doing 5FU adjuvant therapy.
Question: There was a 5FU protocol.
Dr. Montague: Yes. Also hyperthermia. Anyway, Fletcher asked if I would like to work with Dr. Suit in those areas and I said, "Well, I'll do anything that you think I should do." About three or four months later, Fletcher said, "Maybe you'd rather do the breast patients.” He didn't say it would be better for Herman too, but I rather thought that it would be. “And then you could help me,” that’s when I began looking at all the breast patients with Fletcher, and I did that for about a year.
Question: This was about 1962?
Dr. Montague: Yes, in 1963, Norah Tapley, MD, came. We started to do chest wall irradiation with the electron beam. Fletcher did a tremendous amount of work in this area. He was always interested in the breast, the head and neck and the GYN patients.
So that was the beginning of the breast program, and the rotation of the staff began to solidify. I think it was Fletcher's idea that every staff member should have an area of interest/expertise. But in the meantime every staff member should rotate every six months to the various machines so that at the end of a couple of years you've rotated through the major sites of cancer. I think it worked very well. While you were rotating you were still expected to see your patients in your specific area once a week, but you didn't lose contact with the other areas.
Question: That's the same way it was all the time when I was there. I imagine it’s different now.
Dr. Montague: Yes, it changed with Peters, MD. At that time we stopped rotating, and we dealt only with the area in which we were involved.
Question: I think it was particularly good for the junior staff because they kept up in all areas. Many of those would go on elsewhere, and they were able to stay in touch and yet gain special expertise.
Dr. Montague: It was wonderful. In the beginning before the staff was given a specific assignment around 1963, the junior staff was left quite alone, and we didn't have much supervision. I do remember that for quite a while we were each doing the radiums by ourselves. Paul Chau, MD, would look at the films, but by the time he looked at the films, the die was cast. Gradually each staff member had a specific site and began to develop good supervision with the other staff. I think that system worked quite well until Fletcher retired.
Question: When did you start seeing all the patients in planning clinic?
Dr. Montague: We were doing it from the beginning. The planning clinic was up on the second floor, and we didn't have much room; maybe ten seats. But the patients would come in, and Fletcher would examine them. Then there would be a discussion and a decision.
Fletcher would also look at the interstitial work, which was quite voluminous at the time. I mean, they were doing a lot of head and neck interstitial treatments, and he would look at every one. So he kept very close tabs in the areas of interest. And that's how the department developed and how we developed.
Question: Now you left them for a while in '68?
Dr. Montague: Yes.
Question: That's just the time I came in, July 1968. I remember going to a party at your house just before you left. We met the first week that I was there.
Dr. Montague: Yes, I went to Baylor because I had to work part-time. I had a particular problem with a child. So I worked part-time at Baylor beginning in 1968 and then returned to Anderson in 1972.
Question: And I think that you were gone about that time also?
Question: Yes, we more or less left about the same time and came back about the same time.
Dr. Montague: And by that time my problems had greatly improved, and I could return to full-time work.
Question: Were you able to cut back much while you were over there?
Dr. Montague: Yes, because for a year I was at Ben Taub Hospital and the VA where we never saw patients pre-operatively. After everybody else got through with whatever treatment they thought the patient should have, then eventually they would come to radiation therapy. So you could manage to do it on a part-time basis. Now, when I went to Methodist on rotation, it was a little bit more difficult because you couldn't leave patients without a supervising physician. And that's ultimately what made me decide to go back to Anderson because I was working longer and longer hours at Methodist, and I thought if I'm going to work these hours, I might just as well go back to Anderson where I enjoyed the practice of radiation oncology more.
At that time we were beginning to see patients with the surgeons prior to the surgery. I'm talking now about the era when we had a number of surgeons who were very willing to have consultation with the radiotherapist before they even biopsied the lesion.
The other thing that interested me was that I had done some work for the NSABP and Bernie Fisher, MD, prior to going to Baylor, and it was a very interesting study.
That was the BO4 protocol, which randomized operable patients to either radical mastectomy, simple mastectomy or simple mastectomy and radiation. And we were just beginning to develop the protocol, and I was hoping that MD Anderson could join that protocol. Baylor would not join. I had talked to Fletcher about joining the NSABP.
