Larry Kun, MD, FASTRO
By Iris C. Gibbs, MD, FASTRO
The following interview of Larry Kun, MD, FASTRO, was conducted on May 16, 2014 by Iris C. Gibbs, MD, FASTRO.
Iris C. Gibbs: I am Iris Gibbs. Today is Friday, May 16, 2014 and on behalf of the ASTRO History Committee, I will be conducting an interview with Dr. Larry Kun. He’s the clinical director of St. Jude’s Children Hospital and an ASTRO Gold Medalist. First, I’d like to say that this is quite an honor for me to talk to you today, because you are definitely one of the luminaries in our field.
Larry Kun: It’s my pleasure and my honor.
Iris C. Gibbs: Can you talk about your background? I understand that you were born in Philadelphia.
Larry Kun: Yes, a native of Philadelphia, born and educated in the area, only person since 1898 in my family, I think, who has left Philadelphia. I went to Penn State and Jefferson Medical College. Starting in 1963, the first year of a BSMD program. I spent a year at Penn State and then went to Jefferson at the age of 18. During my time at Jefferson, Simon Kramer and I spent summers and whatever free time I had in radiation oncology. He subsequently introduced me to Juan del Regato and a 6-week elective at Penrose in Colorado Springs further interested me in radiation oncology. After a general internship in Rochester, New York, I joined the residency program at Penrose Cancer Hospital under Dr. del Regato in 1969; a very exciting program itself. And then, subsequently, out to Colorado Springs.
Iris C. Gibbs: So, you moved around a bit and were able to meet with quite a few very important leaders in radiation oncology of that time. It seems that your entrée into radiation oncology started pretty early.
Larry Kun: As sophomore med students we had the privilege of attending a series of lectures. Simon Kramer who gave an intro to both cancer and radiation oncology. Even at that time when our field was quite small and not very prominent, to choose training in radiation oncology. There were three of us when I graduated who went into radiation oncology. I spent the summers after my first year at med school just briefly and then for much of the summer second year of med school with Dr. Kramer in his department that included a number of people active in many areas in radiation oncology including Carl Mansfield who was his then third in command at the time. I worked with Carl Mansfield in both nuclear medicine and radiation oncology, then watched as Simon introduced combined chemotherapy and radiation in head and neck cancer and worked along with neurosurgery exploring malignancies of adolescent pediatric brain tumors. Simon was just a phenomenal guy, a tremendous asset and a very interesting individual, both as a physician and also as a mentor for med students and others.
Iris C. Gibbs: Do you recall what it was about that lecture that captivated you? Was it about the technology at that time or was it just Simon’s personality and engagement with the students?
Larry Kun: In the 1960s, things were very simple in radiation therapy. Simon was very interested in cancer, obviously, and in ways that cancer grew and spread, and in how one would approach this with radiation therapy. I think most impressive was following him on rounds. Simon, whose history is perhaps much more apparent, is one who, although he grew up initially in Germany, pursued medical training in England. Although he was not a native of Great Britain, he had a very cultured English accent, and I was very impressed with the fact that he had a fairly large inpatient service.
At the time, he was just exploring combined chemotherapy into radiation for head and neck cancer. In fact that protocol was methotrexate and irradiation, exported to Hahnemann and, I believe, to NYU, provided the initial nidus for what became RTOG. But he would round on patients who were incredibly ill, who had severe episcleritis, and difficulty maintaining things at the time when we didn’t really have IV support we do today. I’ve always been convinced it was his charm, in part his accent, at a time when Americans idolized Great Britain, and just his incredible ability to be in a crowd of eight or ten or 12 people and be clearly focused on this one patient. He and his colleagues impressed me as a physician and interested me in his field.
Iris C. Gibbs: You had mentioned that during that time you also were introduced to and worked with Juan del Regato.
Larry Kun: I went to Simon Kramer in the very early part of my senior year. We didn’t have electives at that time, but during our junior and senior year, at some point, there was a six-week period that was meant to be a vacation; most of us spent it in elective at some location. I spoke to Simon, essentially saying something like, “You know I consider this really a crazy field, quite far from the norm.” But at that time was debating between neurology and radiation therapy and asked him if he could identify a place for me to go as an elective that would further introduce me to do radiation therapy.
Dr. Kramer arranged for me to spend time with Juan del Regato. This was in the last six weeks of 1967. And I went out and he had warned me that Dr. del Regato would always convene his entire crew for lunch, both an exciting and sometimes intimidating time. But it was something that I would ultimately come to cherish. On my very first day I walked through the door at Penrose and it was mid-day, and I saw this group of people sitting at a large table in the front of the cafeteria. I never went up to say hello at that point, but I quickly ran over to the office and introduced myself and signed in with Dr. del Regato that day after lunch. The six weeks I had out there was quite an exciting time. It included several luminaries in our field who were in training with Dr. del Regato at the time, including Jim Cox and Frank Wilson others. Our group, a very closely knit, both faculty level which was quite small when I first got there, it was really just two, Juan del Regato and Chahin Chahbazian, who was in charge of the training program.
There was a large number of residents, ten to twelve at that time. And just an opportunity to see yet another outstanding clinician, different accent this time, Spanish-Cuban accent. But again someone who was just incredibly interested in cancer, what it was like, how it manifested itself. Extremely interested in history, both the history of the field and the history of medicine but also in a very broad sense of world history in several areas that I also found fascinating.
It was a time in the 1960s when American Society was going through tremendous turbulence. And del Regato at the time seemed quite grandfatherly to me and still seemed fatherly, I think, to many of those yet in training. He was interested in liberal politics, as was I, although his definition of that preceded somebody who is at that point was just beyond his teenage years in the 1960s. I became very fond of him as a mentor and friend. Similarly enjoyed following him both in rounds and in his various arguments both verbally and in writing with some of the people at the time who were just beginning clinical trials in surgery and radiation therapy as the cooperative groups were being founded or just beginning. It was just a fascinating opportunity. By the time I left there, I asked if they considered me at a subsequent time for residency and we spoke about that. It was premature to do anything formal but the die was sort of cast at that point. That became obviously, throughout his life and throughout my continuing career, a tremendous guidance from Juan del Regato.
Iris C. Gibbs: Wow. That’s quite intriguing, your pathway into the field, meeting and working with such great individuals who made such an impact, as well. According to your CV, it looks like you went then to the NIH?
Larry Kun: Yes, following residency at the time, the program in the U.S. Public Health Service was one that was an option to being available for the draft for the Vietnam War. That was one point of interest potentially for a large number of us going into training at NIH. And one of del Regato’s former trainees, Ralph Johnson, a fairly interesting, bright and rather enigmatic man, was in charge at NIH and I went to speak with him and interview just really the last week of my medical school training. They were doing things in a very interesting manner. It was a place at the time that was just beginning a tremendous upswing in the visibility and recruitment of people who really set the trend for clinical investigation in pediatric, adult, medical oncology, pediatric oncology and surgical oncology. It was a very exciting place. And I sort of negotiated with Ralph Johnson the opportunity to complete the then three-year training program in radiation oncology, before coming back to him, which was then four years in an internship and three years yet to go. But it did turn out to be a very worthwhile two years. Most of our focus in the radiation branch at the time was on Hodgkin’s Disease and other malignant lymphomas which was an area which I had an interest in, particularly since del Regato had some very unconventional thoughts about Hodgkin’s Disease. I found myself in an area with Vince DeVita, Paul Carbone and Ralph Johnson, all of whom set the pace as had others obviously at Stanford and up in Tirano in Hodgkin’s Disease at that time.
Iris C. Gibbs: I see that your first paper was 1974, looking at the hematologic recovery and deterioration after successful radiotherapy for Hodgkin’s Disease.
