Lawrence Coia, MD, FASTRO
By Joseph Barthold, MD, FASTRO and Laura Vallow, MD
The following interview of Lawrence Coia, MD, FASTRO, was conducted on November 13, 2018 by Joseph Barthold, MD, FASTRO and Laura Vallow, MD.
Joseph Barthold: Where did you grow up?
Lawrence Coia: I was born in Philadelphia but grew up in a rural area of Southern New Jersey, in the East Vineland section of Buena Vista Township. I grew up on a vegetable farm and learned the value of hard work. I also learned from farming that hard work is not always rewarded, so I did not want to pursue farming as a career. But rural life provided many opportunities for my brother and me to explore. Our parents were loving and supportive but fortunately they did not coddle us. The region we grew up in was ethnically diverse and again our parents raised us to respect and be friendly to others. We were both good at baseball. In fact, the Little League All Star League team that I pitched for went 6 or 7 games without a defeat and almost took the New Jersey title, but we lost to a South Jersey team from Haddonfield by 2 to 1. The pitcher for that team was Rawley Eastwick who later pitched 8 seasons in the Major Leagues. Despite out rural location, our high school had nearly 700 students in the graduating class and I was at the top in science studies. I was also good at math and was surprised that two unassuming but very nice girls got 800s in the math SAT’s but no guys did, so I learned not to assume much based on gender relatively early in life. I enjoyed school and I really wanted to pursue a career in a science related field. I was able to do so as a radiation oncologist for 30 years, however later in life I returned to farming because I saw unmet challenges and questions in viticulture that my background in science could address.
I was accepted at the University of Pennsylvania but RPI offered a full scholarship and Penn didn’t so my parents said its RPI and I was fine with that. Then I continued studies in physics at Bryn Mawr College to get my Masters degree..
Joseph Barthold: So you did RPI and then Bryn Mawr for physics. Was it radiation physics or general physics?
Lawrence Coia: My undergraduate degree from RPI was in Physics, and at Bryn Mawr College, I was also a Scholar in Physics, however my research there was in biophysics. There under the direction of Dr Rosalie Hoyt, I developed mathematical models for potassium ion channels from data from nerve conduction voltage clamp experiments. At Bryn Mawr I also met my future wife, Barbara Schreiber who was a Classics major. We have been married for over 40 years.
Joseph Barthold: Perfect. Then you went to Temple and then to Jefferson, and Simon Kramer was still at Jeff, right?
Lawrence Coia: Yes, Simon Kramer was Chairman of Radiation Therapy and Nuclear Medicine at Jefferson. I decided to go into medicine because I thought I would be able to accomplish more in that field than in physics. I think I would have been a good physicist but not a great one. Also, I began to recognize that health and disease were challenging topics and that I enjoyed contact and interaction with people and that medicine might offer a better opportunity to do so than physics. Medicine provided opportunities for me to best use my abilities to do good in the world. It allowed me to pursue research in cancer treatment while at the same time have direct contact with patients where I could see the results of my work in helping to cure or palliate. I was fortunate during medical school to work with outstanding radiation biologists, Alan Conger and Darrel Brown. I studied radiation protectors and sensitizers and worked with tumor spheroid research in their labs. I also was able to do clinical rotations at the Fox Chase Cancer Center, then known as the American Oncologic Hospital.
After Medical School I chose to join Simon Kramer’s radiation oncology residency program at Jefferson.
Joseph Barthold: Was Dick Whittington in your era?
Lawrence Coia: Yes. I think Dick joined the year after I started, but we were contemporaries and, in fact, we shared the chief residency our final year along with others.
Joseph Barthold: And then who else was in your era of residents at Jeff?
Lawrence Coia: Dave Moylan
Joseph Barthold: Oh, sure.
Lawrence Coia: We wrote a book together called Radiation Therapy for the House Officer. David continued at Jeff then went into private practice in northern Pennsylvania where he has done great work in radiation oncology at the Simon Kramer Institute which he established. We wrote subsequent primers in radiation oncology called Introduction to Clinical Radiation Oncology. Other residents I remember quickly include Jerry Derdel, Alan Shaiman, Beatrice Bloom, Larry Solin, Bruce Borgelt, Doug Colkitt, Dave Nagel, John McDay and Gary Fisher.
Joseph Barthold: Yeah, and then who were the attendings in that era besides Simon?
Lawrence Coia: We had a great staff. Barbara Fowble (then Barbara Danoff), Mo Mohiuddin, Ralph Dobelbower, John Fazekas and Gunther Seydel were all outstanding clinicians and great mentors. The Radiation Physics division was outstanding too under the direction of N. Suntharalingham. Dave Moylan and I both scored in the 98th percentile of the physics portion of the national residency written exam, no doubt largely due to Suntha’s great teaching. The head of the radiation biology division then was Dennis Leeper. I enjoyed working in his lab for several months on caffeine induced cell cycle changes. Again, Dave and I were prepared well for our national exam radiation biology section, I think we were above the 90th percentile. Jefferson prepared us well for our careers as radiation oncologists.
Joseph Barthold: Then you did Fox Chase after that. Is that right?
Lawrence Coia: Yes. At that time, I was looking at joining Penn. Bob Goodman had taken over Penn the year before I interviewed for a residency position but I decided to join Simon Kramer’s program.-- But following my residency, four years later, Bob had developed a strong clinical research program and recruited some outstanding staff, like Barbara Fowble who left Jeff for Penn as I completed my residency. Bob also had an outstanding radiation biologist in John Yuhas.
Penn faculty were also operating the Radiation Oncology Department of the American Oncologic Hospital in Fox Chase, a beautiful suburb of Philly. Eventually AOH was joined with the adjacent Institute for Cancer Research to become the Fox Chase Cancer Center. I was interested in working with Mel Richter, then head of radiation oncology at AOH, particularly with the newly developed, NCI funded d/t neutron generator. My initial faculty employment at Penn was to work at Fox Chase for six months, and then switch from Fox Chase back to Penn. I really liked working with Mel at Fox Chase, so continued my academic career there at Fox Chase as a faculty member of Penn for most of the time.
Joseph Barthold: So did you work anywhere other than Fox Chase? I can’t remember whether you rotated out to the suburbs.
