John Archambeau

By Robert Kwon, MD

The following interview of John Archambeau, MD, was conducted on October 26, 2005, by Robert Kwon, MD, James Slader, MD and Bill Preston, MD.

Robert Kwon: Maybe you can tell us a little bit about your background, where you were born and how you grew up. 

John Archambeau: That question goes back a long time. I was born in Maine and had my basic education there. In 1943, I went to the Maine Maritime Academy and served as a Merchant Marine Officer, traveled the world and then switched to the Navy. After leaving the Navy in 1945, I was accepted to go to college. I went to college in San Francisco, graduated from Stanford in 1950 and went immediately into Stanford Medical School. I graduated in 1954 and went to the University of Chicago to become a pathologist, but I quit because I couldn't communicate with my patients. I started looking for another venue. I had worked with Mel Griem, who was the Chairman of Radiation Medicine at the University of Chicago, and he thought it would be useful for me to look into radiation medicine. I then took a residency with Simon Cantril in Seattle, and when I finished my residency there, I had a full-fledged scholarship to go to Paris. After that, I went to Brookhaven National Laboratory to work on neutron capture therapy.

Robert Kwon: Let me go back … so you grew up in Maine. Did you have any siblings when you grew up in Maine? 

John Archambeau: I'm an only child.

Robert Kwon: What kind of work did your folks do? 

John Archambeau: I had working folks. I'm the only one who ever got to college.

Robert Kwon: And your background, because of your name … ? 

John Archambeau: Oh, it's French Canadian. Maine is right hard against Quebec.

Robert Kwon: And what gave you the idea of going into medicine in the beginning? 

John Archambeau: I never heard anything else. It was before I could read, I was going to become a physician.

Robert Kwon: Did you have any outside influence? Somebody who guided you? Or were you interested in science, or you were just interested in … . 

John Archambeau: No, it was main line all the way. During the war, I had to do something, so I went to the Maine Maritime Academy and then as quickly as I could, I got into Stanford and, out of Stanford, then went into medical school.

Robert Kwon: Very good. Do you recall any experiences that you had as you were growing up or in school that influenced your studies or inspired you? 

John Archambeau: The only thing I can recall that affected my career was when I was flunking calculus and they said I could never get into graduate school or physics at Stanford. That frightened me. So that influenced me to come into medicine.

Robert Kwon: And you said you started out as a pathology resident, right? And how was that? 

John Archambeau: Philosophically, the only way to study disease is to get it in your hands and look at it. so I thought that being a pathologist would better prepare me for getting into other work. And then having done that, cancer therapy was certainly of interest, and it applied to pathology and what I was doing at the University of Chicago.

Robert Kwon: After you finished your pathology residency, then you went to Seattle for radiation medicine? 

John Archambeau: The leader of the tumor institute in Seattle was Simeon Cantril. There were three or four major players at that period, which was the late 1950s. There was Juan Del Regato at Penrose in Colorado Springs, there was Gilbert Fletcher at MD Anderson in Houston and there was Cantril at Swedish in Seattle. They all came through the French door pretty much, as I recall it. And then there was Milton Friedman at NYU, but they didn't have any residency program. So there was only Cantril, del Regato and Fletcher. I interviewed with Cantril, and I was sold. The department there at that time was equivalent to anything we have now. This was in 1955. Buschke and Cantril set it up. It was high-energy. We had a two MeV Van de Graaff.

Robert Kwon: So later you went to Paris to learn more about radiation, or was that just tradition? 

John Archambeau: Yes, it was in order to keep the French relation. Cantril had done his work in Paris, so had del Regato at the Curie, so I went for a year.

Robert Kwon: And how did you learn about radiation initially? 

John Archambeau: Through Mel Griem, who was the radiation therapist at the University of Chicago. We wrote a paper on effective radiation on the pancreas.

Robert Kwon: He was one of the main people who influenced you as far as getting into the field of radiation? 