Larry Kun: Yes. There were several things then, immune changes. There were a lot of observations, at the time in the Radiation Branch, even though a lot of it wasn’t ultimately followed through in the way we might today. For example, the first introduction of combined radiation and chemotherapy for Ewing’s sarcoma in kids, for small cell carcinoma in adults. All of these were introduced amongst the faculty and staff in Ralph’s department at that time. And the fact that we could meet weekly with people like Vince DeVita and, Cos Berard in Pathology who had helped define the classification at that time for lymphomas and review all the cases in staging conference and argue a bit about how best to treat them. It was quite a worthwhile endeavor and an opportunity to meet people with whom I interacted for many years thereafter in my career.
Iris C. Gibbs: Yes, for sure that was definitely a very active time in redefining and redirecting some of the treatments for that disease. I think some of these early papers and early efforts certainly changed the trajectory for that disease. When was it that you became more interested or worked more with pediatric malignancy?
Larry Kun: Yes, it was actually the second year of my two years at NIH. Tom Pomeroy was one of the senior radiation oncologists working with Ralph Johnson and he had started a program, following Ralph’s initial idea combining chemotherapy and radiation for Ewing’s sarcoma. He was also the interface with the pediatric oncology branch at NCI. I became involved through him, very closely, with the leukemia lymphoma and then the solid tumor programs within the pediatric branch. People like Phil Pizzo and David Poplack, continued to be leaders in those areas, within pediatric oncology and in other prominent positions. It was an opportunity to look at things a little bit differently since clearly pediatric cancers were more responsive to chemotherapy than adult cancers were at a time when chemotherapy was quite new and defining where radiation therapy would interface. It was really a very interesting challenge at that point. That was my first real interest in pediatrics that subsequently played out over the next two or three phases in my career development.
Iris C. Gibbs: Around that time, was the Pediatric Oncology Group just forming or had it already been active?
Larry Kun: POG came later. The Pediatric Oncology Group was started in 1980. The initial pediatric group was SWOG. Actually it was started as a pediatric group between Donald Pinkel, who was in charge at St. Jude, and the MD Anderson group. They quickly morphed into a largely adult group. Soon thereafter the CCSG, Child Cancer Study Group, came about as well as the pediatric part of CALGB. The three of those pediatric groups were basically non-funded back around 1979 and 1980, when NCI made a purposeful change to fund a second pediatric group. The CCSG continued, but CALGB and SWOG were defunded. At that point, POG was founded in 1980.
Iris C. Gibbs: I see. And then ultimately it’s been joining CCG and becoming the COG twenty years later. Well, I think I am getting a little ahead of myself. I see something very interesting, the time in Rotterdam, in the Netherlands, was that a one year exploratory experience or was that something that you were taking the opportunity to just teach and train abroad?
Larry Kun: It was a combination of two things, Iris. One of the requisites that del Regato could not enforce but encouraged at the time, was to spend time in Europe after completing training with him. Number one, the center at Penrose was relatively small, and number two, the centers in Europe at that time were both larger and in many ways more advanced and more incorporated into medicine than we were as a much younger sub-specialty in the United States at that point.
So, it was something I was somewhat expected to do, and then as I got into my time at NIH and I realized that the Radiation Branch was so disease focused that much of my time would be spent in pediatrics and maybe just three of the more common adult type cancers. I really felt I needed a broader experience before I sought a faculty position. So, I actually went to Steve Brown, who had been one of the people training with del Regato when I was a medical student. Steve was in charge at the University of Vermont and after looking around, I arranged to go back there as faculty after I had the opportunity to go to Rotterdam.
I went to Rotterdam, worked primarily Birgit van der Werf-Messing, who also had an interest in both lymphomas and pediatric cancers. She had organized a tremendous program in Rotterdam that at the time I think was the dominant program in the Netherlands. And it was a tremendous opportunity just to see a large number of cancer cases with excellent follow-up and really advanced technology in radiation therapy. They were far more sophisticated than what my experience had been prior to that. It was really very exciting year, in every way and personally my wife and one-year old daughter and I enjoyed the entirety of the time we spent abroad.
Iris C. Gibbs: Were they far more sophisticated, in terms of the machinery or just in terms of the general approach to treatment?
Larry Kun: They were using linear accelerators that were more sophisticated than what I’d seen earlier. They had developed some of the earlier, more flexible blocks and they had a very advanced and integrated physics group. At the time, they were looking at further developing some of the higher energy linear accelerators, which were then quite new. It was a nice opportunity to see how that would play out and they were very systematic in introducing modifications in technology in a way that is common to us today but was new at that time.
Iris C. Gibbs: Let's talk about your first faculty appointment at the University of Vermont. How did that come about?
Larry Kun: That was the result of my discussion with Steve Brown about the opportunity at the University of Vermont, I was very much a child of the 1960s, and having an academic program and a place that was up in the mountains and sort of away from things suited my personality very well. I went there and it turned out to be a smaller center from which to launch an academic career than I might have liked. Although, it was a very worthwhile year for me. It was about a year and a half, total time. It was pretty obvious to me within a few months, that the people in surgical and medical oncology encouraged me to look elsewhere because they recognized the limitations of a very small radiation therapy department and the lack of opportunity to achieve some of the goals I had.
It also, though, did serve to introduce me at the time to CALGB which was the adult and pediatric group, with which Vermont was associated. And to see it as a career opportunity, but to realize that I needed to be in an institution that was larger and more progressive, beyond simply a national type of opportunity in the cooperative group. It was worthwhile. And I started there in early part of 1975. By the latter part of that year, actually right after ASTRO, I interviewed at the Medical College of Wisconsin, to which I moved shortly thereafter.
Iris C. Gibbs: So tell me about your time at Wisconsin. How did that influence your career development?
Larry Kun: Well, Milwaukee was very exciting, and along with Simon Kramer and Juan del Regato, I would certainly identify Jim Cox, both as a very close friend as well as a mentor. I had met Jim and his family when I was a med student out in Colorado Springs. We continued a very close relationship and as a matter of fact, we considered working together in Washington where he became chair at Georgetown and where I was thinking of staying when I completed my time at NIH. It was pretty obvious to Jim that Georgetown wasn’t going to give him the opportunities he wanted and when he decided to move out to the Medical College of Wisconsin, I thought of that as well.
The timing worked quite nicely as I was then in Vermont and looking potentially to go elsewhere. Going to the Medical College of Wisconsin was like rekindling a lot relationships. Jim Cox was there, along with Frank Wilson, Roger Byhardt, Don Eisert. All of whom trained with del Regato, either while I was there as a med student or later during my residency. As a matter of fact, three of the four lived on one corner, so it was a chance to both continue friendships, continue the culture, if you would, in radiation oncology based upon the “Chief,” as we called Del Regato, and some of his principles. And to go to an institution that was beginning to grow considerably in Milwaukee, at that time, and where radiation oncology quickly became the dominant oncologic department that really supported and grew medical oncology and supported surgical oncology as well.
The other positive aspect, which we can explore a little bit in a few minutes, is that Don Pinkel, who was the founding director at St. Jude Children’s Research Hospital in Memphis, had moved to Milwaukee just before Jim Cox had settled there. And, at the time I was being recruited by MCW, it was really jointly by Jim and Don Pinkel. And then we had sort of a memorable evening on the phone at the time when I was speaking with both Jim and with Don. It was the first time that I looked seriously at creating a career focus that would be, essentially in pediatric radiation oncology. It seemed to me very exciting and at the same time limiting. It was hard to envision exactly where it might go. It was something that was met with a certain skepticism by my wife who envisioned me, as I had been even at that time, very uptight and involved, both from the stand point of professional and emotional involvement with kids. I had taken a leading role in treating the few kids we saw at Penrose and then obviously, developed that further as indicated in my time at NIH.