Lawrence Coia: I would go to HUP, the Hospital of the University of Pennsylvania, in West Philadelphia to hear lectures, coordinate the residency program and give lectures to the residents, et cetera, but I didn’t take care of patients at HUP. I took care of patients at Fox Chase only.
Jerry Hanks joined the Penn/Fox Chase Radiation Oncology faculty in ’85 and greatly strengthened the department. Due to a design flaw the d-t generator did not function consistently well and very few patients with head and neck cancers were treated. Ultimately that unit was dismantled and along with it the ability to pursue one of my research interests disappeared. But Jerry brought tremendous leadership and offered me work with the Patterns of Care study, which turned out to be quite interesting and rewarding for me. I also had an interest in clinical research in gastrointestinal malignancies which I was able to continue. Jerry was very encouraging and interested in that work, especially with the early results of our trial of treatment of esophageal cancer with chemoradiation.
There was this strong push in our department towards clinical research and really questioning what was being done traditionally, especially radical surgery. Organ preserving approaches were ongoing in breast, esophagus, larynx, sarcomas, anal cancer and prostate cancer. We were involved in clinical trials in all those areas. Jerry in particular proceeded to escalate the dose in prostate cancer treatment to improve local control.
You know, one of the things I had to endure initially at the American Oncologic Hospital, which was one of the first NCI designated cancer centers in the nation, was the provincial attitude of some of the surgeons. They were skilled surgeons who until the early 80’s had largely run the small less than 100 bed hospital. Yet they fiercely opposed breast preservation efforts. I suppose this was the response of many surgeons nationwide at the time who were confronted with breast preserving efforts as an alternative to radical mastectomy. For example, after Bob Goodman gave a Grand Rounds lecture at Fox Chase about breast preservation, the Chair of the surgery department walked out of the lecture hall and began pounding on a wooden desk and said, “Within 5 years this is what the women’s breasts are going to be like after they get their breasts irradiated!”
Fortunately, after that initial period Fox Chase recruited many outstanding surgeons like John Hoffman, Mel Goldberg and Drew Ridge who worked extremely well in a multimodality treatment setting and were proponents of organ preservation in lieu of radical surgery when feasible and when similar control and survival were likely.
Joseph Barthold: I know you did Patterns of Care. Were you active in RTOG as well?
Lawrence Coia: Yes, I was active in RTOG. I co-chaired the GI Committee for a few years. I don’t know that I had any studies where I was the first author, although I was a contributing author on many studies. One of the important things that we learned at Jefferson under Simon and then with Jerry at Fox Chase was the importance of participating in clinical trials and getting sufficient data to determine if statistical significance existed.
Our radiation oncology department at Penn/Fox Chase was fortunate because multiple training backgrounds existed within the faculty. At the top Goodman was Harvard system trained, Jerry was Stanford trained, but all good work and techniques from various programs were examined and considered. Large clinical trial participation usually took precedence over small in-house trials and ad-hoc treatments were not allowed.
Joseph Barthold: When did you become a wine maker and stop being a radiation oncologist?
Lawrence Coia: My career in radiation oncology spanned over 30 years. The first half was in academics and the second was in private practice. I never became a wine maker but rather a grape grower. My family owns some farm land in Vineland, New Jersey but we never grew grapes when I was growing up there, but I had one grandfather that was still alive when I was young, and he grew some grapes. The gnarly growth of his old vines and fact that wine can be made from the berries intrigued me.
During my junior year of college I got a view of commercial grape growing. I did my Junior Year in Switzerland. I was the first student from RPI to initiate an exchange program at the Swiss Federal Institute of Technology in Zurich. Switzerland is a beautiful country but with cold winters. I noticed that they could grow wine grapes in many regions of Switzerland. Not longafter I returned to the US, I asked my parents if I could use part of their farm ground to plant some grapes. They consented and helped me get started, but I couldn’t do much because by that time I was in grad school and then medical school. I managed a couple hundred grapevines and then continued slowly expanding acreage. It wasn’t until 2006, right before my retirement from full time radiation oncology in 2008, that we started planting acres and acres of grapes. Our son and I now have 13 acres planted. We own a hundred acres of farmland.
Joseph Barthold: Wow. What was your Switzerland time? I don’t have that piece.
Lawrence Coia: When I was at Rensselaer, I was very fortunate because I was a physics major and my adviser had been a PhD physics graduate of ETH, the Swiss Federal Institutes of Technology. It was just a fantastic place. That’s where many famous physicists, including Einstein and Roentgen, studied or worked in the past. I told my adviser I knew German relatively well and said I want to go to Germany for my junior year to study physics. He said, well, how about Switzerland? I said okay. So, I got a full a scholarship and studied a year at ETH in Zurich. Switzerland is a very civil place and it had many positive effects on my life. It’s a wonderful country, very expensive now but not back then in 1971 when it was 4 Swiss francs per dollar.
Joseph Barthold: Have you done any ongoing radiation oncology as a locum or fill-in person over the last 10-plus years or did you just go cold turkey?
Lawrence Coia: No, I haven’t done any locums work after retiring from full time work in 2008. However, between 2008 and 2013, I continued to work with my group for three days a month, so less than one day a week. And then in 2013, I completely retired.
Joseph Barthold: Was that over in New Jersey?
Lawrence Coia: Yeah, I started a private practice group, East Coast Radiation Oncology, in New Jersey in 1996. Just before that I did look at a chairmanship at an academic institution, but I was turned off by the approach of the COO there who appeared to view the patient as merely a product on a product line.
So, I decided maybe I should look not just at academic places but rather also at private practices. The St. Barnabas health care system was the largest in New Jersey and needed some help at one of their radiation oncology facilities. So, they recruited me there to Community Medical Center in Toms River. And then shortly thereafter -–
Joseph Barthold: Did you say St. Barnabas?
Lawrence Coia: Yes.
Joseph Barthold: Okay, yeah, I know St. Barnabas.
Lawrence Coia: Yeah. It’s a large health care system. Now they’ve merged with Robert Wood Johnson so its an even bigger system. But back then they did have several radiation facilities besides the one in Toms River that needed help. After the Saint Barnabas system recruited me, I recruited Radiation Oncologists to staff Monmouth Medical Center in Long Branch, and Newark Beth Israel, in Newark and Kimball Medical center in Lakewood. Most of the radiation oncologists recruited had trained at Fox Chase or Memorial Sloan Kettering and all were great colleagues.