Question: Were the surgeons interested?
Dr. Montague: There was no interest in randomizing patients.
Now, George Brown, MD, who had been at Anderson working in the breast area, had done good work discussing the protocol with Dr. Fisher, and they had already outlined the simple mastectomy - radiation therapy protocols.
Then he left, and I went back to Anderson trying to develop the protocol and interest our surgeons into joining it. They were not interested. Since the 1960s they were already doing simple mastectomy and radiation therapy for patients with more advanced disease; stage III.
Also included in this group were the patients who were TxNx because of unknown stage. They had been biopsied before they were referred to us.
Our surgeons were already accepting the locally advanced patients for simple mastectomy (which became extended simply if they had clinically positive nodes) and radiation therapy. So we never did get any interest amongst our surgeons to join into the protocol. By that time it didn't matter because there were 27 other institutions that were participating.
Question: What about the famous white paper that Fletcher wrote? I think he had a big confrontation with the surgeons.
Dr. Montague: He had several. In fact, I talked to Fisher last week, and he still remembers some of the arguments that he had with Fletcher. (Laugh) They never saw eye-to-eye on the use of postoperative radiation. And there were arguments on both sides.
Of course, Fletcher by that time had a lot of data on patients with negative nodes, one to three positive nodes or four or more positive nodes. He demonstrated that in the MD Anderson patients with four or more positive nodes; the local regional recurrence rate was about one-third of what the NSABP had with simple mastectomy alone. But they never really completely agreed that postoperative radiotherapy was necessary.
This was the era before the tylectomy or segmental/partial mastectomy. This was the radical mastectomy versus simple mastectomy versus simple mastectomy and radiation therapy. Interestingly enough, the 30-year results were in the New England Journal of Medicine about four or five months ago. And in all three groups the local regional recurrences are different, certainly, but all three survival curves are superimposed on each other.
Question: One of the residents where I am now just presented that paper in one of our conferences.
Dr. Montague: Yes, it's an interesting study. I think Fletcher was disappointed that we didn't join the study because we could have contributed a great many patients. But he was not happy with the fact that some of the simple mastectomies were done without any radiation therapy. But of course that was the biologic interest of Fisher and his committee. They figured that they would learn something about the biology of breast cancer if one-third of the patients who were treated with simple mastectomy were left unirradiated.
Question: As I recall, there was concern that the radiation therapy would not have been adequate.
Dr. Montague: Yes.
Question: That's why you and George Brown did a lot of traveling. To make sure that every place did the irradiation correctly.
Dr. Montague: We did, and one thing you have to say about Fisher was that he agreed that when we found some egregious problem than those institutions would be eliminated from the study. I think he was very brave.
He was courageous because he agreed to do this. For instance, we had someone who was treating all breast cancer patients standingup. There was no way that we could corroborate some of the fields that were used, so the NSABP Board said that for problems like this (where we were really up a creek,) they would be eliminated from the study.
So that made it a little bit more manageable, but Brown and I and the outreach physics staff went everywhere. We looked at every institution that had joined that study. So by the time the study ended, I do think that the treatment technique had gelled a bit.
The only problem was in the axilla as I recall. The internal mammary chain didn't bother us much because two-thirds of the patients weren't getting treatment to it anyway, and we figured that we'd never know how important it was (laugh), and we still don't know. But the axilla was the big question mark. Is the axilla being adequately treated?
Because if there were positive nodes in the axilla, one was supposed to give a boost. So there were some questions relating to the axilla. But all in all, it was a good study, and it was the first really good, I think, randomized study of patients with breast cancer. The earlier study with postop therapy didn't have any kind of radiotherapy control, nor did we know exactly who was getting the postop therapy. In some of that early data, only the people who had the more advanced disease got the postop therapy, so the results as far as survival is concerned would be expected to be very poor in that group. In fact, Fisher had reported on the increased mortality in patients who had received postop therapy. That made Fletcher and most radiotherapists really rabid because there was no control on who was given the postop irradiation. The postop therapy was not controlled.
But I think the simple mastectomy study was good. Anyway, the BO4 study, showed that radiation therapy could control disease on the chest wall in a great majority of patients, even in the axilla, where the recurrence was six percent, and the superclav area. We never got any recurrences there, and more interest began to develop in saving the breast amongst this same group. And that's how the BO6 study got started.