John Archambeau: Yes.

Robert Kwon: Do you have any thoughts about Paris as far as your training there? 

John Archambeau: I would expect that you know something of the history. Regaud was one of the first eminent radiation biologists, and he was one of the many in Paris in the 1930s. Madame Curie had set up part of the mathematical approach to survival, and Regaud had worked out some survival curves using what was essentially the beginning of in vitro work—so it was all radiation biology. The French school was, I thought, very modern in its outlook, and I never saw anything change very much until the British started who … was the one who wrote the book? I can't remember his name … 1946, I believe, it was re-edited in 1950 … I just can't recall his name. Oh, yes, Jack Fowler. His book was great. I still have it.

Robert Kwon: So then when you joined up with Dr. Cantril in Seattle, he shortly died. 

John Archambeau: Yes. Franz Buschke was second in command, and Bob Parker was there at that time. Buschke took over when Cantril died. Buschke then went to the University of California, and Parker went over to the University of Washington.

Robert Kwon: What was your experience like at the Seattle Tumor Institute? 

John Archambeau: Everybody seems to think that in the 1950s we were treating with 200 kV machines and that the diagnostic/general radiologist was in charge. However, Cantril was exclusively a radiation therapist. He had developed a lot of the French techniques, especially for the treatment of cancer of the cervix. He had a large patient population that he alone controlled, and (one of the things that I have reflected on) therapy for some of these illnesses has not changed much from what we experienced then. We were aware of the Hodgkin’s approach using sequential contiguous fields for the active and potential disease sites, and chemotherapy was coupled with irradiation. The only thing different from the present was that we had our own radiation therapy service and beds.

Robert Kwon: Back in those days, you would admit and take care of your own patients in the wards, right? It's different now. 

John Archambeau: Cantril and Del Regato and even Fletcher still had the French approach to radiation medicine. The only thing different was that we were not allowed to tell the patient the diagnosis. That was not the time; they felt that patients would degenerate as soon as they learned that it was cancer. And just for the record, I wrote a paper in 1959 describing the radiation therapy training program there, and it was published in JAMA. Looking that over, I don't see any difference in what Slater, MD, established here for the residency program and for the relationship of the staff, but I haven't been any place else.

Robert Kwon: Well that's very interesting. Did you see much in the way of change as far as our field goes? You've been through many decades of what our field has been like, way back when … . 

John Archambeau: I saw it forming, if you want to put it that way, because in 1958 or 1959, Phil Rubin and Cantril and others set up the first meetings that became ASTRO. And I learned that at that time Phil Rubin was riding in his tour de force on the pathology of malignancy, and like the hurricanes with this wave front, the wave front was there, and I was in it. I was a resident at that time, and radiation medicine and all the modern concepts were there.

Robert Kwon: And with your pathology background, that must have helped a lot as far as clinically being able to treat patients. And back in the day when they took biopsies and you could pretty much read those pathology slides yourself. 

John Archambeau: Well, I could, yes, but I didn't necessarily. It was still a training period, and I was looking forward to my future. Later, I went to Brookhaven, where they had neutron capture therapy. And I stayed there for probably six years, got in with Vic Bond and was able to be a coauthor on the book, Mammalian Radiation Lethality, which is a textbook of the effect of whole body radiation and the response to different syndromes to this irradiation. And then it was time to go to work. So I stayed on Long Island and went to work in Nassau County. Nothing remarkable there.

Robert Kwon: What are some of the significant events you recall about being a radiation oncologist? 

John Archambeau: Kaplan established prospective controlled clinical trials, and I think that's been the greatest benefit to all of us. Admittedly, Kaplan worked with somebody by the name of Peters, doing the abutted field on Hodgkin’s.

Robert Kwon: And back in your days when you were starting out, was there much in the way of combined modality therapy? You recall your relationship with the surgeons, and did they consider chemotherapy? 

