Lester J. Peters, MD, FASTRO
Dr. Campbell: I'm Dr. Belinda Campbell and I'm accompanied today by professor Herman Suit. It is our great pleasure to introduce professor Lester Peters, former ASTRO President from 1993 to 1994 and recipient of the prestigious ASTRO Gold Medal in 2003. Professor Peters' work has earned him the well-deserved respect of his colleagues around the world, and in 2001 his dedication to radiation oncology was further recognized when he received the award of Member of the Order of Australia for “service to medical research, education and clinical practice in the field of radiation oncology, resulting in improved treatments for people with cancer, particularly in the head and neck region”. It is, indeed, an honor to be interviewing you today, professor Peters, and we thank you for your time.
We would like to begin by asking you to tell us a little about you, your childhood and your family background. Where you were born and where did you grow up?
Dr. Peters: Thank you, Belinda and Herman. It's a great honor to be interviewed for this purpose.
I'm a child of country Queensland, the northernmost state of Australia. My father was a small-town banker and his job involved his being moved from town to town every three or four years, so I had quite an itinerant existence as a kid. Looking back, the requirement to make new friends, that I faced every few years, stood me in good stead because my professional life turned out to be fairly itinerant as well. I ended up going to high school in a country town in Queensland called Maryborough. It was an unusual class that I belonged to because whereas on average maybe one or two of each graduating class from that high school might go on to tertiary education, however, in my class there were ten of us who went on.
Dr. Suit: How big was the class?
Dr. Peters: Twenty. Twenty students, Herman.
Dr. Suit: So about half of them went on to university?
Dr. Peters: Yes. And that was quite unusual, in that era, from the country.
Dr. Campbell: Did you have any childhood ambitions or childhood dreams?
Dr. Peters: Well, interestingly enough when I was at high school, I became very interested in physics and I had it in my mind that I wanted to become a physicist/astronomer.
Dr. Suit: How fantastic!
Dr. Peters: I was all set to go to university majoring in physics and I had my goal set on becoming an astronomer, or, more specifically, a cosmologist, because I was fascinated in the origins of the universe. But in the long vacation before university started, I had a job in a sawmill and one of the other people I was working with had a father who was an employment officer in Maryborough and he asked me what I wanted to do. When I told him he said, "You're mad. You'll never get a job. Do medicine instead.” And I said, "Okay, Mr. Willis." So I called up and changed my enrollment into medicine. You could do that in those days, with about six weeks notice. And so I ended up almost serendipitously in medical school, but once I got started I realized I'd made a good choice.
Dr. Suit: Wonderful.
Dr. Campbell: Very interesting.
Dr. Suit: Well then, you didn't have any mentors in high school or any friends that were strongly influencing you into physics and astronomy, and none in medicine? Is that the story?
Dr. Peters: No, not really, Herman. It was my physics teacher in high school, I think, who excited me about physics. But there was no history of medicine in our family and I didn't have anyone as a role model prior to medical school. After that, of course, I had many great role models and mentors, yourself included.
Dr. Suit: Oh, well, gee. Thank you. But anyway, so this was really more of a private initiative of yours to be so fascinated by physics. And it's interesting that you got into probably the most physics-oriented aspect of medicine.
Dr. Peters: It is, indeed. Yes. It was a happy coincidence because as I went through medical school I became fascinated with cancer as a disease process. When I'd finished my internship and general medical residency, I was looking for a job that would lead me into a specialist role in cancer. At that time the only discipline that was dedicated to cancer was radiation oncology. There was no such thing as medical oncology or surgical oncology. This was in the late 1960s. So I found the happy coincidence of the field of medicine I wanted to be in with also a physics background, so I was quite pleased with the opportunity to specialize in radiation oncology.
Dr. Suit: Very good. And then, when you went out of high school, you went directly into medical school? There wasn't anything like going into university for a few years and then going to medical school like in this country?
Dr. Peters: No, Herman. It was the English system of direct entry into medical school from high school, a six-year course in medicine. The university had an interesting strategy at the time, designed to give kids from disparate school backgrounds a chance to compete. There was an essentially open policy into medical school followed by a severe culling at the end of year one and year two, so that only about one-quarter of the students who actually started in a given year would finish within six years.
Dr. Suit: Oh! What a traumatic experience for most students.
Dr. Peters: If you got through the second year, and then didn't screw up completely, you were more or less guaranteed to graduate. But in each of the first two years there was a 50 percent cull of the class.
Dr. Suit: That must have been very competitive.
Dr. Peters: Yes. The class went from 200 on day one to about 50 at the end of year two.
Dr. Suit: It went from 200 to 50?
Dr. Peters: Yes. But anyway, I made the cut and ended up getting the university gold medal for topping the medical class in the year when I graduated, so I felt as if it was worth all the hard work.
Dr. Suit: Yes. Well, it seems like you had a very productive outcome from your hard work all along the way.
Dr. Campbell: So, the boy from rural Queensland becomes a professor of international standing and acclaim. What, or perhaps who, have been motivating factors during your career that have kept you on this path of persistent hard work and fruitful success?
Dr. Peters: I think, Belinda, to succeed in life you've got to have opportunities and you've got to grasp those opportunities. And I've been really lucky to get a lot of wonderful opportunities. My first big opportunity, I think, came when I had just completed my training program in radiation oncology in Brisbane, and a visitor came to Australia who was a very eminent radiation biologist from the Hammersmith Hospital in England called Tikvah Alper.
Dr. Suit: Oh, I know Tikvah.
Dr. Peters: Yes. Anyway, the director of the radiotherapy department in Brisbane said to me, "Look, I'm worried about what the staff is going to talk to Dr. Alper about. None of us has any background in radiation research or anything like that and she's not a clinician, so what are we going to talk about?" He said, "Why don't you prepare a briefing paper for us." So I went to the library and looked up Index Medicus and made an abstraction of the papers that Tikvah had written, mainly about the oxygen effect and also some very interesting work on scrapie in sheep. If I can digress for a minute, she should have won the Nobel Prize for discovering the prion because she proved by radiation target theory that the transmissible agent for scrapie was too small to be a virus. And she caught a bit of flak for that because at the time no replicating thing was believed to be non-nucleic-acid-based. But anyway, getting back to the story, when Tikvah Alper came, with the aid of these cheat sheets that I'd produced, some of the staff asked intelligent questions, I guess, and she was most impressed. One of the staff said, "We've had these little dossiers prepared by one of our juniors." And she said, "Well, can I meet him?" So I got to meet Tikvah Alper and, anyway, she was a wonderful woman and she said, "What do you want to do with your life?" And I said, "Well, the thing I'd really like to do is radiation research because I'd love to follow in the pathway of Rodney Withers." And she said, "Oh, leave it with me. I'll see what I can organize." And lo and behold, a few months later I got this notification from the Gray Laboratory in London saying that they would offer me a scholarship to go and study radiation biology.
Dr. Suit: How beautiful! That's a wonderful story.
Dr. Peters: It is a wonderful story. And it was just so lucky for me to have the opportunity to meet Tikvah and to convince her that I was serious about wanting to study research. So off I went, then, to the Gray Lab in 1972. My supervisor there initially was Harold Hewitt, whom you also know well, Herman.
Dr. Suit: Yes, of course.
Dr. Peters: Yes. Harold had the distinction of being the first to produce an in vivo tumor cell radiation survival curve in a mouse leukemia. It was a great pleasure to work with him, although my research thesis work didn't actually involve radiation. It was a project aimed at elucidating the mechanism of the Révész effect. The Révész effect, for those who are not familiar with it, is the situation where if you inject viable tumor cells admixed with lethally irradiated tumor cells, fewer viable cells are required to transplant the tumor than if you inject just the viable cells alone. This phenomenon was described by Laszlo Révész in probably the '60s. And my project was to try to work out why that happened. The interesting outcome of that work, which has never been refuted, interestingly enough, is that the lethally irradiated cells create a thrombotic stimulus at the site of implantation. By using radio-labeled tumor cells, we were able to show that if you inject viable cells by themselves, they migrate away from the implantation site unless you inject a large number of them, whereas if they're mixed with lethally irradiated cells, it forms a little micro-clot there that holds the viable cells in situ and they grow more efficiently.
Dr. Suit: A very nice find.
Dr. Peters: It was. It was interesting. And, of course, Harold was much more than a scientific mentor to me. He was a philosophic mentor as well. He used to require that every morning when I came into work, I'd sit with him and talk over general matters of life and philosophy until about 10:00 am. I was, of course, itching to get into the lab and get my work done, and he'd sit there puffing his pipe and talking about all sorts of things. Another thing that Harold taught me, which has been a lesson that I've appreciated throughout my whole professional life is that one should never become emotionally invested in the outcome of an experiment. He said to me, "Never be disappointed by the result of an experiment. The results are telling you something, even if it's not what you were expecting. And you must let the data tell you what they will. Don't say this was a disappointing result because if you did the experiment properly, it's a correct result. So don't try to manipulate the results to suit your preconceptions. Take them as they come."
Dr. Suit: Well, that's a very important lesson he was teaching, because I know one of the things that has so bothered me over the years is to hear people say we're going to do this experiment to prove such-and-such.