Question: Was that generated in the United States, or was it just because of the data that was coming in from France?
Dr. Montague: It was also generated by what was going on in the United States. And it was to a large degree what was happening in the BO4 study. I mean, for the first time, surgeons who might have been skeptical about the use of radiation could see that the irradiated patients had very few recurrences even in a positive axilla.
And it was a gradual development from the BO4 to get to the BO6 study, and then I do think that the data coming from other institutions, including ours, was beginning to demonstrate that you didn't have to remove everybody's breast. And, of course, the Italians already had a randomized trial. Their surgery was a bit more radical but nevertheless of interest.
Question: Did you want to go ahead and talk about the conservative treatment. Did you finish that?
Dr. Montague: I think so. You know, by 1972, '76, '78 we already had accumulated a number of patients treated with radiotherapy without removing the breast, and the NSABP was interested in developing a protocol.
Question: I'd be somewhat interested in the Baclesse technique - how that came about - and your impressions of its efficacy and so forth.
Dr. Montague: Of course, Fletcher was very interested because he had actually seen patients treated by Baclesse in France when he visited there. He often made the statement that Baclesse told him that the most important thing in radiotherapy was to stay in one place. He said that was the only way that you're going to find out how you're doing and what complications you're going to have. And this resulted in Fletcher's famous statement that “a good way to avoid complications is to move from place to place” because you never saw them. And apparently Baclesse had his share of some complications, but it was the only way of treating these patients with very far advanced breast cancer.
So Fletcher brought back from France Baclesse’s treatment, which was done with orthovoltage over a twelve-week period of time. We used to say that one good way of staging patients was that if they survived their treatment, they were an earlier stage than what you had postulated. Because so many of them were disturbed breasts that had already been biopsied, we really didn't know what stage they were. But twelve weeks of treatment plus another two or three weeks of a boost was a long treatment.
Question: I remember once Kligerman telling me that if you're a radiotherapist you had to be a rugged individualist. You really had to be able to put up with those complications.
Dr. Montague: Yes, the complications were severe. After you follow patients for a long period of time, you get to know them and suffer the complications. I still remember the chest wall necroses and the fact that nobody would touch them. Nowadays I think there are things that we could have done.
We had McMurtry, MD, who was a very good chest surgeon. When he came, he did tackle some of the necroses, and he would do chest wall eradication and then put in a mesh or pedicle, and some of them we did get to heal. But it was an era of attempting to see how much dose you could get by with, how much dose would control the tumor.
It was only after looking at some of the complications that we decided that by far the best effort would be to try to surgically remove the gross disease at the primary site, and even in the axilla first, and then treat with radiotherapy because you could then limit the radiation therapy to 5,000 plus a boost. That was a reasonable approach. I've forgotten when we stopped the Baclesse technique.
Question: It seemed that it was supplanted, I guess, by the simple (toilet) mastectomy.
Dr. Montague: Yes, exactly. Our surgeons were told not to make the flaps too thin and never to use a skin graft. I mean, this was far advanced disease. They were to leave thick flaps that would heal in two or three weeks and then could be followed by moderate doses of radiation. And in the beginning, we would leave the positive nodes and then at the end of 5,000 rads to the chest wall we'd give more boosts into the axilla. We had a couple of axillary necroses, and they are hard to deal with.
So after a few years we decided to do a low axillary dissection, removing the big nodes, and then we'll add radiation therapy.
And the advantage, of course, is that the results are good as far as local regional control, and the cosmetic results were good. The necroses were then very rare.
We also began to do interstitial implants of the scar because it was the scar that required the boost. Of course, by that time we had electron beam too, and so we used whatever we could and was appropriate.
Question: You didn't seem to be as much a champion of implants, though, as Sam Hellman was?
Dr. Montague: No. And of course this treatment was for far advanced disease.
The results were excellent and local-regional control was really very good. As I recall we had less than 10 percent failure on the chest wall which, when you consider that you're getting by with 5,000 rads plus a boost, is good.
And the axilla was well controlled and with the superclav areas we very rarely had any recurrences. And we actually had only one internal mammary chain recurrence in this patient group. We put all of this data into the computer. When did we start? I guess in the 1970s.