John Archambeau: It was always collegial … I would go to the operating room and look over his shoulder to see where the disease was and tell him where to put the clips. We had a good relationship with the medical oncologists and the OB/GYN people. We always had a collegial relationship, just like now; it was very collegial but multi-opinionated.

Robert Kwon: And how did you end up here at Loma Linda? 

John Archambeau: After finishing at Nassau, Jerry Bennett and I (at Brookhaven) decided that protons would be useful, and so we wrote a seminal paper. Dr. Slater read it and discovered that I was close by in California, as I was chairman at City of Hope some 25 years ago … .

Robert Kwon: And Slater, what made you want to hire Dr. Archambeau? 

James Slater: That was about 1983. I wanted to hire Archambeau because I knew of his previous experience with protons back in New York and of his interest in particle therapy.

I was interested in starting a program here at Loma Linda in protons, actually even before I really started at the institution in 1970. I came here with that in mind, and we quickly began to do a lot of work toward getting ready. Many things had to be done. For example, we knew we would not be able to aim the beam precisely enough to have the Bragg peak positioned at a tumor deep inside the patient. The way we were doing treatment planning in 1970, it wasn't reasonable to expect we could aim the beam with sufficient precision. So we started out developing a treatment planning system. I started that during my residency and then finished it here. I was taking my residency at this institution but at our Los Angeles campus at the White Memorial Medical Center. This was in the 1960s. I worked with a physicist out here, named Ivan Neilsen. I had wondered whether ultrasound images (which were the state of the art then) could be used in a computer-assisted planning system. Dr. Neilsen confirmed that they were digital images, and indeed they could be used in such a system. That encouraged me, and we discussed how we could develop a computer-assisted treatment planning system and make this happen back in the late '60s. So once I arrived at Loma Linda in 1970 to start a radiation oncology program, we really went to work on developing that technology, using ultrasound first, simply because ultrasound was the first digital imaging of the human body that we had. There wasn't anything else to build it on, and by 1970 we were getting things put together.

In 1971, the ultrasound-based planning system was working, and then we switched it over to CT when it became available. We went to GE and bought the second CT scanning system that they built and hard-wired our treatment planning system into that system and developed pretty nice images for those days.Looking at the radiation distribution on the patient's anatomy was a major asset to us, especially as we considered using protons in the future. (I have added pictures of the first and second systems we developed, if this would be of interest.)

Robert Kwon: Yes, that was a major breakthrough. 

James Slater: It soon spread worldwide, and it is now in use globally and being manufactured by several companies since its beginning in our laboratory in the early '70s. We followed through with that planning system, and by 1984 I figured it's time to move aggressively toward protons.

We did a feasibility study back in 1970 to evaluate the development of protons. We contacted NCI. They gave me the name of a firm down in San Diego to help with that study. We quickly concluded it was too early back then to even think of protons because imaging was inadequate, as we were doing it with X-rays having only two-dimensional views. You can't plan proton therapy adequately with plain films. You can develop treatment plans using 3-D digital imaging ultrasound, which was better than nothing, even though it was very crude back in 1970. But later we got CT and began developing our planning system as we waited for the imaging to continue improving.And then MRI became available. That's when I went after John Archambeau to partner with.

I called him up, and we met over here at a restaurant on a few occasions, and we talked about what we could do together and how we could do it. I was worried that he wouldn't come because he was chairman at the City of Hope, and he would have to drop that position. John did join, we knew it was time to begin, and we agreed to set out on this long road of developing protons for a hospital study. Protons were being investigated in high-energy physics laboratories. I knew about that when I was a resident, and that's when I got interested in protons (as a resident) because it didn't seem good to me that we had to cause people all the distress from the side effects our treatment. We made some very, very sick. And that was troublesome, and that's why I was always looking for a better way.

After bringing John in, we went together to visit several physics laboratories. We started out at Argonne National Laboratory. We looked at Brookhaven, went to Fermilab, and also Berkeley and Los Alamos. Essentially, when the computer technology was ready, Archambeau and I said we're going to do this, and we did.