Dr. Peters: Exactly.
Dr. Suit: That is not the comment of a scientist.
Dr. Peters: Indeed, it's not. Harold used to have Karl Popper's book on his book shelf there, you know, The Logic of Scientific Discovery, and he said all you can do in an experiment is disprove a hypothesis. You can't prove it. It was a very good basic training in scientific philosophy that Harold gave me that I've been so grateful for my whole life.
Dr. Suit: Even if it did use up part of the morning.
Dr. Peters: Yes. Well, the corollary was, because I couldn't get started until about 10:00 each morning, I used to stay fairly late. So I wasn't too popular with my wife. But never mind. After I finished that research work with Harold, I moved on in the Gray Lab to work for my last year with Jack Fowler. That was a complete change of direction because Jack and Julie Denekamp and their group were mainly interested in radiation fractionation. So I got my first exposure to the issues of the fractionation parameters in that time at the Gray Lab and, in particular, the relative importance of fraction size and duration of treatment as well as total dose, of course, in determining the biologic effect. So I ended up having about three and a half years at the Gray Lab. Then, one of Harold Hewitt's friends, who was at the St. Thomas Hospital, was taking a year off and he happened to be an Australian, Van den Brenk . . .
Dr. Suit: Oh, yes. I remember him.
Dr. Peters: Yes, Henry Van den Brenk. Anyway, Harold put the pressure on me to do a locum for him. So I went to St. Thomas' Hospital and spent a year there basically keeping his lab running. I didn't do any significant new work in that year except some studies on the effects of stress and stress hormones on tumour cell transplantability. But I did have the opportunity to spend some time in the clinic where Churchill Davidson was the head. He was running a hyperbaric oxygen study at the time as you probably remember. They were giving 6 times 6 Gy, with or without hyperbaric oxygen. It was about that time that I first noticed the bad late effects that people were getting who'd had the large doses per fraction. I think one of the first publications that ever came out about the perils of hypofractionation was a letter to the editor of the BJR that Thelma Bates and I wrote saying that it was risky to the brachial plexus particularly to give 6 times 6 Gy, even though according to the NSD formula it should have been safe.
So anyway, that was my time in London. At the end of Van den Brenk's leave, when he came back to resume his job, I had to decide what I wanted to do. There were no opportunities at all in radiation research in Australia at that time, and I wanted a job where I could combine clinical and research work if possible. And this is where Herman, I was so influenced by you; I think you must have been one of the very first examples of what we now call “translational research workers” in radiation oncology because you were the prototypical clinician scientist when you set up the department of experimental radiotherapy at MD Anderson.
Dr. Suit: Well, just to clarify, I was recruited to go there and do it. So Warren Sinclair, you probably met him.
Dr. Peters: Yes, I knew Warren.
Dr. Suit: He gave me a big sales pitch about going to MD Anderson and doing just this and he got me to swim out into the middle of this lake at Burlington, Vermont. The International Radiation Research Conference was having a meeting there. He was very keen on this whole idea and I had already gone to Toronto to get such a position and they turned me down because they told me that, "Herman, we think that you're a nice guy, but you're indecisive. You can't make up your mind whether you want to work in the clinic or in the lab and so we don't have a position for you." And I had been just rejected from that when Warren Sinclair told me about this. So I leapt onto that like crazy.
Dr. Peters: That's fantastic. And it was such a legacy you left at MD Anderson. When I finished in London, you had moved to Harvard probably a year or so earlier, and Rod Withers was in charge of the experimental radiotherapy section, as it was called then. He managed to arrange a job for me at the MD Anderson where I could work in both the lab and the clinic. And that was another example of what I said before how important it is to have opportunity: that was a fabulous opportunity.
Dr. Suit: Oh, sure.
Dr. Peters: I remember also, about that time, my wife and I were thinking whether we really wanted to live in Houston, because it was quite a culture shock after London, but we actually grew to love living in Texas. It was a tremendous era of opportunity to work at MD Anderson because at the time they had the resources to let the faculty do more or less whatever reasonable project they wanted to. And as long as you didn't make too many mistakes, you didn't get fired. But there was no security of tenure. It was quite competitive. The time I spent in experimental radiotherapy at MD Anderson was quite formative in my professional life because I had the opportunity to work not only with Rod and his colleagues, but also with Fletcher and the clinical people. Fletcher had this aura about him and everyone seemed as if they were afraid to ever disagree with him on anything. Maybe it was my naiveté or whatever, but I used to argue with him from time to time and he actually appreciated it in a way, in a strange way, I think. He had an innate desire to link the science of radiation biology with clinical radiotherapy but he didn't have any training in radiation biology. When we would talk about things, he seemed as if he liked being able to put his clinical findings into a radiobiological context, like his discovery about treatment of subclinical disease, for example. It made a lot of sense when you looked at the radiobiologic characteristics of cell survival to think that 50 Gy was about the right dose to sterilize the small tumor burden that you might have in the subclinical disease setting. So Fletcher was an incredibly strong influence on my clinical background.
Dr. Suit: Well, for me also because, as you know, I was there for about 11 years and he was very supportive of the whole idea of split of time between the lab and the clinic. And I know of very few people that would ever have done what he did. After I got there, and I was working on the betatron, he told me to come down and he took me around to each of the therapy machines in the department. There were about six and he introduced me to the technicians and he said, "Now, look, Dr. Suit is here to do research and clinical work. When he is on his half time working in the laboratory, you are not to call him. He's been instructed that he must keep his notes up to date and you're to call the person who is covering for him, and I do not want him bothered by any of your calls."
Dr. Peters: That's fantastic, isn't it? Particularly in the era that we're talking about.
Dr. Suit: It's not too common now for people to go around and make that effort to make certain that the sessions of lab time are respected.
Dr. Peters: That's right.
Dr. Suit: I was very impressed. In fact, I could hardly believe it was happening.
Dr. Peters: Yes. Well, the clinical services that I got assigned to were TBI for bone marrow transplantation and the fast neutron radiotherapy project which was then based at College Station at a university cyclotron.
Dr. Suit: It's Texas A&M, Agricultural and Mechanical College. It's a very highly-regarded university now.
Dr. Peters: Indeed, yes. David Hussey was the director of the fast neutron program. I had a very good working relationship with David and we used to go up there twice a week to treat patients on the Texas A&M cyclotron. That is where we completed the preliminarily studies that led eventually to the installation of a dedicated cyclotron for fast neutron therapy at MD Anderson under the auspices of the NCI. That facility along with a couple of others in Los Angeles and Seattle and Chicago were the centers that did the definitive trials on fast neutron therapy in the 1980s.
Dr. Suit: Right.
Dr. Peters: I also had my other clinical job that I was in charge of.
Dr. Suit: But before we leave that, I'd just like to ask during that time at MD Anderson, did you have much interaction with clinical or laboratory research going on in Canada, the European countries, Japan or any place else? Did you have the opportunity to visit any of those places?
Dr. Peters: Yes, indeed. I had the chance to visit several international centers through being at MD Anderson and going to conferences and so forth. Was your question specifically related to particle therapy or general?
Dr. Suit: No, I just wondered if your involvement with the international community was significant. You were a young fellow there and I would assume that you had developed colleagues.
Dr. Peters: Yes, there were many. By going to meetings like the Radiation Research Society and ASTRO, I had the opportunity to meet many of the famous people in the field. It was amazing and to be able to put names to faces or faces to names, I should say, and to be able to go and visit some of them in their own environment was a tremendous advantage. I didn't realize at the time how far off the beaten track we were in Australia because there were very few opportunities to meet eminent people in the field at that time in Australia. You had to go overseas to meet them. Whereas when I was in Houston it was like a cross-road of international people who were coming and going all the time. And there were so many more conferences that were available to attend in the US.
Dr. Suit: It certainly did change. Because when I was a medical student and wanted to go into radiation therapy, I'd talk with a number of people, including Fletcher, who were unambiguous that I should go to Europe, ie that I should not stay in the United States for my residency. They didn't have the opinion that there was much going on anywhere else, viz the action was in Europe. Fletcher changed that attitude pretty quickly, but he had just come from there.
Dr. Peters: Yes, that's right.
Dr. Suit: So then, I had about the same experience in the US that you had in Australia.
Dr. Peters: Is that right? I guess things changed fairly quickly.
Dr. Suit: Oh, they do.
Dr. Peters: It's important not to be born 10 years too soon or too late.
Dr. Suit: The thing to do is to leap-frog. I assumed you had met a lot of colleagues and I just wanted that to be brought out.
Dr. Peters: Yes, indeed. I did meet lots of international colleagues. In France, for example, I had quite a bit to do with Tubiana and Dutreix, both husband and wife. Let's think, where else in Europe? Oh, the Einhorns from Stockholm, I had the opportunity to visit them.
Dr. Suit: Well, this is enough. I just wanted to make sure this was brought out.
Dr. Peters: Yeah. It was a great opportunity. Being at MD Anderson was also, I think, responsible for getting invitations to go places that you might not have gotten had you come from a less well-known institution.
Dr. Suit: Oh, I think that's for sure.
Dr. Peters: Of course, you have to do good work, but you also have to have a good address, and I think that's important for young people deciding where they're going to go to work.