Norah Tapley did all the post radical mastectomy patients, and I did all the other ones. So we entered an era where we could actually look back and pick out any group of patients we wanted to. And that's when we also started to analyze the excision biopsies.
Question: Do you have any thoughts or comments you want to make about the internal mammary area and the controversies regarding the need for treating the internal mammary nodes? I'm thinking now about Jay Harris who wrote an editorial called "Let's put the hockey stick on ice.” I know there was some controversy when Fletcher was a visiting professor at Harvard and pointed out to Sam Hellman that at Anderson they were covering internal mammary nodes as well.
Dr. Montague: Right. Fletcher always felt that you either had to angle the medial tangent inferiorly (towards the floor) 10 degrees in order to get the internal mammary chain. Or better yet, have a separate internal mammary chain (IMC) field because then he said you could not miss it. We did a lot with cobalt and then with the electron beam or a combination of both.
Question: Fletcher thought it was the key to improved survival as I recall.
Dr. Montague: Yes, that's right. And the results at MD Anderson were excellent, even with four or more positive nodes. One other advantage in treating the IMC is for the opposite axilla- a very common failure site in patients with heavy lymphatic infestation in the chest wall that’s very frequent, and when I looked it up, I found that 30 percent of the first failures were in the opposite axilla in patients who did not get internal mammary chain irradiation.
And I think the lymphatic’s become increasingly important in patients with heavy tumor infestation. I think that would be an interesting thing to review again now that there would be more patients. When Norah and I looked at it, the opposite axilla was rarely a failure site as the first failure in patients who had internal mammary chain irradiation in stage III cancer. Now, whether that was also due to the fact that these patients were treated to the chest wall (so that you were treating the lymphatic’s of the chest wall), we could never tell because we never treated just the chest wall alone. We always treated the internal mammary and the chest wall. It's an interesting speculation, but I know that Fletcher felt that it was the internal mammary chain that was the important site.
Question: You had a group that you treated only the first couple of interspaces.
Dr. Montague: Yes, the more recent ones were treated to only the first three interspaces. And I don't think we've answered that question yet. But the time for doing this is probably gone. There are more urgent questions than going back and treating the internal mammary chain. I think we could have done a good study in the late '60s and early '70s, but we didn't, and nobody else did it. I just don't think we can answer that question. It remains a mystery.
Question: Would you comment about your appearance on “Nightline” with Ted Koppel and Jerry Urban, MD, from MSK?
Dr. Montague: It was in 1985, I think. Well, that was about the time that the early studies on BO6, the segmental mastectomy protocol, were coming out. The important part of that interview was disseminating information that the study was accomplished. This was a very hard study to get the surgeons to do, even in the NSABP. It took a lot of arguing. It took Bernie Fisher a number of years of trying to convince his surgeons to do this very conservative surgery. The surgery in that study was much more conservative than Veronesi’s study. I mean, Veronesi removed a whole quadrant of the breast. Bernie Fisher just wanted negative margins, so it took a lot of effort for him to get them to agree to do minimal surgery, a lumpectomy. And the fact that the study was even accomplished, I thought, was a major success.
Because then you could follow the patients and really learn how many of them needed radiation, which subgroup did not need it and which ones required it. And then, of course, by that time we were also looking at the noninvasive intraductal (IN SITU) patients. We already had some patients treated with radiotherapy to just the breast and not the peripheral lymphatics. So as an offshoot of the segmental mastectomy protocol, we were already looking into what happens if you treat patients with noninvasive (IN SITU) cancer with radiation therapy. How many of those would recur after irradiation, and how many would recur without the radiation therapy?
These are interesting biological questions. It was not so much that you're a radiotherapist so you want to use radiotherapy but rather that you are a breast cancer researcher and you want to know some of the answers. So that was the pitch that I was trying to make with Jerry Urban, MD. The fact was that he could continue doing his radical mastectomies forever, and he'd never learn anything about breast cancer. It took him 25 years to find out he could save the pectoralis muscle. He was really an advocate of the really radical mastectomy.
Question: Didn't he split the sternum?
Dr. Montague: Yes, that too, although he had stopped doing it by 1985. But it was a basic question; are you interested in breast cancer or are you interested in promulgating your own specialty? It seemed to me that the BO6 study was a very important study.