When I moved to Milwaukee, it was with the knowledge that I would take the leadership role in pediatric radiation oncology and that we were developing a program in radiation oncology and pediatric cancer. And it was a phenomenal opportunity, Don was creating what’s still known as the Midwest Children’s Cancer Center, based at Children’s Hospital of Wisconsin now. And he fully integrated me into that program. I was based in the Department of Radiation Oncology, five miles away from the Children’s Hospital at the time, but went back and forth more than once every day. We were able to set up the service at Children’s where essentially all the brain tumors, most of the Hodgkin’s disease and half of the solid tumors were on my service and it meant that the radiation oncology residents and I were responsible for both in-hospital and out-patient care, and chemotherapy as well as radiation therapy and the fields were young enough at the time that mixing them was easy.
And it developed into sort of a parallel career opportunity to really grow clinical care, clinical investigation and training, related both to radiation oncology and to pediatric oncology. It was an exciting time, there was a lot of growth in both areas, some very good people with whom I worked to become lifelong colleagues and friends. And it really enabled us to set the pace for that institution becoming one of the founding members of POG in 1980 and create an opportunity that catapulted me into a position to really lead the development in pediatric brain tumors within POG, at the same time we were focusing on what was relatively small but vibrant program, in Milwaukee.
Iris C. Gibbs: And so you had mentioned earlier that Pinkel was thinking of the concepts for the St. Jude Children’s Hospital. How did that evolve? Obviously, it looked like you were being groomed for that leadership role.
Larry Kun: Yeah, in retrospect it seems all pre-programmed. Don had been recruited by Danny Thomas when St. Jude was first being built, to become the Scientific Director, the Director at St. Jude. St. Jude opened in 1962. Don, who had been a very creative, at the time rather young, I think he was in his mid-thirties, pediatric oncologist who had been at Boston University and at Roswell Park in Buffalo. When there, he recruited a small cadre of both clinicians and scientists interested in aspects that were relevant at that time in pediatric cancer including Omar Hustu, who was the radiation oncologist there from the very beginning and my initial colleague when I moved to St. Jude. And Don obviously was the individual responsible for taking what actually was a laboratory experiment that Ralph Johnson had done at NIH in trying to cure the 12-10L model of leukemia with chemotherapy in mice had never been successful, until they added cranial radiation and found that they could cure leukemia. Don picked up on that and began what became known as the total therapy approach to ALL, childhood lymphoblastic leukemia in the early to mid-1960s. By 1968-1970, Don was publishing what became the first curative approach to childhood leukemia. That was based upon modifications of initial cranial, then craniospinal, then cranial radiation in combination with IT chemotherapy, cementing radiation therapy into the development at St. Jude as well as indicating the importance of collaborative networks in pediatric oncology which, to this day remains very easy amongst the specialties in pediatric cancer, perhaps easier than in many adult cancers.
From the time I got to Milwaukee, within a year or two, Don was trying to move me down to St. Jude which I looked at in 1979, but it wasn’t yet right for me. It was too confining, I thought, nor right for St. Jude, I think at that point. Then five years later, Joe Simone, became the third director at St. Jude, a well-known pediatric oncologist, involved in both organizational aspects of oncologic medicine as well as several cooperative groups. And Joe recruited me to St. Jude to take over radiation oncology as chair in 1984, it was a time when I think my goals were to identify the then diminishing indications for radiation therapy in pediatric cancer because of the balance we saw with more and more introduction of effective chemotherapy agents at that point and increasing recognition of some of the late effects of radiation therapy. And it seemed the right time to really concentrate on areas where radiation therapy made a significant difference and at the same time begin to fine-tune how that radiation therapy was given as well as an opportunity, perhaps unique at St. Jude, to do some long-term follow-up studies.
Fortunately, it was at a time when number one, the chemotherapy that was introduced presented a lot of challenges in how one best combined chemotherapy in radiation. Number two, the cooperative groups were very strong and relatively well-funded and so I was able to enjoy a position in developing the brain tumor committee in POG in 1984 with really great neurosurgery, pediatric oncology and radiation therapy and focus on opportunities in radiation oncology that were very important to us in the mid-1980s. At the same time, I was committed to developing a brain tumor program at St. Jude. At the time I arrived at St. Jude, they were treating every type of childhood cancer except brain tumors. There was no interest. There was no neurosurgery, no neuropathology, no neuroradiology, no neuro-anything and as part of my recruitment, we agreed we would establish a small but focused pediatric brain tumor program. We estimated we would bring in about 12 patients per year and I promised the tumor group who was reluctantly willing to support this with me that we would never see more than 12-15 patients per year. Now we see 12 patients every two to three weeks and it took off in a very successful and worthwhile manner.
Over a very brief period of time, I recruited neurosurgery, neuropathology, neuropsychology, and the entire network of individuals who specialized in brain tumors. We focused the brain tumor efforts within the radiation oncology department including neuro-oncology, neurology, and psychology initially within that structure and gradually recruited so that each became independent departments at St. Jude and were able, in parallel, to develop a lot of pilot protocols and studies in Memphis and to use those in part as one of the several mechanisms of bringing studies into the national clinical trials network through POG and then combining POG’s studies jointly with CCSG at that time. So it became a tremendous opportunity to learn and to apply some of the new principles.
Iris C. Gibbs: What do you think were the keys to that success? Obviously, many departments tried to build a team across disciplines and you have been very successful in the brain tumor program. Was it a willingness to work together? Was it more about being open to thinking outside the box? What were the keys you believed were the success there?
Larry Kun: I think the most important aspect of it was the good fortune in recruiting really good people. In each one of the areas that we were involved with, certainly neurosurgery and phycology, people like Alex Sanford in neurosurgery, who not only at St. Jude but within POG, in parallel, developed the neurosurgical interests as we were developing the broader multidisciplinary interests. Ray Mulhern, psychology, who did the first studies in Milwaukee and then followed through when he moved with me to St. Jude and within POG and doing the first studies that documented the neurocognitive changes in children after brain radiation.
From the very beginning, we organized the program in such a way that there was a weekly brain tumor conference that initially included four or five of us and within a very short period of time, 20 or more, now 30 or more individuals, representing every discipline ranging from nutrition, rehabilitation up to neurosurgery and our own field. Every new patient was presented there. Initially, we would actually round to see the patients in the clinic at the same time and as time went on that was done either before or after conference. And we would commit anywhere from 1 to 3 hours every Wednesday afternoon to reviewing cases in a way which is now common in a tumor board setting with review of clinical imaging, pathology and then pretty lively discussion. It wasn’t quite as common and it wasn’t at all common in brain tumors at the time when a lot of neurosurgeons were very possessive of their patients. And people in our field, as well as in pediatric oncology, just weren’t as interested.
So, from the very beginning brought, fortunately the right people together and also neurosurgery was just then developing, what subsequently became a recognized program but a program in pediatric neurosurgery for fellowship so that we had a training focus there. We were able to bring in residents from ultimately over 20 to 25 different training programs in the United States whose residents would rotate through radiation oncology for anywhere from 1 to 3 months for the opportunity to be exposed to pretty intensive experience in pediatrics at St. Jude as well in CNS tumors and psychology as well. So we were able to bring people in with different backgrounds and perspectives and just build upon that in a multidisciplinary manner and we did the same thing in parallel in POG.
Iris C. Gibbs: So, I think we probably have another 10 to 15 minutes left. I would like to focus on your reflections on radiation oncology as a field. What do you think have been the most important advances in pediatric brain tumors or radiation oncology in general during your time of practice?
Larry Kun: I think the ability to combine a field that truly looks at cancer as a disease and a challenge where one has to understand how and where tumors begin and where they spread. It has always been a privilege to identify in radiation therapy, the necessity to be an outstanding clinician, to be as good a neurologist as you can be, in dealing with neurologists and neurosurgeons and straight down the line.