Dr. Suit: What was your next project? Comment on your assessment of the outcomes of your trials and work with neutrons?
Dr. Peters: I think this is where I should hark back to what Harold Hewitt said about letting the data tell you something. The clinical results from the fast neutron trials showed that the therapeutic ratio was not improved and may, in fact, have been worsened by treatment with neutrons. And there are many reasons for that. I think the most significant reason was the very poor ability to collimate neutrons and create the nice dose distributions that you can achieve to an increasing extent with photons. But to any objective observer, the results with neutrons were inferior and I think it was appropriate that that form of treatment was abandoned. The people in Seattle, as you know, tried to make a case from a very small trial that neutron therapy was beneficial in the case of malignant parotid gland tumors. But that was a very flimsy evidence base from which to argue and I think neutrons are appropriately being consigned to history. Maybe charged particles are worth a bit more investigation.
Dr. Suit: With neutron therapy you're looking at differences, major differences in RBE. But with protons it's simply a question of dose distribution.
Dr. Peters: Yes. But I was really alluding to carbon ions.
Dr. Suit: Oh, carbon ions. Yes. Dose distributions for carbon ion and proton beams are closely similar; the differences usually considered are those of biological effectiveness, RBE.
Dr. Peters: In Japan and now in Europe they're running carbon ion trials -- and in China, did you know they've got a big new Siemens particle accelerator in Shanghai now?
Dr. Suit: I knew they were getting one. Does it also have a carbon ion beam line?
Dr. Peters: Yes. Yes, it does. And the Chinese physician in charge of that facility, a fellow called Liang Jiang, did his training at MD Anderson when I was there as Division Head. He's now the head honcho at Shanghai.
Dr. Suit: Well, very good. I hope he can have many successes. I mean, there have been some pretty impressive results out of Japan.
Dr. Peters: Yes. It's just a shame they don't do definitive studies, though, isn't it? Their results are all based on series of patients without any control groups.
Dr. Suit: Well, I've talked with the people who are there many times about this, but to no avail. But it seems to me that what they're doing is diminishing the role of high RBE. As you increase the dose per fraction, the RBE goes down.
Dr. Peters: Yes.
Dr. Suit: And so it seems to me, that were we thinking that the RBE is important, you would use hyper fractionation. But they're going to the extreme opposite. But anyway, maybe what they're basically interested in dose distribution, ie more narrow penumbra and greatly improved position of the target on the radiation beam. But anyway, you carry on.
Dr. Peters: No, no, no. Not at all. It's fun to get your perspective. But I think what you were saying is very important for the current advocates of hypofractionation using stereotactic body radiotherapy to take notice of, because they're really just using radiation as an ablative tool and not looking for differential effects on tumor and normal tissue. So it's purely a volume effect play and I think there's a real concern that using these ablative doses to larger volumes is going to end up being something we come to regret.
Dr. Suit: Well, we learned that in the 1930s.
Dr. Peters: Yes, yes. And those who don't learn from history are destined to repeat it, aren't they?
Dr. Suit: Even with proton or carbon ion beams and our current technology to know the target position, there remains a reduced but not zero volume of normal or minimally involved normal tissue. And the large doses per fraction to those tissues are likely to cause severe local reactions, but if the volume is quite small, this might not result in no clinical problems.
Dr. Peters: Exactly.
Dr. Suit: Now, how many years were you director at the MD Anderson?
Dr. Peters: Well, after those years in experimental radiotherapy, I had a short return to Australia where I worked in Sydney for a couple of years. And then completely out of the blue I got a phone call one morning asking me if I would be willing to be considered for Fletcher's job. I just about fell off my chair when I got that phone call because in no way did I think I would be in the running for a job of that level of seniority because I was only about 40 at the time. Anyway, I had a very long talk to Desley, my wife, about whether I should go into the pool of candidates because, if by any chance I did get chosen, then it would mean definitively relocating to Houston. I wasn't going to go there for a few years. And she said, "Okay, well, go for it and we'll see what happens." And lo and behold, against all odds, they offered me the job. That was in 1982. Fletcher had retired but he was still around and I can't tell you the level of anxiety and nervousness I had on my first day at work when I trotted up to the planning clinic. The planning clinic, Belinda, was a morning clinical conference where all the new patients were physically presented in front of the gathered staff. And Fletcher used to sit at the front and actually examine these patients and make comments about them and so forth. I decided that when I did my planning clinics, I wasn't going to have the patients physically present and be examined in front of 40 or 50 people. But it was otherwise the same. As chair of the planning clinic, you were expected to make sage comments about each of the cases and give some direction about their management.
Dr. Campbell: And this planning clinic included patients from all tumor sites?
Dr. Peters: Yes. So my strategy was to invite the leader of the relevant tumor service to make the first comments and then sort of just act as a chair rather than saying anything definitive myself. It was incredibly nerve-racking to go into that environment. But I had a very nice talk to Fletcher and I said to him, "The only way I can succeed here, Dr. Fletcher, is if you keep a low profile because if you're in the planning clinic, my job will be impossible." So he said, "Okay, I'll stay in my office." But he said, "I'll be interested, I'll be listening to the comments after the meeting to see how you've gotten on." And anyway, I eventually got his nod of approval and Fletcher became a great supporter of mine as were Eleanor Montague and Luis Delclos. I had a cadre of people there who really made it easy for me to get started and to establish myself as the chair there. To answer your question, Herman, I was chair there for 13 years which is probably not a bad length of time because you tend to get into a groove, I suppose, after a long time. But I didn't intend to leave MD Anderson. I've often said my career was almost on cruise control at that point. Things were going well and there was no reason to leave. The department was going well. It was in an era where many radiation oncologists were scared to death about the impact of managed care and how it was going to cause academic institutions to go bankrupt and so forth. But the way the MD Anderson administration handled the managed care contracts, I think, was very clever. They actually built up the business of MD Anderson during that pessimistic era and there was hardly a blip in the growth of the institution as managed care was introduced. So things were going well at MD Anderson. But the way I came back to Australia was that I got an unsolicited call from a headhunter, a fellow in California who said that he'd been engaged by Peter MacCallum [Cancer Centre], the premier cancer institute in Australia, to help recruit a head of radiation oncology and that they had big plans for the organization to re-position itself as an academic center. About the same time they recruited a very high-powered basic researcher called Joe Sambrook to head up the Division of Research at Peter MacCallum. And so, one thing led to another. This opportunity, combined with the atavistic instinct that everyone has to go back to their place of origin, were the motives in moving back. Also, my wife was very keen that we should move back to Australia before our kids became too old to want to move back, and that was more or less the last opportunity because our oldest daughter had just finished college and she would have very soon established her own life in the US had we stayed any longer. So we came back as a family in 1995 and I've been at Peter Mac ever since. About five years ago I cut my work down to part time and now I'm not doing any direct clinical work. I go to the clinic one day a week as a consultant, but I don't actually care for patients personally. I'm also the chair of our philanthropic foundation, so that keeps me considerably involved with the workings of the institution. So it's been a bit of a very slow around-the-world trip for me.
Dr. Suit: Well, you've certainly covered a lot of ground. But I would like to ask if you would just comment about a few of the developments that you've initiated or put forth and how you think they've gone and just some of the things that you consider to be kind of star lights in your career.
Dr. Peters: I think the thing that gives you the greatest sense of pride, if you like, or worth in a professional life is to feel as if something you've done has made a difference in the way people practice. It's not easy to do that, but I think the one thing that I've been associated with that probably has made a difference the way people practice radiation oncology was with Rod [Withers] and Howard Thames, working out the clinical iso-effect formula that included the alpha/beta ratio. Our paper in the green journal, “A new iso-effect curve for changes in dose per fraction”, is probably the highest cited paper I've ever been an author. That, I think, has influenced the way people practice quite a bit. And then the corresponding work with Rod about the time factor in head and neck cancer, in particular, when treated with radiation was also influential, I think. Interestingly, the time factor probably is less of an issue with combined chemo radiotherapy, apparently. Another thing that I've tried to emphasize in writing, at least, is how important it is to consider the therapeutic ratio and not just the tumor efficacy of new treatments. It worries me that as in the last 20 years or so there've been improvements in tumor control through treatment intensification, but every time treatment is intensified, it's been by adding something onto an existing high-dose regimen and nothing is being taken away. I remember giving a talk at Memorial Sloan-Kettering about five years ago where I argued that in head and neck cancer, by treating people with high dose cisplatin and 70 Gy, we might be curing more people but we're making the survivors so much more miserable that we must question whether we are really improving the therapeutic ratio? Don't we need to learn some lessons from colleagues who treat lymphomas and pediatric cancers and back off the dose of radiation when we're using high-dose chemotherapy or back off the dose of chemotherapy if we're using high-dose radiation and not just blast people with both barrels? It's very gratifying now to see the move toward de-intensification coming forward particularly in patients with HPV-positive oropharyngeal cancers. I think that will yield much better clinical outcomes than the previous regimens.
Dr. Suit: Well, I just commend you for taking that position. I know that for me, the concept, when using protons or anything else, is that you have to look at the NTCP for the reference treatment and then plan the new treatment method to achieve the same or a lesser NTCP but with the expectation of a higher TCP. Because if you get a higher TCP and a higher NTCP, it's not very meaningful. It's how it relates to the complication frequency and severity as a function of post treatment time.