Robert Kwon: That's great. When did you know that computers for treatment planning came into play as far as the protons? 

James Slater: Well, as a resident, my background was in physics before I went to medicine, so I wanted to do my own treatment planning. I wanted to come in with multiple portals and use a variety of angles, which was very difficult in those years because you couldn't see your target. We used cross-sectional anatomy books, took pictures, projected them on the wall, overlying them on an outline of the patient. The physics staff was not interested in this approach. I got permission to do it myself and the physicists would check it for accuracy, so things went fine, and I learned from the experience.

After a couple years of residency, I figured that there had to be a better way because it was so time-consuming. I soon learned why it was not being done as I had suggested: it required hours and hours to work out a good plan. So I thought, computers are coming onboard, let’s get them to do the work. That's why I came out to this part of the Loma Linda campus, to meet with Dr. Neilsen. He was very, very helpful, and we put a team together and finished that job on the treatment planning system. This was undertaken in preparation for protons as well as photons and other particles because it was pretty clear that if you can't precisely place the Bragg peak within the target in any anatomic site, you can’t take full advantage of protons. You could in an experimental physics laboratory, but that was not good enough for routine clinical work. Early on, computers weren't good enough, either. Remember the big discs? Those big platters would crash multiple times a day, but we worked with them and just kept going and got treatment planning to run. ASTRO, RSNA and other special agencies like the Department of Energy and the Atomic Energy Commission, they were vitally interested with this approach and invited us to come and present it at their international meeting in Europe. We did, and it excited everyone that saw it. I remember we presented it in depth at ASTRO in New Orleans one year, and after it was over and I walked to the back of the room, Mary Caterall, from England, spoke out, stating, “That's the missing link for radiotherapy.”

Robert Kwon: That's some of the history that we're looking for as far as the development of our radiation technology. What do you think is the most significant contribution, aside from getting this program up and running with the protons? 

James Slater: At Loma Linda there was no program in radiation therapy when I came here and got started. I think the treatment planning was the first and the most universally accepted contribution. It has made a huge difference in creating fewer side effects when you treat patients. Treatment today is much more tolerable; we don't make patients nearly as sick as we did when I started. We couldn't see the target then. We couldn't tell the beam location with enough precision to tightly conform it to the target. We treated larger fields, and so we injured more normal tissue and caused more grief and damage to the patient than is even dreamed about today. I think that was the real, major contribution that had more impact worldwide than anything we did.

I think protons are going to be another major advantage because we can control those particles much better than we can photons because of their mass and their charge. We can place them wherever we want and get the Bragg peak to stop precisely where we want. That is an enormous advantage, and I would rank this as contribution number two.

I wanted to reduce normal-tissue injury. That's the crucial limiting factor to radiation therapy, and we've just got to do everything possible to do this. As our dose to the tumor can be safely increased, one can expect to increase the cure rate and yet, if you avoid the normal tissue, the side effects are less.

John Archambeau: One thing that struck me as remarkable was when Slater told me, some years ago, that the whole idea with protons is to reduce the normal-tissue injury. If we did nothing else but reduce morbidity, protons would be accepted, even if they never increased cure rates and control rates at all. And to add to what Slater said, I think he'll remember from Los Alamos how ill some of those patients got when they treated with pi mesons. They couldn't control the beam. They were treating large fields. Even Bob Parker was having problems with fast neutrons. They tried other particles and couldn't do anything. That was the whole point.

I set up a colloquium at BNL and had all the people, Kaplan and Withers and a lot of people came, and it was perfectly evident to me that what Slater just paraphrased was correct. The idea was that we didn't have to give a higher dose if we could eliminate normal-tissue injury, so I just never was interested in any other particle therapy. I was offered jobs working with fast neutrons, pi mesons and high-LET particles, but I wanted to concentrate on protons.