And I think that, in retrospect, so will the intraductal study be important. You know, the intraductal carcinoma has a very low recurrence rate with radiotherapy, whereas without radiotherapy it was about a quarter of the patients. I don't know where it is now. Anyway, so the pitch wasn't so much you've got to stop doing a radical mastectomy on everybody; the pitch was do something that's scientifically interesting by which you will learn something about the biology of breast cancer. And I think that the NSABP studies have done that.
Question: Bernie Fisher was given honorary membership in ASTRO two years ago. I know that in his acceptance speech he commented about working with you in those earlier years.
Dr. Montague: I talk to him occasionally every few weeks or so because I'm very fond of his wife, Shirley, and of Bernie, too, and they've been very dear friends. I give him all the credit for convincing many surgeons and presenting them with the protocol and saying to them, 'This is the protocol that we're going to follow.' That takes guts. (Laugh)
Question: What of the people that he was battling at that time?
Dr. Montague: As you know he suffered a great deal because it was discovered that one of the Canadian surgeons didn't follow the protocol. Then Dr. Fisher was actually fired from the University of Pittsburgh, and the NCI didn't back him up.
Question: That was one of the reasons, I think, for ASTRO giving him the honorary membership. Radiation oncologists have appreciated what he has done and his contributions in breast cancer management. What about the future? What do you see? Any directions? I'd be interested in your thoughts and questions as well about the “mammosite:” a balloon that they fill up and put a source in the center of to irradiate the surgical bed after lumpectomy.
Question: As an adjuvant to a conservative resection?
Dr. Montague: Yes, and some therapists want to do that as the only treatment.
Question: I worry a little bit about disease elsewhere in the breast and the length of time for follow up. Do you use the “mammosite,” Dr. Maor?
Question: We haven't done it yet. Actually the company is pushing this technique also for use in the brain of all places.
Question: They market it heavily in San Antonio.
Dr. Montague: Do they really?
Question: And I just worry about the dose distribution. It doesn't seem to me that the physics is too good with this technique.
Question: You know, I haven't been enchanted by balloons because I can see so many problems with balloons. I mean, a balloon is efficient if you have a source right in the center of a spherical or hemispherical geometric center. They have tried that in the bladder. I recall in Manchester that they did try to treat the bladder with a balloon.
Question: Well, a lot of people are pushing it for a quick fix, and you don't have to have six weeks of treatment and so forth.
Question: Is there any more you want to add, or is there anything you want to ask?
Dr. Montague: No, I have talked too much.
Question: I think it was superb.
Dr. Montague: Well, it was an interesting time. You know, in retrospect I'm so grateful to Fletcher because I think he could see in his mind the development of radiation and radiotherapists.
Question: He saw the big picture.
Dr. Montague: He certainly did.
Question: That is one thing that has come out on all these tapes. I've interviewed Luis Delclos, Bob Lindberg, Sey Levitt and you. I would expect all of you to be very positive on Fletcher. But then others that have been interviewed, Sam Hellman and Herman Suit, were also very complimentary of Fletcher.
Dr. Montague: Fletcher had an uncanny way of making complex problems look simple. In the beginning you would think, 'Oh my God, we'll never get through this,' but then as you worked it down, you saw that his message really was a simple one, but he had a very intricate mind.
Question: When did chemotherapy start to be a player in the initial or in preoperative . . . in the initial treatment of breast cancer? Rather than in an adjuvant . . .
Dr. Montague: I think at Anderson it came very quickly. It started primarily with the advanced disease because they were trying to make advanced disease more operable, and that was a worthy thing to do. But then, of course, with Dr. Bonadonna, adjuvant chemotherapy took on a life of its own.
The chemotherapy came on very quickly, and I can't remember exactly, but it seems to me as though it was in the early ’80s that they really began to push the chemotherapy. And then gradually they began to give it earlier and earlier, and now they're giving the chemotherapy after the surgery and then adding the radiation therapy later.
Question: Although the trial between when to give what in terms of radiation and chemotherapy was a toss-up. I mean, the results were equal both in terms of distant mets and in terms of local control.
Question: Well, Eleanor, thank you.
Dr. Montague: Oh, my pleasure.