Dr. Peters: Exactly, yes. I couldn't agree more, Herman.
Dr. Suit: And so I just hope that you keep pushing that.
Dr. Campbell: Well, I've got a slightly different question. I'm curious to know about your transition from USA to Australia, and I'm interested to hear how the work environments were different and if you think there are different challenges facing radiation oncologists in the USA compared to Australia?
Dr. Peters: Well, certainly the work environments are very different. In the US, I think the clinical environment is such that the ratio of patients to consultant is much lower than it is here. People have a smaller clinical workload that gives them a chance to devote more time to treatment planning. It also allows them to spend more time reading and writing. We've got a situation in Australia where the reimbursement for medical services is set by the government and, this is for you, Herman, people can't insure for out-patient medical treatment. The only insurance you can have is for hospitalization.
Dr. Suit: You say that's in Australia or in the US?
Dr. Peters: That's in Australia. You can't insure for ambulatory treatment. In an environment like Peter MacCallum, which is a public hospital, essentially none of the patients pay for their treatment so that the revenue that's generated from patient care activity can't be used to subsidize clinical research or equipment acquisition and things like that. I've been trying to get the governance people responsible for a major new cancer center, incorporating Peter MacCallum, that's currently being built in Melbourne to look at places like MD Anderson. The Anderson has some similarities in being a state hospital which is responsible for indigent care, but that's more than offset by the large volume of patients they have who are fee paying. I got the management people from here to go over and visit MD Anderson and have a look at how it works, so hopefully they'll start to apply some of those principles at least to out-of-state and out-of-country patients and bill them accordingly. But in order to do that, we've got to have facilities that are attractive to such patients and the new cancer center will provide them. So I'm quite optimistic about the way things are moving in Australia. At the present time, we are very restricted in how much research and development work we can subsidize from clinical revenues. We depend almost entirely on research grants even for clinical research activity and it's very difficult to get trials off the ground because you can't start the trial until you've got funding and you can't get funding from granting agencies by and large without runs on the board. So it's a difficult environment but it's not impossible, and I think our track record here in Melbourne is pretty good when you look at the output of papers and so forth that have come from this institution and more generally from Australia.
Dr. Suit: Well, I would suggest that you might be interested in reading the article about what the hospitals charge patients that appeared in a recent Time Magazine. The issue was about three or four weeks ago. It discusses MD Anderson up front and very extensively about the way in which it's being run as a business. I think you might find it interesting. I'm sure it's likely to be in your hospital library. This change in medicine is quite widespread and in no way limited to one or a few centers.
Dr. Peters: Yes, I would be very interested to read that. Presumably it was not a very complimentary article, was it?
Dr. Suit: Well, it's about the way American medicine is becoming a business.
Dr. Peters: Right.
Dr. Suit: And I know I've heard a number of very top academic people refer to patients as customers.
Dr. Campbell: Really?
Dr. Peters: As customers?
Dr. Suit: Yes. And you can tell by the way I'm talking, it was not something that was pleasant for me to hear. But anyway, I've said enough on this. We're talking about you, but you brought that up and I thought you might find it interesting.
Dr. Peters: Indeed, yes, I will. I'll look it up. There are many similarities, of course, between places like MD Anderson and Peter MacCallum in the context that they're both dedicated to the concept of multidisciplinary care and we have management by tumor streams rather than by disciplinary groups. So all patients who come in are treated within a multidisciplinary team, all dedicated to the same disease type; it's not a sequential system of referral as you might get in some other places. We also have the common business model of MD Anderson where all the practitioners have a common remuneration system so there’s no financial competition between different specialties to see who gets to treat the patients, which I think is very important.
Dr. Suit: I would say yes. The business aspect of our cancer centers have not affected the quality of care. From my observations, patients who are admitted receive quite excellent care in the best sense of the word.
Dr. Peters: So there are very positive things. Our biggest frustration in Australia is having a demand that exceeds supply and not being able to react to that demand by increasing capacity. If we ran our own show rather than having the government run it for us, we would have many more accelerators running and many more clinical offices open so that everyone who wanted to come here could come here. It's very frustrating to have to turn people away who want to access the skills that are available at places like Peter MacCallum simply because there's no room for them. And you face a very strong ethical dilemma when you have to decide between making someone wait for highly expert treatment or send them away to a lesser expert practitioner who can see them tomorrow: you know, what is better for the patient? It's a real struggle and I think it's stressful for the staff and, of course, it's very frustrating for the patients not to be able to get access to the place in a timely fashion.
Dr. Suit: Surely. Well, listen, is there something you would like to add to this? Because we're getting close to our allotted time limit. But if there's something that you would like to bring out about you and your career and your future or anything of this sort, what you think about medicine's future, whatever, I think we would like to hear an opinion.
Dr. Peters: Well...
Dr. Campbell: That leads very nicely, actually, to my next question. I wanted to ask professor Peters about his presidential address at the ASTRO Annual Meeting in 1994 and his presidential address, entitled “Looking Through the Glass Darkly, Predicting the Future of Radiation Oncology”. That was now almost 20 years ago and so I was wondering if you could tell us about how you feel that the practice of radiation oncology has changed in the last 20 years, and perhaps how you might see it changing in the future?
Dr. Peters: Oh, gee. Thanks, Belinda. The goal of my presidential address was to try to convince people not to be so pessimistic about the future of radiation oncology. There was a great sense of gloom pervading the specialty at the time: that radiation oncologists were being marginalized and there was nowhere for us to go and so forth. I tried to make the point that nobody can foretell the future with any accuracy, hence “looking through the glass darkly”. The theme of my talk was that the best way to predict the future is to create it. So we should be out doing things that will create a guaranteed future for radiation oncology, and we do that by involving ourselves in research and development and establishing an evidence base for what we do that makes it indisputable that radiation is an essential component of modern cancer treatment. The big things that have happened in the last 20 years are dominated by the technological advances which have been absolutely phenomenal: not just in radiation therapy planning and delivery, but also in diagnostic imaging as well. The way that we now incorporate sophisticated imaging and exquisitely accurate planning into the use of radiation has been a major step forward for the specialty. There's also been a great deal of refinement, I think, in the way combined modality treatment has been given with the extension beyond simple cytotoxics into biologics, and that will increase for sure in the next 20 years. One of my biggest personal disappointments is the failure of predictive assays of radiation sensitivity to gain much traction. I've spent quite a bit of my life working on assays of tumor and normal tissue radio-resistance, but there's nothing that ever has come forward that's sufficiently accurate and reproducible to be used in the clinic. But I think genetic profiling of tumor cells and normal tissue cells will probably reach a point in the next 20 years where we can customize treatment according to individual genetically-determined parameters of radio resistance.
Dr. Campbell: Do I have time for one more question? I wanted to ask about your passions, professor. It seems to me that you've always been a very strong advocate for education, whether at the junior trainee level or at the ASTRO refresher courses for practicing radiation oncologists. Certainly when I was a junior trainee, we all regarded your lectures as “words dipped in gold”, that was exactly how we described them. And so I was wondering, do you consider teaching to be one of your passions?
Dr. Peters: Oh, undoubtedly, Belinda. I've never considered myself a great teacher, but I do love doing it. You mentioned about the ASTRO refresher courses. One of the innovations I brought in when I was president of ASTRO (as the president gets to plan the annual meeting), was to run the refresher courses all day rather than just have them as pre-breakfast offerings. That became very popular because so many practicing radiation oncologists would go to ASTRO just to get an update on how the experts see things rather than to learn cutting-edge new research. At the resident level, the trainee level, I really enjoy interactive teaching where you talk backward and forward with the young people. The look you see in their eyes when something suddenly makes sense that was previously a bit of a mystery is one of the greatest joys of teaching. And I think if you can help people to understand concepts and use them, it's always a huge reward to any teacher.
Dr. Campbell: And do you have any other passions?
Dr. Peters: Well, you know about my Harley. I've been a motorbike rider ever since I was 17, so when people say you're having your late-life crisis, that's not right because I've been riding my motorbike for over 50 years. But I do love my motorbike and spend a bit of time on it. I play a lot of tennis and I enjoy doing lots of things with the family and just nothing sometimes-- oh, I love Sudoku, too.
Dr. Campbell: Very good. Do you have any other questions, Herman?
Dr. Suit: No, I think we've been very fortunate being able to listen to Lester discuss his medical career, and it was very positive and just a fine experience. I really have been a long-time admirer of Lester as a superior human being as well as a radiation oncologist. I tried hard to recruit him to the MGH, but I didn't succeed.
Dr. Peters: Well, Herman, you know about my admiration for you, as well. You've truly been a role model for me and I think your philosophy of life and mine are just so simpatico. It's been an honor to be able to have this interview with you and Belinda. And thanks to ASTRO very much.
Dr. Suit: Well, congratulations to you and your family and to Peter MacCallum and so hopefully we'll get to see you in this country before too long, before too many months go by.
Dr. Peters: Okay, Herman.
Dr. Suit: Take care.