The opportunity as the mid-1990s approached when the technological development in our field became so overwhelmingly positive, changed entirely the focus in pediatrics and in brain tumors, I think both in children and adults. From one of being somewhat defensive and trying to look at how we would minimize the use and impact of radiation therapy to really being able to capitalize on 3D conformal and IMRT and now particle based radiation therapy where the risk benefit ratios could be optimized. At the time, I initially went into St. Jude, we were treating every leukemia child and because of that we were treating perhaps 60 to 70 percent of children who entered the institution. Now, we treat zero leukemia children at St. Jude but because of the size of the brain tumor and Solid Tumor Programs and the central importance of radiation therapy, with the technical capabilities we have today, we’re still treating 60 to 70 percent of kids, which just amazes us. I think it has been the opportunity to combine the interests and the insights of the clinical field with the technology developments that have been so profound over the past 15 years.
Iris C. Gibbs: Where do you see the field going in the next, let’s say, 10 to 20 years?
Larry Kun: I think, clearly, the intense interest in chemotherapy has changed and the impact of new cytotoxic drugs plateaued, certainly in pediatric areas, and I think in many areas, now 15 years ago at the time when our technology became so paramount. I think we will define new roles for protons and other potential particle based therapies, certainly in pediatrics, and presumably in several other adult areas in cancer. I think that the ability to interface radiation therapy with the molecular targeting agents is something that is just beginning to be explored and perhaps will be one of the major areas of focus, certainly in pediatrics, and in adult areas as well, over the next 5 to 10 years. I don’t know what other new biological innovations will potentially require some of the same challenges be met in interfacing them with radiation therapy, but I suspect that will continue to evolve over the next 5 to 10 years. And then the sometimes tricky interface of radiation therapy and immunotherapy as it now reaches its second or third generation, with interest in vaccine therapies, etc. will also require quite a bit of interesting thought and prospective studies to best integrate those treatments.
Iris C. Gibbs: One of the impressions I have, hearing all the wonderful stories you’ve shared about your journey in radiation oncology and pediatric neuro-radiation oncology, is the importance of your mentors and importance of key people who essentially gave you ideas on how to structure things. In an apprenticeship model in which the trainees of leaders like Juan del Regato, took what they learned and became like yourself, luminaries in the field. Do you think our current environment of training and radiation oncology lends itself to that degree of apprenticeship and mentorship?
Larry Kun: I think it does. I think it’s harder for trainees now in the field. At the time, I went into training, the field was small. The opportunity to meet people like del Regato and Henry Kaplan and Gilbert Fletcher was easy and the challenges that we had in knowledge base required breadth of science related to medicine in general, let alone to oncology. It’s a lot right now that faces each one of our trainees. I think that the broad understanding that’s required, clinically number one, and then you can go into every different aspect whether it’s pathology or imaging and beyond, is certainly a greater hurdle than it was for us at that time. Does that change the importance of personal interactions and mentorship? I don’t think so. I think that if you’ll look now at the generation behind me, as those of us at my level are beginning to step down from leadership positions, or have already done so, I think that those that we have trained have similar interests in developing outstanding training programs and committing the time and effort to that goal. But I think that the trainees face a real challenge in what they have to grasp, put into their knowledge base and understanding, and then move forward with their own plans.
Iris C. Gibbs: In reflecting on how you described your time at Wisconsin and how, as the chief of that service you were giving chemotherapy, planning radiation and managing a great number in-patients, it is clear that things have really changed in our current training approaches.
Larry Kun: They have and I think the only caution that I would express and it’s something that goes back now decades, even to the time I first started my own training. It’s really important in radiation oncology to get out from the basement as people used to say, and away from the sense that we’re sort of the dark side, often our own because of the emphasis we placed on physics and technology. It’s really important to be integrated, into the hospital systems even more so as we get into some of the social economic changes that now confront medicine. I think the, the best mentors at many of the better institutions around the country, recognize that and I think try very hard to integrate the radiation therapy training into the full aspect of both science and medicine. It is something that’s not easily available except with time and effort, I think it’s available and worthwhile for everybody.
Iris C. Gibbs: Okay, before I ask my final question, I first want to find out what activities are you passionate about outside of medicine?
Larry Kun: I guess number one at this point in my life is grandchildren, I have five of them and they range from eight to five years of age. That is a great time commitment, and obviously my wife and I spend more and more time together. Although, at the moment I both chair a department and run a hospital so that time becomes scarce, it’s a daily challenge. Travel is important, as well as continuing to read avidly in history and politics, which have been primaries of interest. Physically, it’s walking, hiking and biking, anytime I can, everywhere I can, and that pretty much takes up the rest of my lifetime.
Iris C. Gibbs: So, is there anything else you wanted to let us know about your family? I don’t think we talked much about your travels, over the several years of your training and career. How important was, you know, your family life during that time?
Larry Kun: Yeah. Well my wife and I have been together now, 43 years and time gets only closer and more enjoyable day by day. We have two daughters. My family is nicely cemented into the world of pediatrics. My older daughter is married to a pediatric urologist in Columbus, Ohio with the Nationwide Children’s Hospital and my younger daughter trained in pediatric oncology and is in Dallas where she is now an active pediatrician. I have three grand kids down in Dallas and two up in Columbus. I don’t think that anybody can succeed in an area that faces as many physical as well as the emotional strains, if you will, without having a strong family background and it’s been my privilege and joy to have that throughout my life.
Iris C. Gibbs: This question about your decision in the last year or so to serve as director-- the clinical director, and then chair of St. Jude Children’s Hospital. What factors influenced your decision to take on that position?
Larry Kun: I guess the term I’ve usually used is military voluntarism. We were at the point where there was a change in the clinical directorship which is one of the three primary administrative positions at St. Jude and I was asked if I would, in a sort of caretaker manner, take over the clinical directorship for a year or so. It turned out to be an unbelievable pleasure and privilege, to really have the opportunity to look at a lot of the functions, structures, organizations within St. Jude that I’ve been a part of now for, it’ll be 30 years now this summer, and have really the opportunity to change them and optimize them so we’ve really looked, upside down, from the top to the bottom, if you will at a lot of the key infrastructures that are important for clinical care and for clinical care in an environment totally dedicated to clinical investigation and translational science. And try to optimize that and it something that it’s been a pleasure to see things rapidly improve and respond to, really again just bring people from different areas together on the table, hour by hour, day by day, during every week just to see how we can make things better. And so I’ve just recently decided it wouldn’t be quite so interim and we’d continued to do this at least for the next two years which will take me to the age of 70. I think at that time, it’s time for me to think about doing some things that are not quite as involving in a usually 14-hour day. But it’s been a real privilege to do this.
Iris C. Gibbs: I just wanted to say what a pleasure it’s been to, to talk with you. Are there any final thoughts or final insights or lessons that you might wish to impart to those who will be reviewing this interview and words of wisdom?
Larry Kun: Well, I’m not sure how wise but I think one of the things we have not touched on at all, is the opportunity people have in, I guess organized medicine, the best way to term it. The opportunities that I have had in ASTRO, the American Board of Radiology and certainly in the pediatric cooperative groups, to really work with some phenomenal people, both colleagues in medicine and an incredibly dedicated staff, to take on challenges in areas that are quite different from those that we face day to day in medicine have just been unbelievably worthwhile and frankly enjoyable. It’s created most of my very best friends along with those I’ve had in training and earlier professional development. And really an opportunity to look at so many different areas of medicine, sociology in people, and bring them to bear and other aspects of career as well as social life so that’s an area that most people don’t think about and really don’t need to early in their training. But as those opportunities become available, they too can be just beautifully enriching. Thank you, Iris, it has been a real pleasure.
Iris C. Gibbs: It’s been definitely a pleasure for me as well and on behalf of the ASTRO History Committee, I really want to thank you for this great honor and opportunity to conduct this interview.