And around 2000 our group also opened a radiation oncology facility at Southern Ocean County Hospital. That hospital is not part of the Saint Barnabas System. We purchased the equipment and staffed the facility that we leased from the hospital. It was a beautiful and efficient facility.
I initially headed the radiation oncology efforts of the southern division of the Saint Barnabas system, although my colleague Robert Ivker staffed the department at Newark Beth Israel. For a while Bob Goodman headed the northern division.
Joseph Barthold: Where do you see it going next? Are we going to stay independent or are we going to get pushed to the side by the immune therapy?
Lawrence Coia: Well, Joseph, my guess is that we will continue to have a real independent role in cancer management because radiation a relatively non-invasive type of treatment. From the advances we’ve had in radiation oncology, we’ve significantly diminished side effects.
When I was asked to run and build the department at Southern Ocean County Hospital in 2000, the CEO of the hospital asked me what I was going to do to prepare the building for expansion 10 and 20 years down the road. I said, you know what, I’m going to build it the best I can right now and prepare for future expansion, but I’m hoping you won’t even need radiation oncology in 20 years. Clearly that has not happened.
I do think we have a critical role in cancer management. Yes, there have been great strides in cancer prevention and treatment. Immunotherapy has taken a log time to develop into a successful treatment approach and will take many more years to perfect. Advances in genetic manipulation and CRISPR-cas9 type discoveries will likely provide the basis for a long-term solution to cancer. But whether it would happen in my lifetime, I don’t know. I’m 67 now, and hopefully I have another 20 years.
Joseph Barthold: So, you spent a fair number of your years training residents and dealing with medical students who are going to go into this. Reflect on that a little bit. You influenced an awful lot of other people to go on and become both clinical or academic or both.
Lawrence Coia: Teaching and training residents is probably one of the things I miss the most. I was involved in training of many residents who have made some important progress in radiation oncology. People like Wally Curran, Howard Sandler, Mitch Machtay, Anthony D’Amico, Marissa Weiss, Rachelle Lanciano and Lori Pierce. I could just continue to go on and on. As far as those residents I helped train who didn’t stay in academics, I’m sure most them are excellent and dedicated radiation oncologists as well.
Joseph Barthold: I didn’t know you had a connection with Howard Sandler. Was he at Penn?
Lawrence Coia: Yes, he was at Penn and Fox Chase. I remember the first day he came in, I had 35 patients in my service and by the next day, he knew the clinical history about each one of them. I was treating patients with cancers of many different types, yet he knew what their cancers were and how they were being treated. That impressed me.
Joseph Barthold: He’s a really good guy.
Lawrence Coia: Yes, he is.
Joseph Barthold: Howard has done a great job. He’s been chair of the GU Committee for probably 10 years on our RTOG and really done some amazing work.
Lawrence Coia: We have made great progress in prostate cancer treatment. I don’t know how much we need to get into it, but one controversy during my time in radiation oncology was that of self-referral, particularly in prostate cancer treatment. We’ve been talking mostly about the academic side, but in the private practice side, it was discouraging to see the self-referral and behavior of urologists and some radiation oncologists in the treatment of prostate cancer. That was a tough thing for me to understand and to deal with, frankly. I should have been ready to deal with that issue because Jerry Hanks warned me when I left Fox Chase for private practice. He said, “You know, you’re going to be in a tough situation with urologists at the hospital you are going to.”
Joseph Barthold: How did you get the balance to -– tell us about your family and kids, et cetera.
Lawrence Coia: After Bryn Mawr College my wife got a Masters degree in Library Science at Columbia University. We married in 1978 after I finished my residency. She worked for an information company, the Institute for Scientific Information and then Thomson /Reuters in Philadelphia for many years and retired around the time I did. Now she volunteers for the county library and plays the harp. She also enjoys the culinary arts and we belong to a couple of gastronomic societies. She loves fly fishing and we belong to the Henryville Conservation Club which owns trout streams in the Pocono Mountain. Our son, Stephen, is 33 and manages the vineyard. He loves work in the vineyard and running and maintaining the equipment. Actually, one of the reasons that I’m involved in viticulture is so I can spend time with him. He lives at the farm where I grew up and manages it well.
The viticulture part has been an amazing thing because I’ve been able to do investigate optimal grape varieties and growing techniques for New jersey. I have gotten many grants funded for viticulture research, probably more than I did as a radiation oncologist. I just co-authored a book with Dan Ward of Rutgers titled Wine Grape Varieties for New Jersey that will be released in December 2018. I’ve been also working with Orley Ashenfelter an economics professor at Princeton University on issues related to wine. Wine economics has been an interesting field to pursue.
Joseph Barthold: Did you know you were going to be right when you were at Jefferson with the pre-op rectal philosophy versus the rest of the city, which, when we were all trained, it supposed to be post-op?
Lawrence Coia: Right, Mo Mohiuddin was the one who was right on this. He had a lot of interesting ideas. One was to give a single dose of pre-op radiaton, 5 Gy or so at the time of surgery, there would be less likelihood that the surgeons would be surgically sending out viable cells and disseminate the cancer. He also designed and pursued longer course pre-op radiation trials. Mo Mohiuddin really is a great man in the field and had many great ideas, and I was happy to work with him.
Joseph Barthold: It’s interesting. I trained at RTOG and at Hahnemann and everybody was post-op except Jeff. And I remember for years, people -- in Philadelphia it was interesting because depending on what side of the street, what medical school you went to determined whether you got pre-op or post-op. I think it pretty much stayed that way until the last 10 years when the German trial came out saying pre-op was better. Now we all do pre-op.
Lawrence Coia: A lot of how we practice has to do with relationships with surgeons, and medical oncologists and I realized early on that an important part of oncology was multi-disciplinary management. At Jefferson there was a terrific surgeon, Jerry Marks, who worked closely with Mo to improve ways of doing things. My surgical and medical oncology colleagues at Fox Chase were excellent to work with.
At Fox Chase, I was extremely lucky because the thoracic surgeon initially there had concerns about the ability of surgery to cure esophageal cancer. He referred many if not most of the patients with esophageal cancer to our program of radio-chemotherapy treatment. That’s how we were able to use definitive management for esophageal cancer with chemo and radiation.
We only got to 20-25 percent survival with chemoradiation, but it was a lot better to be able to tell a patient there were some chance at cancer survival than none.