Dr. Peters: Thank you. All the best.
Dr. Suit: Au revoir to you and Belinda.
Dr. Peters: Good-bye.
Dr. Campbell: To finish up, I would like to thank professor Peters for generously sharing his time, recollections, and his insights with us today. It has been a great pleasure and an honor to have had this interview with you today, professor Peters.
Dr. Peters: Thank you, Belinda.
We would like to begin by asking you to tell us a little about you, your childhood and your family background. Where you were born and where did you grow up?
Dr. Peters: Thank you, Belinda and Herman. It's a great honor to be interviewed for this purpose.
I'm a child of country Queensland, the northernmost state of Australia. My father was a small-town banker and his job involved his being moved from town to town every three or four years, so I had quite an itinerant existence as a kid. Looking back, the requirement to make new friends, that I faced every few years, stood me in good stead because my professional life turned out to be fairly itinerant as well. I ended up going to high school in a country town in Queensland called Maryborough. It was an unusual class that I belonged to because whereas on average maybe one or two of each graduating class from that high school might go on to tertiary education, however, in my class there were ten of us who went on.
Dr. Suit: How big was the class?
Dr. Peters: Twenty. Twenty students, Herman.
Dr. Suit: So about half of them went on to university?
Dr. Peters: Yes. And that was quite unusual, in that era, from the country.
Dr. Campbell: Did you have any childhood ambitions or childhood dreams?
Dr. Peters: Well, interestingly enough when I was at high school, I became very interested in physics and I had it in my mind that I wanted to become a physicist/astronomer.
Dr. Suit: How fantastic!
Dr. Peters: I was all set to go to university majoring in physics and I had my goal set on becoming an astronomer, or, more specifically, a cosmologist, because I was fascinated in the origins of the universe. But in the long vacation before university started, I had a job in a sawmill and one of the other people I was working with had a father who was an employment officer in Maryborough and he asked me what I wanted to do. When I told him he said, "You're mad. You'll never get a job. Do medicine instead.” And I said, "Okay, Mr. Willis." So I called up and changed my enrollment into medicine. You could do that in those days, with about six weeks notice. And so I ended up almost serendipitously in medical school, but once I got started I realized I'd made a good choice.
Dr. Suit: Wonderful.
Dr. Campbell: Very interesting.
Dr. Suit: Well then, you didn't have any mentors in high school or any friends that were strongly influencing you into physics and astronomy, and none in medicine? Is that the story?
Dr. Peters: No, not really, Herman. It was my physics teacher in high school, I think, who excited me about physics. But there was no history of medicine in our family and I didn't have anyone as a role model prior to medical school. After that, of course, I had many great role models and mentors, yourself included.
Dr. Suit: Oh, well, gee. Thank you. But anyway, so this was really more of a private initiative of yours to be so fascinated by physics. And it's interesting that you got into probably the most physics-oriented aspect of medicine.
Dr. Peters: It is, indeed. Yes. It was a happy coincidence because as I went through medical school I became fascinated with cancer as a disease process. When I'd finished my internship and general medical residency, I was looking for a job that would lead me into a specialist role in cancer. At that time the only discipline that was dedicated to cancer was radiation oncology. There was no such thing as medical oncology or surgical oncology. This was in the late 1960s. So I found the happy coincidence of the field of medicine I wanted to be in with also a physics background, so I was quite pleased with the opportunity to specialize in radiation oncology.
Dr. Suit: Very good. And then, when you went out of high school, you went directly into medical school? There wasn't anything like going into university for a few years and then going to medical school like in this country?
Dr. Peters: No, Herman. It was the English system of direct entry into medical school from high school, a six-year course in medicine. The university had an interesting strategy at the time, designed to give kids from disparate school backgrounds a chance to compete. There was an essentially open policy into medical school followed by a severe culling at the end of year one and year two, so that only about one-quarter of the students who actually started in a given year would finish within six years.
Dr. Suit: Oh! What a traumatic experience for most students.
Dr. Peters: If you got through the second year, and then didn't screw up completely, you were more or less guaranteed to graduate. But in each of the first two years there was a 50 percent cull of the class.
Dr. Suit: That must have been very competitive.
Dr. Peters: Yes. The class went from 200 on day one to about 50 at the end of year two.
Dr. Suit: It went from 200 to 50?
Dr. Peters: Yes. But anyway, I made the cut and ended up getting the university gold medal for topping the medical class in the year when I graduated, so I felt as if it was worth all the hard work.
Dr. Suit: Yes. Well, it seems like you had a very productive outcome from your hard work all along the way.
Dr. Campbell: So, the boy from rural Queensland becomes a professor of international standing and acclaim. What, or perhaps who, have been motivating factors during your career that have kept you on this path of persistent hard work and fruitful success?
Dr. Peters: I think, Belinda, to succeed in life you've got to have opportunities and you've got to grasp those opportunities. And I've been really lucky to get a lot of wonderful opportunities. My first big opportunity, I think, came when I had just completed my training program in radiation oncology in Brisbane, and a visitor came to Australia who was a very eminent radiation biologist from the Hammersmith Hospital in England called Tikvah Alper.
Dr. Suit: Oh, I know Tikvah.
Dr. Peters: Yes. Anyway, the director of the radiotherapy department in Brisbane said to me, "Look, I'm worried about what the staff is going to talk to Dr. Alper about. None of us has any background in radiation research or anything like that and she's not a clinician, so what are we going to talk about?" He said, "Why don't you prepare a briefing paper for us." So I went to the library and looked up Index Medicus and made an abstraction of the papers that Tikvah had written, mainly about the oxygen effect and also some very interesting work on scrapie in sheep. If I can digress for a minute, she should have won the Nobel Prize for discovering the prion because she proved by radiation target theory that the transmissible agent for scrapie was too small to be a virus. And she caught a bit of flak for that because at the time no replicating thing was believed to be non-nucleic-acid-based. But anyway, getting back to the story, when Tikvah Alper came, with the aid of these cheat sheets that I'd produced, some of the staff asked intelligent questions, I guess, and she was most impressed. One of the staff said, "We've had these little dossiers prepared by one of our juniors." And she said, "Well, can I meet him?" So I got to meet Tikvah Alper and, anyway, she was a wonderful woman and she said, "What do you want to do with your life?" And I said, "Well, the thing I'd really like to do is radiation research because I'd love to follow in the pathway of Rodney Withers." And she said, "Oh, leave it with me. I'll see what I can organize." And lo and behold, a few months later I got this notification from the Gray Laboratory in London saying that they would offer me a scholarship to go and study radiation biology.
Dr. Suit: How beautiful! That's a wonderful story.
Dr. Peters: It is a wonderful story. And it was just so lucky for me to have the opportunity to meet Tikvah and to convince her that I was serious about wanting to study research. So off I went, then, to the Gray Lab in 1972. My supervisor there initially was Harold Hewitt, whom you also know well, Herman.
Dr. Suit: Yes, of course.
Dr. Peters: Yes. Harold had the distinction of being the first to produce an in vivo tumor cell radiation survival curve in a mouse leukemia. It was a great pleasure to work with him, although my research thesis work didn't actually involve radiation. It was a project aimed at elucidating the mechanism of the Révész effect. The Révész effect, for those who are not familiar with it, is the situation where if you inject viable tumor cells admixed with lethally irradiated tumor cells, fewer viable cells are required to transplant the tumor than if you inject just the viable cells alone. This phenomenon was described by Laszlo Révész in probably the '60s. And my project was to try to work out why that happened. The interesting outcome of that work, which has never been refuted, interestingly enough, is that the lethally irradiated cells create a thrombotic stimulus at the site of implantation. By using radio-labeled tumor cells, we were able to show that if you inject viable cells by themselves, they migrate away from the implantation site unless you inject a large number of them, whereas if they're mixed with lethally irradiated cells, it forms a little micro-clot there that holds the viable cells in situ and they grow more efficiently.
Dr. Suit: A very nice find.
Dr. Peters: It was. It was interesting. And, of course, Harold was much more than a scientific mentor to me. He was a philosophic mentor as well. He used to require that every morning when I came into work, I'd sit with him and talk over general matters of life and philosophy until about 10:00 am. I was, of course, itching to get into the lab and get my work done, and he'd sit there puffing his pipe and talking about all sorts of things. Another thing that Harold taught me, which has been a lesson that I've appreciated throughout my whole professional life is that one should never become emotionally invested in the outcome of an experiment. He said to me, "Never be disappointed by the result of an experiment. The results are telling you something, even if it's not what you were expecting. And you must let the data tell you what they will. Don't say this was a disappointing result because if you did the experiment properly, it's a correct result. So don't try to manipulate the results to suit your preconceptions. Take them as they come."
Dr. Suit: Well, that's a very important lesson he was teaching, because I know one of the things that has so bothered me over the years is to hear people say we're going to do this experiment to prove such-and-such.
Dr. Peters: Exactly.
Dr. Suit: That is not the comment of a scientist.
Dr. Peters: Indeed, it's not. Harold used to have Karl Popper's book on his book shelf there, you know, The Logic of Scientific Discovery, and he said all you can do in an experiment is disprove a hypothesis. You can't prove it. It was a very good basic training in scientific philosophy that Harold gave me that I've been so grateful for my whole life.