Robert Kwon: What have you been focusing your time and energy on these days? 

John Archambeau: I have quantified the dose-response curve of the skin to irradiation. Here we've quantified the dose-response of the microvessels, using the micro-vessels of the retina as the model. And now we are looking at microvessels to the brain, and we're quantifying those. I think my research turned into a method by which we can quantify cell number. In other words, I can tell you that the eye has 78,000 epithelial cells in it, and I know how much they change over time. That was the grail that I was searching for. Instead of using words to describe retinas and/or different illnesses, I wanted to put numbers on it, and so I've been able to. And now we're doing three-dimensional reconstructions of the microvessels of the brain. It's quite exciting and, along the same line, quantifying it.

Robert Kwon: Are you doing mostly research now? 

John Archambeau: I'd be a hazard in the clinic. Nobody listens. One lesson I learned was to listen to the patients and let them tell you what's wrong with them. Now, too many doctors and too many therapists get talking and telling the patients something. That's something that I'd be glad to see change.

Robert Kwon: Are there any other questions or comments? Of all the historically well-known radiation oncologists, whom did you admire the most? 

James Slater: Gilbert Fletcher was kind of the star that I learned from. He was an engineer before he was a physician, so he was an organized physician-scientist from day one. He knew how to set up clinical trials and to do protocols to test for the best way to treat. For head and neck cancers especially, he was exquisite in his capabilities there, and I really looked to him as the person that had the most influence over me in going for this high- precision treatment. I traveled in Europe looking for better ways to do things, and they had a lot of good concepts that I brought back here, but nothing exceeded what he taught because of the precision and thinking about direct invasion, the lymphatic pathways (and how to cover those), what dosage you need and the metastatic site versus the primary site. I just think there's nothing that's come up to excel what he did there.

Robert Kwon: You were on friendly terms with Phil Rubin? 

James Slater: Yes, we had a very good time together, Phil Rubin, Luther Brady, Bob Sagerman and Mel Bagshaw. We had many good times skiing together back in the Rockies, both in Utah and Colorado.

Robert Kwon: Did you meet Del Regato? 

James Slater: Yes, I did. I visited his place in Colorado Springs. Del Regato had such a colorful history. I went to his clinic and visited with him at one time. A very nice person. It was kind of a hobby of mine to visit places around the world, including the majority of physics facilities that were doing any kind of treatment with protons, heavy ions and/or pions.

John Archambeau: And I can tell you a story about Fletcher. He came up to Seattle and was making rounds with Simeon Cantril and me. We were examining a larynx patient, and so we invited Gilbert to look in. He practically took the patient by the nose and stuck his finger down his throat. The patient had tears coming down his eyes and was feeling very uncomfortable, and Cantril reached over the patient and told him, “Bite him.” (Laugh) He was a rough man, but he was a very good thinker.

James Slater: One comment about the history of radiation therapy: it's good to think back and see where their major achievements have come from. It is from the physics and engineering laboratories. Our equipment primarily originates in these laboratories, and it's good we realize that. I'm not talking about the manufacturers - they came along afterwards - but about those brilliant folks who invented and designed the first accelerators and other therapy machines of all types. Now we're growing because of the work they did, and we should remember them.

Robert Kwon: On what type of cancers do you think that protons have had the most impact? 

James Slater: One of the most impressive impacts is within the brain; there's been great impact on brain cancer therapy, especially for those tumors growing around the brain stem, because you can wrap the treatment beam right around the brain stem, avoiding it and the spinal cord. It is not as complex with protons as it is trying to do it with any other particles. I look for major impacts in virtually every site that we really explore, as I think we're going to find improvements.