Joseph Barthold: Did you do any sabbaticals when you were at Fox Chase? Did you get to go and do anything fun?
Lawrence Coia: I have made many friends, including non-American ones through ASTRO. Around 1983 I was an ASTRO ESTRO travel grant recipient and I went to Austria, to the University of Vienna for a couple of weeks observing work in the radiation oncology department. There I met Robert Hawliczek who became a life-long friend. He just retired from radiation oncology practice in Vienna. Another example of an ASTRO initiated friendship occurred after a talk I gave at ASTRO. An Italian radiation oncologist, Franco Campostrini, asked me some questions. I noticed he had an accent, I asked where he was from, and I was told he was from Verona near Valpolicella. I told him how much I loved Amarone and we’ve become life-long friends. In fact, four years ago, I went to Italy, and stayed with his family while taking Italian language lessons in Verona. He helped me meet a grape geneticist and breeder at the Foundation Edmund Mach north of Verona. Through that meeting I since have established an exclusive US licensee arrangement for our grape growing organization, the Outer Coastal Plain Vineyard Association to sell several of the wine grape varieties developed at that research center. I owe that partially to ASTRO, I guess.
Laura Vallow: This is Laura Vallow. I was on the call. I got in a little bit late, I’m sorry for that.
Lawrence Coia: Laura, I’m sorry we didn’t include you. I didn’t know -- I thought you hadn’t gotten --
Laura Vallow: No, I didn’t want to interrupt. You guys were on such a good roll and I just thought if we had time, I’d throw out a couple more questions if that’s okay.
You know, talking about your interest and what led you to radiation oncology, you mentioned the ability to cure or help palliate a patient. Do you feel with so much hypofractionation, SBRT, and SRS where our patient interaction is really decreasing, do you think that is going to affect the satisfaction of practitioners in our field?
Lawrence Coia: That’s a great question, Laura. It’s one that I hardly had to face because I left the field before cyber knife, hypofractionation, et cetera had come into common usage. I enjoyed interacting with the patients, not just devising a treatment plan and working it through, but meeting patients at least once every week for at several weeks and sometimes seven or eight weeks. It allowed time for a good trusting relationship and team attitude to form.
Laura Vallow: In my breast practice, I see patients three times instead of six times, and it definitely affects the collegiality.
Joseph Barthold: I think it’s different. I find that as you get to know a patient during the course of their six weeks or eight weeks of prostate, you get to know them a lot and they’ll tolerate side effects more if they like you. We don’t have a relationship with people. And then when they get the side effects a year or two or five years later and they did not have a relationship with you that included six weekly visits and a bunch of follow-ups over the course of several years, I think they’re more likely to sue when they get side effects that we warned them about.
Laura Vallow: Yes, I agree.
Lawrence Coia: That is very interesting. I would have found it difficult to explain clearly what we were doing with such limited encounters. I would imagine that the patients are more likely to remember the therapist treating them than they will the doctor if hypofractionation is taking that strong a hold, which sounds like it has.
Laura Vallow: I have another question about your employment history, since you have an extensive history in private practice and academics. As you probably know, the national demographics are showing a decline in private practice. People are moving towards hospital base or academic practices. Do you have any insights for those new graduates that are struggling to find their place in either academic medicine versus private practice?
Lawrence Coia: Well, I think when they’re interviewing, they should try to determine the role in which the hospital or the department see themselves regarding patient care. I had mentioned to Joe earlier, I had interviewed in an academic place and it just sounded like the patient was viewed as a product on a product line. I’m sure that could happen in private practice or in academics, but if that’s the attitude of the CEO or department head, I would stay away from that place. The reason for us to go into radiation oncology should be to see what good we can do in the world for patients with cancer. The product or the product line view of the patient is not the right solution. I don’t know if I answered that or --
Laura Vallow: No, that’s wonderful. In terms of the future of our specialty, what do you see as the major barriers or challenges that face us today?
Lawrence Coia: Well, part of my challenge was how we would interact with medicine and surgery and work together with the patient as a team. For the most part, we did well. Now we have another modality of immunotherapy too, and I guess the question is how much of this modality should be integrated into a radiation oncology training program so that we understand it. Even if we don’t give immunotherapy, we can really make sure that we’re involved and play an important role in a patient’s cancer management. Like I mentioned to Joe, radiation is a non-invasive technique that’s pretty effective in curing cancer and palliating pain.
The majority of patients we treat with radiation could be cured with radiation as part of the treatment and it remains an important tool, but we have to make sure that we’re able to integrate it with other disciplines even better than we have because there are more types of cancer treatments now.
Laura Vallow: Absolutely. I have one more question, because it seems that you transitioned so well into retirement. Well-being and work-life balance have really evolved into major topics of conversation in medicine. How did you personally deal with those issues? Do you have any insight for those of us that are struggling with work-life balance?
Lawrence Coia: Well, it was important for me to know what I wanted in life. Joseph Campbell, the famous 20th century writer, said “Follow your Bliss” but the first question for me was what was my bliss? What do I really want to do? I like science and have many interests. Radiation oncology satisfied me because I realized my bliss came from pursuing and overcoming challenges that might improve life quality, relieve pain and suffering or prolong survival. Following my bliss has been easy. My joy is doing good in the world by helping others. I also love my family, and nothing can separate a family when there is love and understanding. My family shares in my current interest of viticulture.
I also realized that I needed to achieve some level of financial success to pursue what I wanted. I remember meeting with Larry Solin when he was a colleague at Fox Chase and I said to him that after I get comfortable financially and have practiced radiation oncology for 30 years, I want to pursue another career. That desire was fulfilled.
Viticulture has provided an exciting career for me. Many people did not believe great wine can be made with grapes grown in New Jersey. Just think, before 1976 people largely did not believe that wine from California could match that of France. That was shown to be false. Well we have demonstrated that wine can be made in New jersey that is indistinguishable in blind tastings from some of the best of France or California. It is a great challenge to do so consistently, but for me it is an enjoyable challenge that really fulfills my interests and employs many scientific skills. So, I would say, more than follow your bliss, know what your bliss is first. And hopefully, it will result in something good not just for you but for others.
My advice in closing is- Work hard toward a goal that will result in some good being done for others, don’t squander precious time and don’t fear ending a pursuit if there is another area of pursuit that greatly interests you.
This has been an honor that I didn’t expect. I’d like to thank Laura, Joseph, Marina and ASTRO for affording me this interview opportunity.