Dr. Suit: Even if it did use up part of the morning.
Dr. Peters: Yes. Well, the corollary was, because I couldn't get started until about 10:00 each morning, I used to stay fairly late. So I wasn't too popular with my wife. But never mind. After I finished that research work with Harold, I moved on in the Gray Lab to work for my last year with Jack Fowler. That was a complete change of direction because Jack and Julie Denekamp and their group were mainly interested in radiation fractionation. So I got my first exposure to the issues of the fractionation parameters in that time at the Gray Lab and, in particular, the relative importance of fraction size and duration of treatment as well as total dose, of course, in determining the biologic effect. So I ended up having about three and a half years at the Gray Lab. Then, one of Harold Hewitt's friends, who was at the St. Thomas Hospital, was taking a year off and he happened to be an Australian, Van den Brenk . . .
Dr. Suit: Oh, yes. I remember him.
Dr. Peters: Yes, Henry Van den Brenk. Anyway, Harold put the pressure on me to do a locum for him. So I went to St. Thomas' Hospital and spent a year there basically keeping his lab running. I didn't do any significant new work in that year except some studies on the effects of stress and stress hormones on tumour cell transplantability. But I did have the opportunity to spend some time in the clinic where Churchill Davidson was the head. He was running a hyperbaric oxygen study at the time as you probably remember. They were giving 6 times 6 Gy, with or without hyperbaric oxygen. It was about that time that I first noticed the bad late effects that people were getting who'd had the large doses per fraction. I think one of the first publications that ever came out about the perils of hypofractionation was a letter to the editor of the BJR that Thelma Bates and I wrote saying that it was risky to the brachial plexus particularly to give 6 times 6 Gy, even though according to the NSD formula it should have been safe.
So anyway, that was my time in London. At the end of Van den Brenk's leave, when he came back to resume his job, I had to decide what I wanted to do. There were no opportunities at all in radiation research in Australia at that time, and I wanted a job where I could combine clinical and research work if possible. And this is where Herman, I was so influenced by you; I think you must have been one of the very first examples of what we now call “translational research workers” in radiation oncology because you were the prototypical clinician scientist when you set up the department of experimental radiotherapy at MD Anderson.
Dr. Suit: Well, just to clarify, I was recruited to go there and do it. So Warren Sinclair, you probably met him.
Dr. Peters: Yes, I knew Warren.
Dr. Suit: He gave me a big sales pitch about going to MD Anderson and doing just this and he got me to swim out into the middle of this lake at Burlington, Vermont. The International Radiation Research Conference was having a meeting there. He was very keen on this whole idea and I had already gone to Toronto to get such a position and they turned me down because they told me that, "Herman, we think that you're a nice guy, but you're indecisive. You can't make up your mind whether you want to work in the clinic or in the lab and so we don't have a position for you." And I had been just rejected from that when Warren Sinclair told me about this. So I leapt onto that like crazy.
Dr. Peters: That's fantastic. And it was such a legacy you left at MD Anderson. When I finished in London, you had moved to Harvard probably a year or so earlier, and Rod Withers was in charge of the experimental radiotherapy section, as it was called then. He managed to arrange a job for me at the MD Anderson where I could work in both the lab and the clinic. And that was another example of what I said before how important it is to have opportunity: that was a fabulous opportunity.
Dr. Suit: Oh, sure.
Dr. Peters: I remember also, about that time, my wife and I were thinking whether we really wanted to live in Houston, because it was quite a culture shock after London, but we actually grew to love living in Texas. It was a tremendous era of opportunity to work at MD Anderson because at the time they had the resources to let the faculty do more or less whatever reasonable project they wanted to. And as long as you didn't make too many mistakes, you didn't get fired. But there was no security of tenure. It was quite competitive. The time I spent in experimental radiotherapy at MD Anderson was quite formative in my professional life because I had the opportunity to work not only with Rod and his colleagues, but also with Fletcher and the clinical people. Fletcher had this aura about him and everyone seemed as if they were afraid to ever disagree with him on anything. Maybe it was my naiveté or whatever, but I used to argue with him from time to time and he actually appreciated it in a way, in a strange way, I think. He had an innate desire to link the science of radiation biology with clinical radiotherapy but he didn't have any training in radiation biology. When we would talk about things, he seemed as if he liked being able to put his clinical findings into a radiobiological context, like his discovery about treatment of subclinical disease, for example. It made a lot of sense when you looked at the radiobiologic characteristics of cell survival to think that 50 Gy was about the right dose to sterilize the small tumor burden that you might have in the subclinical disease setting. So Fletcher was an incredibly strong influence on my clinical background.
Dr. Suit: Well, for me also because, as you know, I was there for about 11 years and he was very supportive of the whole idea of split of time between the lab and the clinic. And I know of very few people that would ever have done what he did. After I got there, and I was working on the betatron, he told me to come down and he took me around to each of the therapy machines in the department. There were about six and he introduced me to the technicians and he said, "Now, look, Dr. Suit is here to do research and clinical work. When he is on his half time working in the laboratory, you are not to call him. He's been instructed that he must keep his notes up to date and you're to call the person who is covering for him, and I do not want him bothered by any of your calls."
Dr. Peters: That's fantastic, isn't it? Particularly in the era that we're talking about.
Dr. Suit: It's not too common now for people to go around and make that effort to make certain that the sessions of lab time are respected.
Dr. Peters: That's right.
Dr. Suit: I was very impressed. In fact, I could hardly believe it was happening.
Dr. Peters: Yes. Well, the clinical services that I got assigned to were TBI for bone marrow transplantation and the fast neutron radiotherapy project which was then based at College Station at a university cyclotron.
Dr. Suit: It's Texas A&M, Agricultural and Mechanical College. It's a very highly-regarded university now.
Dr. Peters: Indeed, yes. David Hussey was the director of the fast neutron program. I had a very good working relationship with David and we used to go up there twice a week to treat patients on the Texas A&M cyclotron. That is where we completed the preliminarily studies that led eventually to the installation of a dedicated cyclotron for fast neutron therapy at MD Anderson under the auspices of the NCI. That facility along with a couple of others in Los Angeles and Seattle and Chicago were the centers that did the definitive trials on fast neutron therapy in the 1980s.
Dr. Suit: Right.
Dr. Peters: I also had my other clinical job that I was in charge of.
Dr. Suit: But before we leave that, I'd just like to ask during that time at MD Anderson, did you have much interaction with clinical or laboratory research going on in Canada, the European countries, Japan or any place else? Did you have the opportunity to visit any of those places?
Dr. Peters: Yes, indeed. I had the chance to visit several international centers through being at MD Anderson and going to conferences and so forth. Was your question specifically related to particle therapy or general?
Dr. Suit: No, I just wondered if your involvement with the international community was significant. You were a young fellow there and I would assume that you had developed colleagues.
Dr. Peters: Yes, there were many. By going to meetings like the Radiation Research Society and ASTRO, I had the opportunity to meet many of the famous people in the field. It was amazing and to be able to put names to faces or faces to names, I should say, and to be able to go and visit some of them in their own environment was a tremendous advantage. I didn't realize at the time how far off the beaten track we were in Australia because there were very few opportunities to meet eminent people in the field at that time in Australia. You had to go overseas to meet them. Whereas when I was in Houston it was like a cross-road of international people who were coming and going all the time. And there were so many more conferences that were available to attend in the US.
Dr. Suit: It certainly did change. Because when I was a medical student and wanted to go into radiation therapy, I'd talk with a number of people, including Fletcher, who were unambiguous that I should go to Europe, ie that I should not stay in the United States for my residency. They didn't have the opinion that there was much going on anywhere else, viz the action was in Europe. Fletcher changed that attitude pretty quickly, but he had just come from there.
Dr. Peters: Yes, that's right.
Dr. Suit: So then, I had about the same experience in the US that you had in Australia.
Dr. Peters: Is that right? I guess things changed fairly quickly.
Dr. Suit: Oh, they do.
Dr. Peters: It's important not to be born 10 years too soon or too late.
Dr. Suit: The thing to do is to leap-frog. I assumed you had met a lot of colleagues and I just wanted that to be brought out.
Dr. Peters: Yes, indeed. I did meet lots of international colleagues. In France, for example, I had quite a bit to do with Tubiana and Dutreix, both husband and wife. Let's think, where else in Europe? Oh, the Einhorns from Stockholm, I had the opportunity to visit them.
Dr. Suit: Well, this is enough. I just wanted to make sure this was brought out.
Dr. Peters: Yeah. It was a great opportunity. Being at MD Anderson was also, I think, responsible for getting invitations to go places that you might not have gotten had you come from a less well-known institution.
Dr. Suit: Oh, I think that's for sure.
Dr. Peters: Of course, you have to do good work, but you also have to have a good address, and I think that's important for young people deciding where they're going to go to work.
Dr. Suit: What was your next project? Comment on your assessment of the outcomes of your trials and work with neutrons?