Larry Kun: Well, thank you very much. Take good care.
The following interview of Larry Kun, MD, FASTRO, was conducted on May 16, 2014 by Iris C. Gibbs, MD, FASTRO.
Iris C. Gibbs: I am Iris Gibbs. Today is Friday, May 16, 2014 and on behalf of the ASTRO History Committee, I will be conducting an interview with Dr. Larry Kun. He’s the clinical director of St. Jude’s Children Hospital and an ASTRO Gold Medalist. First, I’d like to say that this is quite an honor for me to talk to you today, because you are definitely one of the luminaries in our field.
Larry Kun: It’s my pleasure and my honor.
Iris C. Gibbs: Can you talk about your background? I understand that you were born in Philadelphia.
Larry Kun: Yes, a native of Philadelphia, born and educated in the area, only person since 1898 in my family, I think, who has left Philadelphia. I went to Penn State and Jefferson Medical College. Starting in 1963, the first year of a BSMD program. I spent a year at Penn State and then went to Jefferson at the age of 18. During my time at Jefferson, Simon Kramer and I spent summers and whatever free time I had in radiation oncology. He subsequently introduced me to Juan del Regato and a 6-week elective at Penrose in Colorado Springs further interested me in radiation oncology. After a general internship in Rochester, New York, I joined the residency program at Penrose Cancer Hospital under Dr. del Regato in 1969; a very exciting program itself. And then, subsequently, out to Colorado Springs.
Iris C. Gibbs: So, you moved around a bit and were able to meet with quite a few very important leaders in radiation oncology of that time. It seems that your entrée into radiation oncology started pretty early.
Larry Kun: As sophomore med students we had the privilege of attending a series of lectures. Simon Kramer who gave an intro to both cancer and radiation oncology. Even at that time when our field was quite small and not very prominent, to choose training in radiation oncology. There were three of us when I graduated who went into radiation oncology. I spent the summers after my first year at med school just briefly and then for much of the summer second year of med school with Dr. Kramer in his department that included a number of people active in many areas in radiation oncology including Carl Mansfield who was his then third in command at the time. I worked with Carl Mansfield in both nuclear medicine and radiation oncology, then watched as Simon introduced combined chemotherapy and radiation in head and neck cancer and worked along with neurosurgery exploring malignancies of adolescent pediatric brain tumors. Simon was just a phenomenal guy, a tremendous asset and a very interesting individual, both as a physician and also as a mentor for med students and others.
Iris C. Gibbs: Do you recall what it was about that lecture that captivated you? Was it about the technology at that time or was it just Simon’s personality and engagement with the students?
Larry Kun: In the 1960s, things were very simple in radiation therapy. Simon was very interested in cancer, obviously, and in ways that cancer grew and spread, and in how one would approach this with radiation therapy. I think most impressive was following him on rounds. Simon, whose history is perhaps much more apparent, is one who, although he grew up initially in Germany, pursued medical training in England. Although he was not a native of Great Britain, he had a very cultured English accent, and I was very impressed with the fact that he had a fairly large inpatient service.
At the time, he was just exploring combined chemotherapy into radiation for head and neck cancer. In fact that protocol was methotrexate and irradiation, exported to Hahnemann and, I believe, to NYU, provided the initial nidus for what became RTOG. But he would round on patients who were incredibly ill, who had severe episcleritis, and difficulty maintaining things at the time when we didn’t really have IV support we do today. I’ve always been convinced it was his charm, in part his accent, at a time when Americans idolized Great Britain, and just his incredible ability to be in a crowd of eight or ten or 12 people and be clearly focused on this one patient. He and his colleagues impressed me as a physician and interested me in his field.
Iris C. Gibbs: You had mentioned that during that time you also were introduced to and worked with Juan del Regato.
Larry Kun: I went to Simon Kramer in the very early part of my senior year. We didn’t have electives at that time, but during our junior and senior year, at some point, there was a six-week period that was meant to be a vacation; most of us spent it in elective at some location. I spoke to Simon, essentially saying something like, “You know I consider this really a crazy field, quite far from the norm.” But at that time was debating between neurology and radiation therapy and asked him if he could identify a place for me to go as an elective that would further introduce me to do radiation therapy.
Dr. Kramer arranged for me to spend time with Juan del Regato. This was in the last six weeks of 1967. And I went out and he had warned me that Dr. del Regato would always convene his entire crew for lunch, both an exciting and sometimes intimidating time. But it was something that I would ultimately come to cherish. On my very first day I walked through the door at Penrose and it was mid-day, and I saw this group of people sitting at a large table in the front of the cafeteria. I never went up to say hello at that point, but I quickly ran over to the office and introduced myself and signed in with Dr. del Regato that day after lunch. The six weeks I had out there was quite an exciting time. It included several luminaries in our field who were in training with Dr. del Regato at the time, including Jim Cox and Frank Wilson others. Our group, a very closely knit, both faculty level which was quite small when I first got there, it was really just two, Juan del Regato and Chahin Chahbazian, who was in charge of the training program.
There was a large number of residents, ten to twelve at that time. And just an opportunity to see yet another outstanding clinician, different accent this time, Spanish-Cuban accent. But again someone who was just incredibly interested in cancer, what it was like, how it manifested itself. Extremely interested in history, both the history of the field and the history of medicine but also in a very broad sense of world history in several areas that I also found fascinating.
It was a time in the 1960s when American Society was going through tremendous turbulence. And del Regato at the time seemed quite grandfatherly to me and still seemed fatherly, I think, to many of those yet in training. He was interested in liberal politics, as was I, although his definition of that preceded somebody who is at that point was just beyond his teenage years in the 1960s. I became very fond of him as a mentor and friend. Similarly enjoyed following him both in rounds and in his various arguments both verbally and in writing with some of the people at the time who were just beginning clinical trials in surgery and radiation therapy as the cooperative groups were being founded or just beginning. It was just a fascinating opportunity. By the time I left there, I asked if they considered me at a subsequent time for residency and we spoke about that. It was premature to do anything formal but the die was sort of cast at that point. That became obviously, throughout his life and throughout my continuing career, a tremendous guidance from Juan del Regato.
Iris C. Gibbs: Wow. That’s quite intriguing, your pathway into the field, meeting and working with such great individuals who made such an impact, as well. According to your CV, it looks like you went then to the NIH?
Larry Kun: Yes, following residency at the time, the program in the U.S. Public Health Service was one that was an option to being available for the draft for the Vietnam War. That was one point of interest potentially for a large number of us going into training at NIH. And one of del Regato’s former trainees, Ralph Johnson, a fairly interesting, bright and rather enigmatic man, was in charge at NIH and I went to speak with him and interview just really the last week of my medical school training. They were doing things in a very interesting manner. It was a place at the time that was just beginning a tremendous upswing in the visibility and recruitment of people who really set the trend for clinical investigation in pediatric, adult, medical oncology, pediatric oncology and surgical oncology. It was a very exciting place. And I sort of negotiated with Ralph Johnson the opportunity to complete the then three-year training program in radiation oncology, before coming back to him, which was then four years in an internship and three years yet to go. But it did turn out to be a very worthwhile two years. Most of our focus in the radiation branch at the time was on Hodgkin’s Disease and other malignant lymphomas which was an area which I had an interest in, particularly since del Regato had some very unconventional thoughts about Hodgkin’s Disease. I found myself in an area with Vince DeVita, Paul Carbone and Ralph Johnson, all of whom set the pace as had others obviously at Stanford and up in Tirano in Hodgkin’s Disease at that time.
Iris C. Gibbs: I see that your first paper was 1974, looking at the hematologic recovery and deterioration after successful radiotherapy for Hodgkin’s Disease.