The following interview of Lawrence Coia, MD, FASTRO, was conducted on November 13, 2018 by Joseph Barthold, MD, FASTRO and Laura Vallow, MD.
Joseph Barthold: Where did you grow up?
Lawrence Coia: I was born in Philadelphia but grew up in a rural area of Southern New Jersey, in the East Vineland section of Buena Vista Township. I grew up on a vegetable farm and learned the value of hard work. I also learned from farming that hard work is not always rewarded, so I did not want to pursue farming as a career. But rural life provided many opportunities for my brother and me to explore. Our parents were loving and supportive but fortunately they did not coddle us. The region we grew up in was ethnically diverse and again our parents raised us to respect and be friendly to others. We were both good at baseball. In fact, the Little League All Star League team that I pitched for went 6 or 7 games without a defeat and almost took the New Jersey title, but we lost to a South Jersey team from Haddonfield by 2 to 1. The pitcher for that team was Rawley Eastwick who later pitched 8 seasons in the Major Leagues. Despite out rural location, our high school had nearly 700 students in the graduating class and I was at the top in science studies. I was also good at math and was surprised that two unassuming but very nice girls got 800s in the math SAT’s but no guys did, so I learned not to assume much based on gender relatively early in life. I enjoyed school and I really wanted to pursue a career in a science related field. I was able to do so as a radiation oncologist for 30 years, however later in life I returned to farming because I saw unmet challenges and questions in viticulture that my background in science could address.
I was accepted at the University of Pennsylvania but RPI offered a full scholarship and Penn didn’t so my parents said its RPI and I was fine with that. Then I continued studies in physics at Bryn Mawr College to get my Masters degree..
Joseph Barthold: So you did RPI and then Bryn Mawr for physics. Was it radiation physics or general physics?
Lawrence Coia: My undergraduate degree from RPI was in Physics, and at Bryn Mawr College, I was also a Scholar in Physics, however my research there was in biophysics. There under the direction of Dr Rosalie Hoyt, I developed mathematical models for potassium ion channels from data from nerve conduction voltage clamp experiments. At Bryn Mawr I also met my future wife, Barbara Schreiber who was a Classics major. We have been married for over 40 years.
Joseph Barthold: Perfect. Then you went to Temple and then to Jefferson, and Simon Kramer was still at Jeff, right?
Lawrence Coia: Yes, Simon Kramer was Chairman of Radiation Therapy and Nuclear Medicine at Jefferson. I decided to go into medicine because I thought I would be able to accomplish more in that field than in physics. I think I would have been a good physicist but not a great one. Also, I began to recognize that health and disease were challenging topics and that I enjoyed contact and interaction with people and that medicine might offer a better opportunity to do so than physics. Medicine provided opportunities for me to best use my abilities to do good in the world. It allowed me to pursue research in cancer treatment while at the same time have direct contact with patients where I could see the results of my work in helping to cure or palliate. I was fortunate during medical school to work with outstanding radiation biologists, Alan Conger and Darrel Brown. I studied radiation protectors and sensitizers and worked with tumor spheroid research in their labs. I also was able to do clinical rotations at the Fox Chase Cancer Center, then known as the American Oncologic Hospital.
After Medical School I chose to join Simon Kramer’s radiation oncology residency program at Jefferson.
Joseph Barthold: Was Dick Whittington in your era?
Lawrence Coia: Yes. I think Dick joined the year after I started, but we were contemporaries and, in fact, we shared the chief residency our final year along with others.
Joseph Barthold: And then who else was in your era of residents at Jeff?
Lawrence Coia: Dave Moylan
Joseph Barthold: Oh, sure.
Lawrence Coia: We wrote a book together called Radiation Therapy for the House Officer. David continued at Jeff then went into private practice in northern Pennsylvania where he has done great work in radiation oncology at the Simon Kramer Institute which he established. We wrote subsequent primers in radiation oncology called Introduction to Clinical Radiation Oncology. Other residents I remember quickly include Jerry Derdel, Alan Shaiman, Beatrice Bloom, Larry Solin, Bruce Borgelt, Doug Colkitt, Dave Nagel, John McDay and Gary Fisher.
Joseph Barthold: Yeah, and then who were the attendings in that era besides Simon?
Lawrence Coia: We had a great staff. Barbara Fowble (then Barbara Danoff), Mo Mohiuddin, Ralph Dobelbower, John Fazekas and Gunther Seydel were all outstanding clinicians and great mentors. The Radiation Physics division was outstanding too under the direction of N. Suntharalingham. Dave Moylan and I both scored in the 98th percentile of the physics portion of the national residency written exam, no doubt largely due to Suntha’s great teaching. The head of the radiation biology division then was Dennis Leeper. I enjoyed working in his lab for several months on caffeine induced cell cycle changes. Again, Dave and I were prepared well for our national exam radiation biology section, I think we were above the 90th percentile. Jefferson prepared us well for our careers as radiation oncologists.
Joseph Barthold: Then you did Fox Chase after that. Is that right?
Lawrence Coia: Yes. At that time, I was looking at joining Penn. Bob Goodman had taken over Penn the year before I interviewed for a residency position but I decided to join Simon Kramer’s program.-- But following my residency, four years later, Bob had developed a strong clinical research program and recruited some outstanding staff, like Barbara Fowble who left Jeff for Penn as I completed my residency. Bob also had an outstanding radiation biologist in John Yuhas.
Penn faculty were also operating the Radiation Oncology Department of the American Oncologic Hospital in Fox Chase, a beautiful suburb of Philly. Eventually AOH was joined with the adjacent Institute for Cancer Research to become the Fox Chase Cancer Center. I was interested in working with Mel Richter, then head of radiation oncology at AOH, particularly with the newly developed, NCI funded d/t neutron generator. My initial faculty employment at Penn was to work at Fox Chase for six months, and then switch from Fox Chase back to Penn. I really liked working with Mel at Fox Chase, so continued my academic career there at Fox Chase as a faculty member of Penn for most of the time.
Joseph Barthold: So did you work anywhere other than Fox Chase? I can’t remember whether you rotated out to the suburbs.
Lawrence Coia: I would go to HUP, the Hospital of the University of Pennsylvania, in West Philadelphia to hear lectures, coordinate the residency program and give lectures to the residents, et cetera, but I didn’t take care of patients at HUP. I took care of patients at Fox Chase only.