Dr. Peters: I think this is where I should hark back to what Harold Hewitt said about letting the data tell you something. The clinical results from the fast neutron trials showed that the therapeutic ratio was not improved and may, in fact, have been worsened by treatment with neutrons. And there are many reasons for that. I think the most significant reason was the very poor ability to collimate neutrons and create the nice dose distributions that you can achieve to an increasing extent with photons. But to any objective observer, the results with neutrons were inferior and I think it was appropriate that that form of treatment was abandoned. The people in Seattle, as you know, tried to make a case from a very small trial that neutron therapy was beneficial in the case of malignant parotid gland tumors. But that was a very flimsy evidence base from which to argue and I think neutrons are appropriately being consigned to history. Maybe charged particles are worth a bit more investigation.
Dr. Suit: With neutron therapy you're looking at differences, major differences in RBE. But with protons it's simply a question of dose distribution.
Dr. Peters: Yes. But I was really alluding to carbon ions.
Dr. Suit: Oh, carbon ions. Yes. Dose distributions for carbon ion and proton beams are closely similar; the differences usually considered are those of biological effectiveness, RBE.
Dr. Peters: In Japan and now in Europe they're running carbon ion trials -- and in China, did you know they've got a big new Siemens particle accelerator in Shanghai now?
Dr. Suit: I knew they were getting one. Does it also have a carbon ion beam line?
Dr. Peters: Yes. Yes, it does. And the Chinese physician in charge of that facility, a fellow called Liang Jiang, did his training at MD Anderson when I was there as Division Head. He's now the head honcho at Shanghai.
Dr. Suit: Well, very good. I hope he can have many successes. I mean, there have been some pretty impressive results out of Japan.
Dr. Peters: Yes. It's just a shame they don't do definitive studies, though, isn't it? Their results are all based on series of patients without any control groups.
Dr. Suit: Well, I've talked with the people who are there many times about this, but to no avail. But it seems to me that what they're doing is diminishing the role of high RBE. As you increase the dose per fraction, the RBE goes down.
Dr. Peters: Yes.
Dr. Suit: And so it seems to me, that were we thinking that the RBE is important, you would use hyper fractionation. But they're going to the extreme opposite. But anyway, maybe what they're basically interested in dose distribution, ie more narrow penumbra and greatly improved position of the target on the radiation beam. But anyway, you carry on.
Dr. Peters: No, no, no. Not at all. It's fun to get your perspective. But I think what you were saying is very important for the current advocates of hypofractionation using stereotactic body radiotherapy to take notice of, because they're really just using radiation as an ablative tool and not looking for differential effects on tumor and normal tissue. So it's purely a volume effect play and I think there's a real concern that using these ablative doses to larger volumes is going to end up being something we come to regret.
Dr. Suit: Well, we learned that in the 1930s.
Dr. Peters: Yes, yes. And those who don't learn from history are destined to repeat it, aren't they?
Dr. Suit: Even with proton or carbon ion beams and our current technology to know the target position, there remains a reduced but not zero volume of normal or minimally involved normal tissue. And the large doses per fraction to those tissues are likely to cause severe local reactions, but if the volume is quite small, this might not result in no clinical problems.
Dr. Peters: Exactly.
Dr. Suit: Now, how many years were you director at the MD Anderson?
Dr. Peters: Well, after those years in experimental radiotherapy, I had a short return to Australia where I worked in Sydney for a couple of years. And then completely out of the blue I got a phone call one morning asking me if I would be willing to be considered for Fletcher's job. I just about fell off my chair when I got that phone call because in no way did I think I would be in the running for a job of that level of seniority because I was only about 40 at the time. Anyway, I had a very long talk to Desley, my wife, about whether I should go into the pool of candidates because, if by any chance I did get chosen, then it would mean definitively relocating to Houston. I wasn't going to go there for a few years. And she said, "Okay, well, go for it and we'll see what happens." And lo and behold, against all odds, they offered me the job. That was in 1982. Fletcher had retired but he was still around and I can't tell you the level of anxiety and nervousness I had on my first day at work when I trotted up to the planning clinic. The planning clinic, Belinda, was a morning clinical conference where all the new patients were physically presented in front of the gathered staff. And Fletcher used to sit at the front and actually examine these patients and make comments about them and so forth. I decided that when I did my planning clinics, I wasn't going to have the patients physically present and be examined in front of 40 or 50 people. But it was otherwise the same. As chair of the planning clinic, you were expected to make sage comments about each of the cases and give some direction about their management.
Dr. Campbell: And this planning clinic included patients from all tumor sites?
Dr. Peters: Yes. So my strategy was to invite the leader of the relevant tumor service to make the first comments and then sort of just act as a chair rather than saying anything definitive myself. It was incredibly nerve-racking to go into that environment. But I had a very nice talk to Fletcher and I said to him, "The only way I can succeed here, Dr. Fletcher, is if you keep a low profile because if you're in the planning clinic, my job will be impossible." So he said, "Okay, I'll stay in my office." But he said, "I'll be interested, I'll be listening to the comments after the meeting to see how you've gotten on." And anyway, I eventually got his nod of approval and Fletcher became a great supporter of mine as were Eleanor Montague and Luis Delclos. I had a cadre of people there who really made it easy for me to get started and to establish myself as the chair there. To answer your question, Herman, I was chair there for 13 years which is probably not a bad length of time because you tend to get into a groove, I suppose, after a long time. But I didn't intend to leave MD Anderson. I've often said my career was almost on cruise control at that point. Things were going well and there was no reason to leave. The department was going well. It was in an era where many radiation oncologists were scared to death about the impact of managed care and how it was going to cause academic institutions to go bankrupt and so forth. But the way the MD Anderson administration handled the managed care contracts, I think, was very clever. They actually built up the business of MD Anderson during that pessimistic era and there was hardly a blip in the growth of the institution as managed care was introduced. So things were going well at MD Anderson. But the way I came back to Australia was that I got an unsolicited call from a headhunter, a fellow in California who said that he'd been engaged by Peter MacCallum [Cancer Centre], the premier cancer institute in Australia, to help recruit a head of radiation oncology and that they had big plans for the organization to re-position itself as an academic center. About the same time they recruited a very high-powered basic researcher called Joe Sambrook to head up the Division of Research at Peter MacCallum. And so, one thing led to another. This opportunity, combined with the atavistic instinct that everyone has to go back to their place of origin, were the motives in moving back. Also, my wife was very keen that we should move back to Australia before our kids became too old to want to move back, and that was more or less the last opportunity because our oldest daughter had just finished college and she would have very soon established her own life in the US had we stayed any longer. So we came back as a family in 1995 and I've been at Peter Mac ever since. About five years ago I cut my work down to part time and now I'm not doing any direct clinical work. I go to the clinic one day a week as a consultant, but I don't actually care for patients personally. I'm also the chair of our philanthropic foundation, so that keeps me considerably involved with the workings of the institution. So it's been a bit of a very slow around-the-world trip for me.
Dr. Suit: Well, you've certainly covered a lot of ground. But I would like to ask if you would just comment about a few of the developments that you've initiated or put forth and how you think they've gone and just some of the things that you consider to be kind of star lights in your career.
Dr. Peters: I think the thing that gives you the greatest sense of pride, if you like, or worth in a professional life is to feel as if something you've done has made a difference in the way people practice. It's not easy to do that, but I think the one thing that I've been associated with that probably has made a difference the way people practice radiation oncology was with Rod [Withers] and Howard Thames, working out the clinical iso-effect formula that included the alpha/beta ratio. Our paper in the green journal, “A new iso-effect curve for changes in dose per fraction”, is probably the highest cited paper I've ever been an author. That, I think, has influenced the way people practice quite a bit. And then the corresponding work with Rod about the time factor in head and neck cancer, in particular, when treated with radiation was also influential, I think. Interestingly, the time factor probably is less of an issue with combined chemo radiotherapy, apparently. Another thing that I've tried to emphasize in writing, at least, is how important it is to consider the therapeutic ratio and not just the tumor efficacy of new treatments. It worries me that as in the last 20 years or so there've been improvements in tumor control through treatment intensification, but every time treatment is intensified, it's been by adding something onto an existing high-dose regimen and nothing is being taken away. I remember giving a talk at Memorial Sloan-Kettering about five years ago where I argued that in head and neck cancer, by treating people with high dose cisplatin and 70 Gy, we might be curing more people but we're making the survivors so much more miserable that we must question whether we are really improving the therapeutic ratio? Don't we need to learn some lessons from colleagues who treat lymphomas and pediatric cancers and back off the dose of radiation when we're using high-dose chemotherapy or back off the dose of chemotherapy if we're using high-dose radiation and not just blast people with both barrels? It's very gratifying now to see the move toward de-intensification coming forward particularly in patients with HPV-positive oropharyngeal cancers. I think that will yield much better clinical outcomes than the previous regimens.
Dr. Suit: Well, I just commend you for taking that position. I know that for me, the concept, when using protons or anything else, is that you have to look at the NTCP for the reference treatment and then plan the new treatment method to achieve the same or a lesser NTCP but with the expectation of a higher TCP. Because if you get a higher TCP and a higher NTCP, it's not very meaningful. It's how it relates to the complication frequency and severity as a function of post treatment time.
Dr. Peters: Exactly, yes. I couldn't agree more, Herman.
Dr. Suit: And so I just hope that you keep pushing that.