Larry Kun: Yes. There were several things then, immune changes. There were a lot of observations, at the time in the Radiation Branch, even though a lot of it wasn’t ultimately followed through in the way we might today. For example, the first introduction of combined radiation and chemotherapy for Ewing’s sarcoma in kids, for small cell carcinoma in adults. All of these were introduced amongst the faculty and staff in Ralph’s department at that time. And the fact that we could meet weekly with people like Vince DeVita and, Cos Berard in Pathology who had helped define the classification at that time for lymphomas and review all the cases in staging conference and argue a bit about how best to treat them. It was quite a worthwhile endeavor and an opportunity to meet people with whom I interacted for many years thereafter in my career.
Iris C. Gibbs: Yes, for sure that was definitely a very active time in redefining and redirecting some of the treatments for that disease. I think some of these early papers and early efforts certainly changed the trajectory for that disease. When was it that you became more interested or worked more with pediatric malignancy?
Larry Kun: Yes, it was actually the second year of my two years at NIH. Tom Pomeroy was one of the senior radiation oncologists working with Ralph Johnson and he had started a program, following Ralph’s initial idea combining chemotherapy and radiation for Ewing’s sarcoma. He was also the interface with the pediatric oncology branch at NCI. I became involved through him, very closely, with the leukemia lymphoma and then the solid tumor programs within the pediatric branch. People like Phil Pizzo and David Poplack, continued to be leaders in those areas, within pediatric oncology and in other prominent positions. It was an opportunity to look at things a little bit differently since clearly pediatric cancers were more responsive to chemotherapy than adult cancers were at a time when chemotherapy was quite new and defining where radiation therapy would interface. It was really a very interesting challenge at that point. That was my first real interest in pediatrics that subsequently played out over the next two or three phases in my career development.
Iris C. Gibbs: Around that time, was the Pediatric Oncology Group just forming or had it already been active?
Larry Kun: POG came later. The Pediatric Oncology Group was started in 1980. The initial pediatric group was SWOG. Actually it was started as a pediatric group between Donald Pinkel, who was in charge at St. Jude, and the MD Anderson group. They quickly morphed into a largely adult group. Soon thereafter the CCSG, Child Cancer Study Group, came about as well as the pediatric part of CALGB. The three of those pediatric groups were basically non-funded back around 1979 and 1980, when NCI made a purposeful change to fund a second pediatric group. The CCSG continued, but CALGB and SWOG were defunded. At that point, POG was founded in 1980.
Iris C. Gibbs: I see. And then ultimately it’s been joining CCG and becoming the COG twenty years later. Well, I think I am getting a little ahead of myself. I see something very interesting, the time in Rotterdam, in the Netherlands, was that a one year exploratory experience or was that something that you were taking the opportunity to just teach and train abroad?
Larry Kun: It was a combination of two things, Iris. One of the requisites that del Regato could not enforce but encouraged at the time, was to spend time in Europe after completing training with him. Number one, the center at Penrose was relatively small, and number two, the centers in Europe at that time were both larger and in many ways more advanced and more incorporated into medicine than we were as a much younger sub-specialty in the United States at that point.
So, it was something I was somewhat expected to do, and then as I got into my time at NIH and I realized that the Radiation Branch was so disease focused that much of my time would be spent in pediatrics and maybe just three of the more common adult type cancers. I really felt I needed a broader experience before I sought a faculty position. So, I actually went to Steve Brown, who had been one of the people training with del Regato when I was a medical student. Steve was in charge at the University of Vermont and after looking around, I arranged to go back there as faculty after I had the opportunity to go to Rotterdam.
I went to Rotterdam, worked primarily Birgit van der Werf-Messing, who also had an interest in both lymphomas and pediatric cancers. She had organized a tremendous program in Rotterdam that at the time I think was the dominant program in the Netherlands. And it was a tremendous opportunity just to see a large number of cancer cases with excellent follow-up and really advanced technology in radiation therapy. They were far more sophisticated than what my experience had been prior to that. It was really very exciting year, in every way and personally my wife and one-year old daughter and I enjoyed the entirety of the time we spent abroad.
Iris C. Gibbs: Were they far more sophisticated, in terms of the machinery or just in terms of the general approach to treatment?
Larry Kun: They were using linear accelerators that were more sophisticated than what I’d seen earlier. They had developed some of the earlier, more flexible blocks and they had a very advanced and integrated physics group. At the time, they were looking at further developing some of the higher energy linear accelerators, which were then quite new. It was a nice opportunity to see how that would play out and they were very systematic in introducing modifications in technology in a way that is common to us today but was new at that time.
Iris C. Gibbs: Let's talk about your first faculty appointment at the University of Vermont. How did that come about?
Larry Kun: That was the result of my discussion with Steve Brown about the opportunity at the University of Vermont, I was very much a child of the 1960s, and having an academic program and a place that was up in the mountains and sort of away from things suited my personality very well. I went there and it turned out to be a smaller center from which to launch an academic career than I might have liked. Although, it was a very worthwhile year for me. It was about a year and a half, total time. It was pretty obvious to me within a few months, that the people in surgical and medical oncology encouraged me to look elsewhere because they recognized the limitations of a very small radiation therapy department and the lack of opportunity to achieve some of the goals I had.
It also, though, did serve to introduce me at the time to CALGB which was the adult and pediatric group, with which Vermont was associated. And to see it as a career opportunity, but to realize that I needed to be in an institution that was larger and more progressive, beyond simply a national type of opportunity in the cooperative group. It was worthwhile. And I started there in early part of 1975. By the latter part of that year, actually right after ASTRO, I interviewed at the Medical College of Wisconsin, to which I moved shortly thereafter.
Iris C. Gibbs: So tell me about your time at Wisconsin. How did that influence your career development?
Larry Kun: Well, Milwaukee was very exciting, and along with Simon Kramer and Juan del Regato, I would certainly identify Jim Cox, both as a very close friend as well as a mentor. I had met Jim and his family when I was a med student out in Colorado Springs. We continued a very close relationship and as a matter of fact, we considered working together in Washington where he became chair at Georgetown and where I was thinking of staying when I completed my time at NIH. It was pretty obvious to Jim that Georgetown wasn’t going to give him the opportunities he wanted and when he decided to move out to the Medical College of Wisconsin, I thought of that as well.
The timing worked quite nicely as I was then in Vermont and looking potentially to go elsewhere. Going to the Medical College of Wisconsin was like rekindling a lot relationships. Jim Cox was there, along with Frank Wilson, Roger Byhardt, Don Eisert. All of whom trained with del Regato, either while I was there as a med student or later during my residency. As a matter of fact, three of the four lived on one corner, so it was a chance to both continue friendships, continue the culture, if you would, in radiation oncology based upon the “Chief,” as we called Del Regato, and some of his principles. And to go to an institution that was beginning to grow considerably in Milwaukee, at that time, and where radiation oncology quickly became the dominant oncologic department that really supported and grew medical oncology and supported surgical oncology as well.
The other positive aspect, which we can explore a little bit in a few minutes, is that Don Pinkel, who was the founding director at St. Jude Children’s Research Hospital in Memphis, had moved to Milwaukee just before Jim Cox had settled there. And, at the time I was being recruited by MCW, it was really jointly by Jim and Don Pinkel. And then we had sort of a memorable evening on the phone at the time when I was speaking with both Jim and with Don. It was the first time that I looked seriously at creating a career focus that would be, essentially in pediatric radiation oncology. It seemed to me very exciting and at the same time limiting. It was hard to envision exactly where it might go. It was something that was met with a certain skepticism by my wife who envisioned me, as I had been even at that time, very uptight and involved, both from the stand point of professional and emotional involvement with kids. I had taken a leading role in treating the few kids we saw at Penrose and then obviously, developed that further as indicated in my time at NIH.