Jerry Hanks joined the Penn/Fox Chase Radiation Oncology faculty in ’85 and greatly strengthened the department. Due to a design flaw the d-t generator did not function consistently well and very few patients with head and neck cancers were treated. Ultimately that unit was dismantled and along with it the ability to pursue one of my research interests disappeared. But Jerry brought tremendous leadership and offered me work with the Patterns of Care study, which turned out to be quite interesting and rewarding for me. I also had an interest in clinical research in gastrointestinal malignancies which I was able to continue. Jerry was very encouraging and interested in that work, especially with the early results of our trial of treatment of esophageal cancer with chemoradiation.
There was this strong push in our department towards clinical research and really questioning what was being done traditionally, especially radical surgery. Organ preserving approaches were ongoing in breast, esophagus, larynx, sarcomas, anal cancer and prostate cancer. We were involved in clinical trials in all those areas. Jerry in particular proceeded to escalate the dose in prostate cancer treatment to improve local control.
You know, one of the things I had to endure initially at the American Oncologic Hospital, which was one of the first NCI designated cancer centers in the nation, was the provincial attitude of some of the surgeons. They were skilled surgeons who until the early 80’s had largely run the small less than 100 bed hospital. Yet they fiercely opposed breast preservation efforts. I suppose this was the response of many surgeons nationwide at the time who were confronted with breast preserving efforts as an alternative to radical mastectomy. For example, after Bob Goodman gave a Grand Rounds lecture at Fox Chase about breast preservation, the Chair of the surgery department walked out of the lecture hall and began pounding on a wooden desk and said, “Within 5 years this is what the women’s breasts are going to be like after they get their breasts irradiated!”
Fortunately, after that initial period Fox Chase recruited many outstanding surgeons like John Hoffman, Mel Goldberg and Drew Ridge who worked extremely well in a multimodality treatment setting and were proponents of organ preservation in lieu of radical surgery when feasible and when similar control and survival were likely.
Joseph Barthold: I know you did Patterns of Care. Were you active in RTOG as well?
Lawrence Coia: Yes, I was active in RTOG. I co-chaired the GI Committee for a few years. I don’t know that I had any studies where I was the first author, although I was a contributing author on many studies. One of the important things that we learned at Jefferson under Simon and then with Jerry at Fox Chase was the importance of participating in clinical trials and getting sufficient data to determine if statistical significance existed.
Our radiation oncology department at Penn/Fox Chase was fortunate because multiple training backgrounds existed within the faculty. At the top Goodman was Harvard system trained, Jerry was Stanford trained, but all good work and techniques from various programs were examined and considered. Large clinical trial participation usually took precedence over small in-house trials and ad-hoc treatments were not allowed.
Joseph Barthold: When did you become a wine maker and stop being a radiation oncologist?
Lawrence Coia: My career in radiation oncology spanned over 30 years. The first half was in academics and the second was in private practice. I never became a wine maker but rather a grape grower. My family owns some farm land in Vineland, New Jersey but we never grew grapes when I was growing up there, but I had one grandfather that was still alive when I was young, and he grew some grapes. The gnarly growth of his old vines and fact that wine can be made from the berries intrigued me.
During my junior year of college I got a view of commercial grape growing. I did my Junior Year in Switzerland. I was the first student from RPI to initiate an exchange program at the Swiss Federal Institute of Technology in Zurich. Switzerland is a beautiful country but with cold winters. I noticed that they could grow wine grapes in many regions of Switzerland. Not longafter I returned to the US, I asked my parents if I could use part of their farm ground to plant some grapes. They consented and helped me get started, but I couldn’t do much because by that time I was in grad school and then medical school. I managed a couple hundred grapevines and then continued slowly expanding acreage. It wasn’t until 2006, right before my retirement from full time radiation oncology in 2008, that we started planting acres and acres of grapes. Our son and I now have 13 acres planted. We own a hundred acres of farmland.
Joseph Barthold: Wow. What was your Switzerland time? I don’t have that piece.
Lawrence Coia: When I was at Rensselaer, I was very fortunate because I was a physics major and my adviser had been a PhD physics graduate of ETH, the Swiss Federal Institutes of Technology. It was just a fantastic place. That’s where many famous physicists, including Einstein and Roentgen, studied or worked in the past. I told my adviser I knew German relatively well and said I want to go to Germany for my junior year to study physics. He said, well, how about Switzerland? I said okay. So, I got a full a scholarship and studied a year at ETH in Zurich. Switzerland is a very civil place and it had many positive effects on my life. It’s a wonderful country, very expensive now but not back then in 1971 when it was 4 Swiss francs per dollar.
Joseph Barthold: Have you done any ongoing radiation oncology as a locum or fill-in person over the last 10-plus years or did you just go cold turkey?
Lawrence Coia: No, I haven’t done any locums work after retiring from full time work in 2008. However, between 2008 and 2013, I continued to work with my group for three days a month, so less than one day a week. And then in 2013, I completely retired.
Joseph Barthold: Was that over in New Jersey?
Lawrence Coia: Yeah, I started a private practice group, East Coast Radiation Oncology, in New Jersey in 1996. Just before that I did look at a chairmanship at an academic institution, but I was turned off by the approach of the COO there who appeared to view the patient as merely a product on a product line.
So, I decided maybe I should look not just at academic places but rather also at private practices. The St. Barnabas health care system was the largest in New Jersey and needed some help at one of their radiation oncology facilities. So, they recruited me there to Community Medical Center in Toms River. And then shortly thereafter -–
Joseph Barthold: Did you say St. Barnabas?
Lawrence Coia: Yes.
Joseph Barthold: Okay, yeah, I know St. Barnabas.
Lawrence Coia: Yeah. It’s a large health care system. Now they’ve merged with Robert Wood Johnson so its an even bigger system. But back then they did have several radiation facilities besides the one in Toms River that needed help. After the Saint Barnabas system recruited me, I recruited Radiation Oncologists to staff Monmouth Medical Center in Long Branch, and Newark Beth Israel, in Newark and Kimball Medical center in Lakewood. Most of the radiation oncologists recruited had trained at Fox Chase or Memorial Sloan Kettering and all were great colleagues.