Dr. Campbell: Well, I've got a slightly different question. I'm curious to know about your transition from USA to Australia, and I'm interested to hear how the work environments were different and if you think there are different challenges facing radiation oncologists in the USA compared to Australia?
Dr. Peters: Well, certainly the work environments are very different. In the US, I think the clinical environment is such that the ratio of patients to consultant is much lower than it is here. People have a smaller clinical workload that gives them a chance to devote more time to treatment planning. It also allows them to spend more time reading and writing. We've got a situation in Australia where the reimbursement for medical services is set by the government and, this is for you, Herman, people can't insure for out-patient medical treatment. The only insurance you can have is for hospitalization.
Dr. Suit: You say that's in Australia or in the US?
Dr. Peters: That's in Australia. You can't insure for ambulatory treatment. In an environment like Peter MacCallum, which is a public hospital, essentially none of the patients pay for their treatment so that the revenue that's generated from patient care activity can't be used to subsidize clinical research or equipment acquisition and things like that. I've been trying to get the governance people responsible for a major new cancer center, incorporating Peter MacCallum, that's currently being built in Melbourne to look at places like MD Anderson. The Anderson has some similarities in being a state hospital which is responsible for indigent care, but that's more than offset by the large volume of patients they have who are fee paying. I got the management people from here to go over and visit MD Anderson and have a look at how it works, so hopefully they'll start to apply some of those principles at least to out-of-state and out-of-country patients and bill them accordingly. But in order to do that, we've got to have facilities that are attractive to such patients and the new cancer center will provide them. So I'm quite optimistic about the way things are moving in Australia. At the present time, we are very restricted in how much research and development work we can subsidize from clinical revenues. We depend almost entirely on research grants even for clinical research activity and it's very difficult to get trials off the ground because you can't start the trial until you've got funding and you can't get funding from granting agencies by and large without runs on the board. So it's a difficult environment but it's not impossible, and I think our track record here in Melbourne is pretty good when you look at the output of papers and so forth that have come from this institution and more generally from Australia.
Dr. Suit: Well, I would suggest that you might be interested in reading the article about what the hospitals charge patients that appeared in a recent Time Magazine. The issue was about three or four weeks ago. It discusses MD Anderson up front and very extensively about the way in which it's being run as a business. I think you might find it interesting. I'm sure it's likely to be in your hospital library. This change in medicine is quite widespread and in no way limited to one or a few centers.
Dr. Peters: Yes, I would be very interested to read that. Presumably it was not a very complimentary article, was it?
Dr. Suit: Well, it's about the way American medicine is becoming a business.
Dr. Peters: Right.
Dr. Suit: And I know I've heard a number of very top academic people refer to patients as customers.
Dr. Campbell: Really?
Dr. Peters: As customers?
Dr. Suit: Yes. And you can tell by the way I'm talking, it was not something that was pleasant for me to hear. But anyway, I've said enough on this. We're talking about you, but you brought that up and I thought you might find it interesting.
Dr. Peters: Indeed, yes, I will. I'll look it up. There are many similarities, of course, between places like MD Anderson and Peter MacCallum in the context that they're both dedicated to the concept of multidisciplinary care and we have management by tumor streams rather than by disciplinary groups. So all patients who come in are treated within a multidisciplinary team, all dedicated to the same disease type; it's not a sequential system of referral as you might get in some other places. We also have the common business model of MD Anderson where all the practitioners have a common remuneration system so there’s no financial competition between different specialties to see who gets to treat the patients, which I think is very important.
Dr. Suit: I would say yes. The business aspect of our cancer centers have not affected the quality of care. From my observations, patients who are admitted receive quite excellent care in the best sense of the word.
Dr. Peters: So there are very positive things. Our biggest frustration in Australia is having a demand that exceeds supply and not being able to react to that demand by increasing capacity. If we ran our own show rather than having the government run it for us, we would have many more accelerators running and many more clinical offices open so that everyone who wanted to come here could come here. It's very frustrating to have to turn people away who want to access the skills that are available at places like Peter MacCallum simply because there's no room for them. And you face a very strong ethical dilemma when you have to decide between making someone wait for highly expert treatment or send them away to a lesser expert practitioner who can see them tomorrow: you know, what is better for the patient? It's a real struggle and I think it's stressful for the staff and, of course, it's very frustrating for the patients not to be able to get access to the place in a timely fashion.
Dr. Suit: Surely. Well, listen, is there something you would like to add to this? Because we're getting close to our allotted time limit. But if there's something that you would like to bring out about you and your career and your future or anything of this sort, what you think about medicine's future, whatever, I think we would like to hear an opinion.
Dr. Peters: Well...
Dr. Campbell: That leads very nicely, actually, to my next question. I wanted to ask professor Peters about his presidential address at the ASTRO Annual Meeting in 1994 and his presidential address, entitled “Looking Through the Glass Darkly, Predicting the Future of Radiation Oncology”. That was now almost 20 years ago and so I was wondering if you could tell us about how you feel that the practice of radiation oncology has changed in the last 20 years, and perhaps how you might see it changing in the future?
Dr. Peters: Oh, gee. Thanks, Belinda. The goal of my presidential address was to try to convince people not to be so pessimistic about the future of radiation oncology. There was a great sense of gloom pervading the specialty at the time: that radiation oncologists were being marginalized and there was nowhere for us to go and so forth. I tried to make the point that nobody can foretell the future with any accuracy, hence “looking through the glass darkly”. The theme of my talk was that the best way to predict the future is to create it. So we should be out doing things that will create a guaranteed future for radiation oncology, and we do that by involving ourselves in research and development and establishing an evidence base for what we do that makes it indisputable that radiation is an essential component of modern cancer treatment. The big things that have happened in the last 20 years are dominated by the technological advances which have been absolutely phenomenal: not just in radiation therapy planning and delivery, but also in diagnostic imaging as well. The way that we now incorporate sophisticated imaging and exquisitely accurate planning into the use of radiation has been a major step forward for the specialty. There's also been a great deal of refinement, I think, in the way combined modality treatment has been given with the extension beyond simple cytotoxics into biologics, and that will increase for sure in the next 20 years. One of my biggest personal disappointments is the failure of predictive assays of radiation sensitivity to gain much traction. I've spent quite a bit of my life working on assays of tumor and normal tissue radio-resistance, but there's nothing that ever has come forward that's sufficiently accurate and reproducible to be used in the clinic. But I think genetic profiling of tumor cells and normal tissue cells will probably reach a point in the next 20 years where we can customize treatment according to individual genetically-determined parameters of radio resistance.
Dr. Campbell: Do I have time for one more question? I wanted to ask about your passions, professor. It seems to me that you've always been a very strong advocate for education, whether at the junior trainee level or at the ASTRO refresher courses for practicing radiation oncologists. Certainly when I was a junior trainee, we all regarded your lectures as “words dipped in gold”, that was exactly how we described them. And so I was wondering, do you consider teaching to be one of your passions?
Dr. Peters: Oh, undoubtedly, Belinda. I've never considered myself a great teacher, but I do love doing it. You mentioned about the ASTRO refresher courses. One of the innovations I brought in when I was president of ASTRO (as the president gets to plan the annual meeting), was to run the refresher courses all day rather than just have them as pre-breakfast offerings. That became very popular because so many practicing radiation oncologists would go to ASTRO just to get an update on how the experts see things rather than to learn cutting-edge new research. At the resident level, the trainee level, I really enjoy interactive teaching where you talk backward and forward with the young people. The look you see in their eyes when something suddenly makes sense that was previously a bit of a mystery is one of the greatest joys of teaching. And I think if you can help people to understand concepts and use them, it's always a huge reward to any teacher.
Dr. Campbell: And do you have any other passions?
Dr. Peters: Well, you know about my Harley. I've been a motorbike rider ever since I was 17, so when people say you're having your late-life crisis, that's not right because I've been riding my motorbike for over 50 years. But I do love my motorbike and spend a bit of time on it. I play a lot of tennis and I enjoy doing lots of things with the family and just nothing sometimes-- oh, I love Sudoku, too.
Dr. Campbell: Very good. Do you have any other questions, Herman?
Dr. Suit: No, I think we've been very fortunate being able to listen to Lester discuss his medical career, and it was very positive and just a fine experience. I really have been a long-time admirer of Lester as a superior human being as well as a radiation oncologist. I tried hard to recruit him to the MGH, but I didn't succeed.
Dr. Peters: Well, Herman, you know about my admiration for you, as well. You've truly been a role model for me and I think your philosophy of life and mine are just so simpatico. It's been an honor to be able to have this interview with you and Belinda. And thanks to ASTRO very much.
Dr. Suit: Well, congratulations to you and your family and to Peter MacCallum and so hopefully we'll get to see you in this country before too long, before too many months go by.
Dr. Peters: Okay, Herman.
Dr. Suit: Take care.
Dr. Peters: Thank you. All the best.
Dr. Suit: Au revoir to you and Belinda.
Dr. Peters: Good-bye.
Dr. Campbell: To finish up, I would like to thank professor Peters for generously sharing his time, recollections, and his insights with us today. It has been a great pleasure and an honor to have had this interview with you today, professor Peters.
Dr. Peters: Thank you, Belinda.