When I moved to Milwaukee, it was with the knowledge that I would take the leadership role in pediatric radiation oncology and that we were developing a program in radiation oncology and pediatric cancer. And it was a phenomenal opportunity, Don was creating what’s still known as the Midwest Children’s Cancer Center, based at Children’s Hospital of Wisconsin now. And he fully integrated me into that program. I was based in the Department of Radiation Oncology, five miles away from the Children’s Hospital at the time, but went back and forth more than once every day. We were able to set up the service at Children’s where essentially all the brain tumors, most of the Hodgkin’s disease and half of the solid tumors were on my service and it meant that the radiation oncology residents and I were responsible for both in-hospital and out-patient care, and chemotherapy as well as radiation therapy and the fields were young enough at the time that mixing them was easy.
And it developed into sort of a parallel career opportunity to really grow clinical care, clinical investigation and training, related both to radiation oncology and to pediatric oncology. It was an exciting time, there was a lot of growth in both areas, some very good people with whom I worked to become lifelong colleagues and friends. And it really enabled us to set the pace for that institution becoming one of the founding members of POG in 1980 and create an opportunity that catapulted me into a position to really lead the development in pediatric brain tumors within POG, at the same time we were focusing on what was relatively small but vibrant program, in Milwaukee.
Iris C. Gibbs: And so you had mentioned earlier that Pinkel was thinking of the concepts for the St. Jude Children’s Hospital. How did that evolve? Obviously, it looked like you were being groomed for that leadership role.
Larry Kun: Yeah, in retrospect it seems all pre-programmed. Don had been recruited by Danny Thomas when St. Jude was first being built, to become the Scientific Director, the Director at St. Jude. St. Jude opened in 1962. Don, who had been a very creative, at the time rather young, I think he was in his mid-thirties, pediatric oncologist who had been at Boston University and at Roswell Park in Buffalo. When there, he recruited a small cadre of both clinicians and scientists interested in aspects that were relevant at that time in pediatric cancer including Omar Hustu, who was the radiation oncologist there from the very beginning and my initial colleague when I moved to St. Jude. And Don obviously was the individual responsible for taking what actually was a laboratory experiment that Ralph Johnson had done at NIH in trying to cure the 12-10L model of leukemia with chemotherapy in mice had never been successful, until they added cranial radiation and found that they could cure leukemia. Don picked up on that and began what became known as the total therapy approach to ALL, childhood lymphoblastic leukemia in the early to mid-1960s. By 1968-1970, Don was publishing what became the first curative approach to childhood leukemia. That was based upon modifications of initial cranial, then craniospinal, then cranial radiation in combination with IT chemotherapy, cementing radiation therapy into the development at St. Jude as well as indicating the importance of collaborative networks in pediatric oncology which, to this day remains very easy amongst the specialties in pediatric cancer, perhaps easier than in many adult cancers.
From the time I got to Milwaukee, within a year or two, Don was trying to move me down to St. Jude which I looked at in 1979, but it wasn’t yet right for me. It was too confining, I thought, nor right for St. Jude, I think at that point. Then five years later, Joe Simone, became the third director at St. Jude, a well-known pediatric oncologist, involved in both organizational aspects of oncologic medicine as well as several cooperative groups. And Joe recruited me to St. Jude to take over radiation oncology as chair in 1984, it was a time when I think my goals were to identify the then diminishing indications for radiation therapy in pediatric cancer because of the balance we saw with more and more introduction of effective chemotherapy agents at that point and increasing recognition of some of the late effects of radiation therapy. And it seemed the right time to really concentrate on areas where radiation therapy made a significant difference and at the same time begin to fine-tune how that radiation therapy was given as well as an opportunity, perhaps unique at St. Jude, to do some long-term follow-up studies.
Fortunately, it was at a time when number one, the chemotherapy that was introduced presented a lot of challenges in how one best combined chemotherapy in radiation. Number two, the cooperative groups were very strong and relatively well-funded and so I was able to enjoy a position in developing the brain tumor committee in POG in 1984 with really great neurosurgery, pediatric oncology and radiation therapy and focus on opportunities in radiation oncology that were very important to us in the mid-1980s. At the same time, I was committed to developing a brain tumor program at St. Jude. At the time I arrived at St. Jude, they were treating every type of childhood cancer except brain tumors. There was no interest. There was no neurosurgery, no neuropathology, no neuroradiology, no neuro-anything and as part of my recruitment, we agreed we would establish a small but focused pediatric brain tumor program. We estimated we would bring in about 12 patients per year and I promised the tumor group who was reluctantly willing to support this with me that we would never see more than 12-15 patients per year. Now we see 12 patients every two to three weeks and it took off in a very successful and worthwhile manner.
Over a very brief period of time, I recruited neurosurgery, neuropathology, neuropsychology, and the entire network of individuals who specialized in brain tumors. We focused the brain tumor efforts within the radiation oncology department including neuro-oncology, neurology, and psychology initially within that structure and gradually recruited so that each became independent departments at St. Jude and were able, in parallel, to develop a lot of pilot protocols and studies in Memphis and to use those in part as one of the several mechanisms of bringing studies into the national clinical trials network through POG and then combining POG’s studies jointly with CCSG at that time. So it became a tremendous opportunity to learn and to apply some of the new principles.
Iris C. Gibbs: What do you think were the keys to that success? Obviously, many departments tried to build a team across disciplines and you have been very successful in the brain tumor program. Was it a willingness to work together? Was it more about being open to thinking outside the box? What were the keys you believed were the success there?
Larry Kun: I think the most important aspect of it was the good fortune in recruiting really good people. In each one of the areas that we were involved with, certainly neurosurgery and phycology, people like Alex Sanford in neurosurgery, who not only at St. Jude but within POG, in parallel, developed the neurosurgical interests as we were developing the broader multidisciplinary interests. Ray Mulhern, psychology, who did the first studies in Milwaukee and then followed through when he moved with me to St. Jude and within POG and doing the first studies that documented the neurocognitive changes in children after brain radiation.
From the very beginning, we organized the program in such a way that there was a weekly brain tumor conference that initially included four or five of us and within a very short period of time, 20 or more, now 30 or more individuals, representing every discipline ranging from nutrition, rehabilitation up to neurosurgery and our own field. Every new patient was presented there. Initially, we would actually round to see the patients in the clinic at the same time and as time went on that was done either before or after conference. And we would commit anywhere from 1 to 3 hours every Wednesday afternoon to reviewing cases in a way which is now common in a tumor board setting with review of clinical imaging, pathology and then pretty lively discussion. It wasn’t quite as common and it wasn’t at all common in brain tumors at the time when a lot of neurosurgeons were very possessive of their patients. And people in our field, as well as in pediatric oncology, just weren’t as interested.
So, from the very beginning brought, fortunately the right people together and also neurosurgery was just then developing, what subsequently became a recognized program but a program in pediatric neurosurgery for fellowship so that we had a training focus there. We were able to bring in residents from ultimately over 20 to 25 different training programs in the United States whose residents would rotate through radiation oncology for anywhere from 1 to 3 months for the opportunity to be exposed to pretty intensive experience in pediatrics at St. Jude as well in CNS tumors and psychology as well. So we were able to bring people in with different backgrounds and perspectives and just build upon that in a multidisciplinary manner and we did the same thing in parallel in POG.
Iris C. Gibbs: So, I think we probably have another 10 to 15 minutes left. I would like to focus on your reflections on radiation oncology as a field. What do you think have been the most important advances in pediatric brain tumors or radiation oncology in general during your time of practice?
Larry Kun: I think the ability to combine a field that truly looks at cancer as a disease and a challenge where one has to understand how and where tumors begin and where they spread. It has always been a privilege to identify in radiation therapy, the necessity to be an outstanding clinician, to be as good a neurologist as you can be, in dealing with neurologists and neurosurgeons and straight down the line.