And around 2000 our group also opened a radiation oncology facility at Southern Ocean County Hospital. That hospital is not part of the Saint Barnabas System. We purchased the equipment and staffed the facility that we leased from the hospital. It was a beautiful and efficient facility.
I initially headed the radiation oncology efforts of the southern division of the Saint Barnabas system, although my colleague Robert Ivker staffed the department at Newark Beth Israel. For a while Bob Goodman headed the northern division.
Joseph Barthold: Where do you see it going next? Are we going to stay independent or are we going to get pushed to the side by the immune therapy?
Lawrence Coia: Well, Joseph, my guess is that we will continue to have a real independent role in cancer management because radiation a relatively non-invasive type of treatment. From the advances we’ve had in radiation oncology, we’ve significantly diminished side effects.
When I was asked to run and build the department at Southern Ocean County Hospital in 2000, the CEO of the hospital asked me what I was going to do to prepare the building for expansion 10 and 20 years down the road. I said, you know what, I’m going to build it the best I can right now and prepare for future expansion, but I’m hoping you won’t even need radiation oncology in 20 years. Clearly that has not happened.
I do think we have a critical role in cancer management. Yes, there have been great strides in cancer prevention and treatment. Immunotherapy has taken a log time to develop into a successful treatment approach and will take many more years to perfect. Advances in genetic manipulation and CRISPR-cas9 type discoveries will likely provide the basis for a long-term solution to cancer. But whether it would happen in my lifetime, I don’t know. I’m 67 now, and hopefully I have another 20 years.
Joseph Barthold: So, you spent a fair number of your years training residents and dealing with medical students who are going to go into this. Reflect on that a little bit. You influenced an awful lot of other people to go on and become both clinical or academic or both.
Lawrence Coia: Teaching and training residents is probably one of the things I miss the most. I was involved in training of many residents who have made some important progress in radiation oncology. People like Wally Curran, Howard Sandler, Mitch Machtay, Anthony D’Amico, Marissa Weiss, Rachelle Lanciano and Lori Pierce. I could just continue to go on and on. As far as those residents I helped train who didn’t stay in academics, I’m sure most them are excellent and dedicated radiation oncologists as well.
Joseph Barthold: I didn’t know you had a connection with Howard Sandler. Was he at Penn?
Lawrence Coia: Yes, he was at Penn and Fox Chase. I remember the first day he came in, I had 35 patients in my service and by the next day, he knew the clinical history about each one of them. I was treating patients with cancers of many different types, yet he knew what their cancers were and how they were being treated. That impressed me.
Joseph Barthold: He’s a really good guy.
Lawrence Coia: Yes, he is.
Joseph Barthold: Howard has done a great job. He’s been chair of the GU Committee for probably 10 years on our RTOG and really done some amazing work.
Lawrence Coia: We have made great progress in prostate cancer treatment. I don’t know how much we need to get into it, but one controversy during my time in radiation oncology was that of self-referral, particularly in prostate cancer treatment. We’ve been talking mostly about the academic side, but in the private practice side, it was discouraging to see the self-referral and behavior of urologists and some radiation oncologists in the treatment of prostate cancer. That was a tough thing for me to understand and to deal with, frankly. I should have been ready to deal with that issue because Jerry Hanks warned me when I left Fox Chase for private practice. He said, “You know, you’re going to be in a tough situation with urologists at the hospital you are going to.”
Joseph Barthold: How did you get the balance to -– tell us about your family and kids, et cetera.
Lawrence Coia: After Bryn Mawr College my wife got a Masters degree in Library Science at Columbia University. We married in 1978 after I finished my residency. She worked for an information company, the Institute for Scientific Information and then Thomson /Reuters in Philadelphia for many years and retired around the time I did. Now she volunteers for the county library and plays the harp. She also enjoys the culinary arts and we belong to a couple of gastronomic societies. She loves fly fishing and we belong to the Henryville Conservation Club which owns trout streams in the Pocono Mountain. Our son, Stephen, is 33 and manages the vineyard. He loves work in the vineyard and running and maintaining the equipment. Actually, one of the reasons that I’m involved in viticulture is so I can spend time with him. He lives at the farm where I grew up and manages it well.
The viticulture part has been an amazing thing because I’ve been able to do investigate optimal grape varieties and growing techniques for New jersey. I have gotten many grants funded for viticulture research, probably more than I did as a radiation oncologist. I just co-authored a book with Dan Ward of Rutgers titled Wine Grape Varieties for New Jersey that will be released in December 2018. I’ve been also working with Orley Ashenfelter an economics professor at Princeton University on issues related to wine. Wine economics has been an interesting field to pursue.
Joseph Barthold: Did you know you were going to be right when you were at Jefferson with the pre-op rectal philosophy versus the rest of the city, which, when we were all trained, it supposed to be post-op?
Lawrence Coia: Right, Mo Mohiuddin was the one who was right on this. He had a lot of interesting ideas. One was to give a single dose of pre-op radiaton, 5 Gy or so at the time of surgery, there would be less likelihood that the surgeons would be surgically sending out viable cells and disseminate the cancer. He also designed and pursued longer course pre-op radiation trials. Mo Mohiuddin really is a great man in the field and had many great ideas, and I was happy to work with him.
Joseph Barthold: It’s interesting. I trained at RTOG and at Hahnemann and everybody was post-op except Jeff. And I remember for years, people -- in Philadelphia it was interesting because depending on what side of the street, what medical school you went to determined whether you got pre-op or post-op. I think it pretty much stayed that way until the last 10 years when the German trial came out saying pre-op was better. Now we all do pre-op.
Lawrence Coia: A lot of how we practice has to do with relationships with surgeons, and medical oncologists and I realized early on that an important part of oncology was multi-disciplinary management. At Jefferson there was a terrific surgeon, Jerry Marks, who worked closely with Mo to improve ways of doing things. My surgical and medical oncology colleagues at Fox Chase were excellent to work with.
At Fox Chase, I was extremely lucky because the thoracic surgeon initially there had concerns about the ability of surgery to cure esophageal cancer. He referred many if not most of the patients with esophageal cancer to our program of radio-chemotherapy treatment. That’s how we were able to use definitive management for esophageal cancer with chemo and radiation.
We only got to 20-25 percent survival with chemoradiation, but it was a lot better to be able to tell a patient there were some chance at cancer survival than none.
Joseph Barthold: Did you do any sabbaticals when you were at Fox Chase? Did you get to go and do anything fun?