One of the things that needs to be remembered is the work that Phil Rubin did when he began to study cytokines and measured the cytokines that appeared in a person's blood stream within minutes to a very few hours after one radiation episode. We have done studies on that here since. We thought that, because we did not see a problem from the large fields and relatively moderate doses, we had left them unharmed, unchanged. Rubin’s work shows, I think, that we're going to see that setting those large fields and sending that beam through more and more cells, using some of these more complex setups, is going to have a negative impact. We're doing a study now measuring the cytokines released into the blood stream because of the trauma to the cells. It doesn't take high doses, and it adds up faster with larger volumes. I don't think we know yet how to use all these data, but it's an excellent area for investigation and should be continued by several good laboratories so we can obtain more answers.

And another thing is comparing the effect of the different particles. For example, cytokine patterns that we see when we treat with protons compared with photons. And we will be doing it with heavy ions also; they're very different. You can see that it's like a fingerprint, and you can identify which beam was used on the studies we've done. We can tell that each beam is different, has a different impact, and that needs to be investigated. What's happening? What are these cytokines doing? We need to know because we do find patients that have complications, such as fibrosis that never stops. It plagues them the rest of their lives, shortens their lives and ruins the quality of their lives because of our radiation, especially with large fields. Not many people experience this, but some do, and we need to identify those people who are at risk.

In other words, radiation medicine is an exciting field. It's not an old field, it's a young field and the growth in it and the new discoveries … there's no end to it. Every time we solve something, more doors open, and we should remember this and always keep looking.

Robert Kwon: Are there any last thoughts or parting thoughts or anything else you wanted to add? 

John Archambeau: You asked the question about which tumor responded the most to protons. I think, for myself, I found it very gratifying the way protons enabled us to reduce side effects in children. The use of protons with children has meant that you could squeak by without leaving them a vegetable. I'm very happy with that angle of it. I don't know when my prostate is going to need treatment, but I look forward to that because I can remember the terrible side effects of patients when we were treating with cobalt.

James Slater: As an example of that, our patients are extremely happy patients. And throughout their treatment of the prostate, as John mentioned, they're out bicycling or hiking and swimming. They don't get sick. They continue their usual life activities, even athletically.

And I do want to mention another one. Protons can be used any place we can use X-rays, electrons or any other type of irradiation. Protons can do it. They're much better controlled, so I think we will find that we cause less grief to the patient, fewer side effects and complications. One good example is another area, and Archambeau is the brains behind this. We came up with a need to treat a group of lung cancer patients from our Veterans Hospital, patients who couldn't tolerate surgery, chemotherapy or conventional radiation. We knew they couldn't because their lungs and their cardiac status were too poor to tolerate it. So Archambeau, with David Bush, MD, came up with a short 10-day course, free of morbidity. The patients couldn't tolerate anything. So we took these very, very sick patients, and Archambeau came up with a plan that he worked out, and John, you should tell them how you did this.

John Archambeau: Go ahead. I love hearing about it.

James Slater: He came to the conclusion that we could get by with a 10-day course of protons on these very sick patients with a fraction size of five Gray, equating 50 Gray total. We have treated several patients like that now. After one of the first was treated, the diagnostic radiologist came to me with films and said, “What did you do to this person?” It was a clear lung, clean, and then he showed me the other film from what it was like before treatment. There was no fibrosis, no pneumonitis or any visible negative effect. That set it off in our minds that this has to be a new clinical trial.

We did it for these people that had nothing else available, and many of them lived many months after. I can't give you the percent, I don't remember, but we published the report. The idea is, they've died of their coronary or pulmonary diseases more frequently than they did from the tumor, which was a major asset for these fellows, and they didn't get sick with the treatment. Their pulmonary function improved quite dramatically, and so I think we don't even begin to know what all protons can do. At our institution, we've treated a little fewer than 11,000 patients now, and most of those have been prostate, but nearly half have been a mixture of other sites. We need more institutions out there to do this so that we can get more clinical research going, and that's when the big changes in this project will come.

Robert Kwon: How did you come up with the actual dose? How did you figure that out? 