The opportunity as the mid-1990s approached when the technological development in our field became so overwhelmingly positive, changed entirely the focus in pediatrics and in brain tumors, I think both in children and adults. From one of being somewhat defensive and trying to look at how we would minimize the use and impact of radiation therapy to really being able to capitalize on 3D conformal and IMRT and now particle based radiation therapy where the risk benefit ratios could be optimized. At the time, I initially went into St. Jude, we were treating every leukemia child and because of that we were treating perhaps 60 to 70 percent of children who entered the institution. Now, we treat zero leukemia children at St. Jude but because of the size of the brain tumor and Solid Tumor Programs and the central importance of radiation therapy, with the technical capabilities we have today, we’re still treating 60 to 70 percent of kids, which just amazes us. I think it has been the opportunity to combine the interests and the insights of the clinical field with the technology developments that have been so profound over the past 15 years.
Iris C. Gibbs: Where do you see the field going in the next, let’s say, 10 to 20 years?
Larry Kun: I think, clearly, the intense interest in chemotherapy has changed and the impact of new cytotoxic drugs plateaued, certainly in pediatric areas, and I think in many areas, now 15 years ago at the time when our technology became so paramount. I think we will define new roles for protons and other potential particle based therapies, certainly in pediatrics, and presumably in several other adult areas in cancer. I think that the ability to interface radiation therapy with the molecular targeting agents is something that is just beginning to be explored and perhaps will be one of the major areas of focus, certainly in pediatrics, and in adult areas as well, over the next 5 to 10 years. I don’t know what other new biological innovations will potentially require some of the same challenges be met in interfacing them with radiation therapy, but I suspect that will continue to evolve over the next 5 to 10 years. And then the sometimes tricky interface of radiation therapy and immunotherapy as it now reaches its second or third generation, with interest in vaccine therapies, etc. will also require quite a bit of interesting thought and prospective studies to best integrate those treatments.
Iris C. Gibbs: One of the impressions I have, hearing all the wonderful stories you’ve shared about your journey in radiation oncology and pediatric neuro-radiation oncology, is the importance of your mentors and importance of key people who essentially gave you ideas on how to structure things. In an apprenticeship model in which the trainees of leaders like Juan del Regato, took what they learned and became like yourself, luminaries in the field. Do you think our current environment of training and radiation oncology lends itself to that degree of apprenticeship and mentorship?
Larry Kun: I think it does. I think it’s harder for trainees now in the field. At the time, I went into training, the field was small. The opportunity to meet people like del Regato and Henry Kaplan and Gilbert Fletcher was easy and the challenges that we had in knowledge base required breadth of science related to medicine in general, let alone to oncology. It’s a lot right now that faces each one of our trainees. I think that the broad understanding that’s required, clinically number one, and then you can go into every different aspect whether it’s pathology or imaging and beyond, is certainly a greater hurdle than it was for us at that time. Does that change the importance of personal interactions and mentorship? I don’t think so. I think that if you’ll look now at the generation behind me, as those of us at my level are beginning to step down from leadership positions, or have already done so, I think that those that we have trained have similar interests in developing outstanding training programs and committing the time and effort to that goal. But I think that the trainees face a real challenge in what they have to grasp, put into their knowledge base and understanding, and then move forward with their own plans.
Iris C. Gibbs: In reflecting on how you described your time at Wisconsin and how, as the chief of that service you were giving chemotherapy, planning radiation and managing a great number in-patients, it is clear that things have really changed in our current training approaches.
Larry Kun: They have and I think the only caution that I would express and it’s something that goes back now decades, even to the time I first started my own training. It’s really important in radiation oncology to get out from the basement as people used to say, and away from the sense that we’re sort of the dark side, often our own because of the emphasis we placed on physics and technology. It’s really important to be integrated, into the hospital systems even more so as we get into some of the social economic changes that now confront medicine. I think the, the best mentors at many of the better institutions around the country, recognize that and I think try very hard to integrate the radiation therapy training into the full aspect of both science and medicine. It is something that’s not easily available except with time and effort, I think it’s available and worthwhile for everybody.
Iris C. Gibbs: Okay, before I ask my final question, I first want to find out what activities are you passionate about outside of medicine?
Larry Kun: I guess number one at this point in my life is grandchildren, I have five of them and they range from eight to five years of age. That is a great time commitment, and obviously my wife and I spend more and more time together. Although, at the moment I both chair a department and run a hospital so that time becomes scarce, it’s a daily challenge. Travel is important, as well as continuing to read avidly in history and politics, which have been primaries of interest. Physically, it’s walking, hiking and biking, anytime I can, everywhere I can, and that pretty much takes up the rest of my lifetime.
Iris C. Gibbs: So, is there anything else you wanted to let us know about your family? I don’t think we talked much about your travels, over the several years of your training and career. How important was, you know, your family life during that time?
Larry Kun: Yeah. Well my wife and I have been together now, 43 years and time gets only closer and more enjoyable day by day. We have two daughters. My family is nicely cemented into the world of pediatrics. My older daughter is married to a pediatric urologist in Columbus, Ohio with the Nationwide Children’s Hospital and my younger daughter trained in pediatric oncology and is in Dallas where she is now an active pediatrician. I have three grand kids down in Dallas and two up in Columbus. I don’t think that anybody can succeed in an area that faces as many physical as well as the emotional strains, if you will, without having a strong family background and it’s been my privilege and joy to have that throughout my life.
Iris C. Gibbs: This question about your decision in the last year or so to serve as director-- the clinical director, and then chair of St. Jude Children’s Hospital. What factors influenced your decision to take on that position?
Larry Kun: I guess the term I’ve usually used is military voluntarism. We were at the point where there was a change in the clinical directorship which is one of the three primary administrative positions at St. Jude and I was asked if I would, in a sort of caretaker manner, take over the clinical directorship for a year or so. It turned out to be an unbelievable pleasure and privilege, to really have the opportunity to look at a lot of the functions, structures, organizations within St. Jude that I’ve been a part of now for, it’ll be 30 years now this summer, and have really the opportunity to change them and optimize them so we’ve really looked, upside down, from the top to the bottom, if you will at a lot of the key infrastructures that are important for clinical care and for clinical care in an environment totally dedicated to clinical investigation and translational science. And try to optimize that and it something that it’s been a pleasure to see things rapidly improve and respond to, really again just bring people from different areas together on the table, hour by hour, day by day, during every week just to see how we can make things better. And so I’ve just recently decided it wouldn’t be quite so interim and we’d continued to do this at least for the next two years which will take me to the age of 70. I think at that time, it’s time for me to think about doing some things that are not quite as involving in a usually 14-hour day. But it’s been a real privilege to do this.
Iris C. Gibbs: I just wanted to say what a pleasure it’s been to, to talk with you. Are there any final thoughts or final insights or lessons that you might wish to impart to those who will be reviewing this interview and words of wisdom?
Larry Kun: Well, I’m not sure how wise but I think one of the things we have not touched on at all, is the opportunity people have in, I guess organized medicine, the best way to term it. The opportunities that I have had in ASTRO, the American Board of Radiology and certainly in the pediatric cooperative groups, to really work with some phenomenal people, both colleagues in medicine and an incredibly dedicated staff, to take on challenges in areas that are quite different from those that we face day to day in medicine have just been unbelievably worthwhile and frankly enjoyable. It’s created most of my very best friends along with those I’ve had in training and earlier professional development. And really an opportunity to look at so many different areas of medicine, sociology in people, and bring them to bear and other aspects of career as well as social life so that’s an area that most people don’t think about and really don’t need to early in their training. But as those opportunities become available, they too can be just beautifully enriching. Thank you, Iris, it has been a real pleasure.
Iris C. Gibbs: It’s been definitely a pleasure for me as well and on behalf of the ASTRO History Committee, I really want to thank you for this great honor and opportunity to conduct this interview.
Larry Kun: Well, thank you very much. Take good care.