Lawrence Coia: I have made many friends, including non-American ones through ASTRO. Around 1983 I was an ASTRO ESTRO travel grant recipient and I went to Austria, to the University of Vienna for a couple of weeks observing work in the radiation oncology department. There I met Robert Hawliczek who became a life-long friend. He just retired from radiation oncology practice in Vienna. Another example of an ASTRO initiated friendship occurred after a talk I gave at ASTRO. An Italian radiation oncologist, Franco Campostrini, asked me some questions. I noticed he had an accent, I asked where he was from, and I was told he was from Verona near Valpolicella. I told him how much I loved Amarone and we’ve become life-long friends. In fact, four years ago, I went to Italy, and stayed with his family while taking Italian language lessons in Verona. He helped me meet a grape geneticist and breeder at the Foundation Edmund Mach north of Verona. Through that meeting I since have established an exclusive US licensee arrangement for our grape growing organization, the Outer Coastal Plain Vineyard Association to sell several of the wine grape varieties developed at that research center. I owe that partially to ASTRO, I guess.
Laura Vallow: This is Laura Vallow. I was on the call. I got in a little bit late, I’m sorry for that.
Lawrence Coia: Laura, I’m sorry we didn’t include you. I didn’t know -- I thought you hadn’t gotten --
Laura Vallow: No, I didn’t want to interrupt. You guys were on such a good roll and I just thought if we had time, I’d throw out a couple more questions if that’s okay.
You know, talking about your interest and what led you to radiation oncology, you mentioned the ability to cure or help palliate a patient. Do you feel with so much hypofractionation, SBRT, and SRS where our patient interaction is really decreasing, do you think that is going to affect the satisfaction of practitioners in our field?
Lawrence Coia: That’s a great question, Laura. It’s one that I hardly had to face because I left the field before cyber knife, hypofractionation, et cetera had come into common usage. I enjoyed interacting with the patients, not just devising a treatment plan and working it through, but meeting patients at least once every week for at several weeks and sometimes seven or eight weeks. It allowed time for a good trusting relationship and team attitude to form.
Laura Vallow: In my breast practice, I see patients three times instead of six times, and it definitely affects the collegiality.
Joseph Barthold: I think it’s different. I find that as you get to know a patient during the course of their six weeks or eight weeks of prostate, you get to know them a lot and they’ll tolerate side effects more if they like you. We don’t have a relationship with people. And then when they get the side effects a year or two or five years later and they did not have a relationship with you that included six weekly visits and a bunch of follow-ups over the course of several years, I think they’re more likely to sue when they get side effects that we warned them about.
Laura Vallow: Yes, I agree.
Lawrence Coia: That is very interesting. I would have found it difficult to explain clearly what we were doing with such limited encounters. I would imagine that the patients are more likely to remember the therapist treating them than they will the doctor if hypofractionation is taking that strong a hold, which sounds like it has.
Laura Vallow: I have another question about your employment history, since you have an extensive history in private practice and academics. As you probably know, the national demographics are showing a decline in private practice. People are moving towards hospital base or academic practices. Do you have any insights for those new graduates that are struggling to find their place in either academic medicine versus private practice?
Lawrence Coia: Well, I think when they’re interviewing, they should try to determine the role in which the hospital or the department see themselves regarding patient care. I had mentioned to Joe earlier, I had interviewed in an academic place and it just sounded like the patient was viewed as a product on a product line. I’m sure that could happen in private practice or in academics, but if that’s the attitude of the CEO or department head, I would stay away from that place. The reason for us to go into radiation oncology should be to see what good we can do in the world for patients with cancer. The product or the product line view of the patient is not the right solution. I don’t know if I answered that or --
Laura Vallow: No, that’s wonderful. In terms of the future of our specialty, what do you see as the major barriers or challenges that face us today?
Lawrence Coia: Well, part of my challenge was how we would interact with medicine and surgery and work together with the patient as a team. For the most part, we did well. Now we have another modality of immunotherapy too, and I guess the question is how much of this modality should be integrated into a radiation oncology training program so that we understand it. Even if we don’t give immunotherapy, we can really make sure that we’re involved and play an important role in a patient’s cancer management. Like I mentioned to Joe, radiation is a non-invasive technique that’s pretty effective in curing cancer and palliating pain.
The majority of patients we treat with radiation could be cured with radiation as part of the treatment and it remains an important tool, but we have to make sure that we’re able to integrate it with other disciplines even better than we have because there are more types of cancer treatments now.
Laura Vallow: Absolutely. I have one more question, because it seems that you transitioned so well into retirement. Well-being and work-life balance have really evolved into major topics of conversation in medicine. How did you personally deal with those issues? Do you have any insight for those of us that are struggling with work-life balance?
Lawrence Coia: Well, it was important for me to know what I wanted in life. Joseph Campbell, the famous 20th century writer, said “Follow your Bliss” but the first question for me was what was my bliss? What do I really want to do? I like science and have many interests. Radiation oncology satisfied me because I realized my bliss came from pursuing and overcoming challenges that might improve life quality, relieve pain and suffering or prolong survival. Following my bliss has been easy. My joy is doing good in the world by helping others. I also love my family, and nothing can separate a family when there is love and understanding. My family shares in my current interest of viticulture.
I also realized that I needed to achieve some level of financial success to pursue what I wanted. I remember meeting with Larry Solin when he was a colleague at Fox Chase and I said to him that after I get comfortable financially and have practiced radiation oncology for 30 years, I want to pursue another career. That desire was fulfilled.
Viticulture has provided an exciting career for me. Many people did not believe great wine can be made with grapes grown in New Jersey. Just think, before 1976 people largely did not believe that wine from California could match that of France. That was shown to be false. Well we have demonstrated that wine can be made in New jersey that is indistinguishable in blind tastings from some of the best of France or California. It is a great challenge to do so consistently, but for me it is an enjoyable challenge that really fulfills my interests and employs many scientific skills. So, I would say, more than follow your bliss, know what your bliss is first. And hopefully, it will result in something good not just for you but for others.
My advice in closing is- Work hard toward a goal that will result in some good being done for others, don’t squander precious time and don’t fear ending a pursuit if there is another area of pursuit that greatly interests you.
This has been an honor that I didn’t expect. I’d like to thank Laura, Joseph, Marina and ASTRO for affording me this interview opportunity.