John Archambeau: I've not reviewed that for a long time. It didn't necessarily come out of thin air. It seemed to be a logical procedure. Call it hypofractionation. I'm trying to convince Slater that we ought to try hypofractionation for prostate.

James Slater: Well, you know, that's a good point. Hypofractionation for prostate, we want to do that once we clearly understand the tolerance of all surrounding normal tissues. What worries me about doing it is our group of patients, with the relatively small number treated and followed up at this time, and when patients are tolerating protons as well as they are now. The risk of hypofractionation causing problems that will affect this process and potentially set the program backwards clearly exists. More study is still needed.

If we do something that causes great complications when the results are good now, there's going to be a lot of people that pay dearly for that. We're not about to do it. We're far too cautious. What we need are clinical studies with multiple institutions involved, including the National Cancer Institute, so that we can have protocols that people accept and then lower the fractions in reasonable steps, not the giant step we took with patients having lung cancer, which was done because there was nothing else to offer. In that instance, they couldn't tolerate any treatments; it was a last resort, nothing else could be done for these folks, and they were delighted after treatment. I'm afraid it would be a different answer with the prostate. We need to take that idea and just work our way down in smaller increments until we get to an optimal level with as few mistakes as is reasonable.

This can be done with further study, and then it could be a very good study and should be done. I think here, again, we need multiple institutions and support from the National Cancer Institute. John is right, and I think the time will come when we will show that hypofractionation in prostate is going to pay off with the use of protons.

John Archambeau: The side I like looking at is that it's going to be cheaper for the patient.

James Slater: Absolutely. Cheaper in time and money. We have to be able to treat in a way that doesn't cause the patient too much injury. This is a major rationale for using protons in addition: we can treat patients in a much shorter period time, thus costing them less, taking less time away from their work and so on. And patients are now coming from many parts of the world and all over this country for protons, and they find that they're pleased they did, and these facilities should be placed around this country and other countries so that patients can get that advantage without having to travel and stay in a hotel, as many do here.

Robert Kwon: What do you think about how nowadays there’s talk about stereotactic body therapy or body treatments, where you give almost like a stereotactic radiosurgery, but to a tumor at a different site outside of the brain? 

James Slater: When you treat with protons, all of your setups are stereotactic. So I think it's just a matter of getting a group of institutions working together and learning to treat any site in the body. There is no problem if one goes carefully and cautiously and shrinks the time down over a number of days and increases the fraction sizes for most sites in the body. One can treat pancreas, renal tumors and lymph node drainage sites from any of those tumors. It’s very doable, but it's going to take a lot of planning, caution and care and, I think, multiple institutions is the preferable method.

Robert Kwon: Do you have any ties to MD Anderson's new proton facility? 

James Slater: I'm on the review group at MD Anderson as an outside reviewer for their proton therapy, and we're going to have meetings annually for this. The whole plan is to get everybody working together. Contacts could be developed between medical institutions and manufacturers for mutual benefits. Resolving patients’ needs with manufactured devices or treatment-room specific issues should prove beneficial to all concerned and therefore of significant value. Physicists, physicians and technologists are in the best position to establish the design requirements of equipment needed for treating patients, and the manufacturers can then create the equipment that fulfills these requirements. Societies like ASTRO could help advance this process. All the factors that will improve safety, efficiency, precision and provide easily upgradable equipment could then be made public.

Robert Kwon: I visited with Kaplan one time and was asking him a question about what would you rather do and what should have been done. He said the worst thing that happened to radiation therapy was the invention of the cobalt machine because it made everybody a therapist, every radiologist. 

James Slater: I agree. The simplicity of a cobalt system gave people who don’t know anything about therapy a means for doing therapy, and that wasn’t very good.

Robert Kwon: It's been very interesting and very informative, and I appreciate your time and your efforts and being able to do this interview, and I'll go back and tell the group more about what we talked about. 

James Slater: Thank you for coming up and visiting with us.

Robert Kwon: My pleasure.