Sarah Donaldson, MD, FASTRO
By David Larson, MD, PhD, FASTRO, and Theodore Phillips, MD, FASTRO
This conversation with Sarah Donaldson, MD, FASTRO, David Larson, PhD, MD, FASTRO, and Theodore Phillips, MD, FASTRO, was conducted on September 28, 2008.
Question: Can you tell us where you were born, Sarah?
Dr. Donaldson: I was born in Portland, Ore.
Question: And who were your parents and what did they do?
Dr. Donaldson: For as long as I can remember, my mother and father, Isabel and Laurance, worked. They divorced when I was young, and I grew up living with a single working mother. We lived next door to my aunt, uncle and two cousins, so I grew up with my aunt and uncle serving as surrogate parents and my cousins like siblings. So, in fact, I was an only child, but I was not brought up as one because I spent most of my waking day with my cousins.
Question: Was there something about your upbringing that said study hard, get educated, get ahead?
Dr. Donaldson: Yes, that message came from my mother. My mother was an extraordinarily hardworking, educated lady with a degree in education, who grew up during the depression. She worked hard to balance the finances. I remember she kept a huge ledger of what she spent and how to allocate the money she had to keep a household going on her wages during the war, World War II. She brought me up, raised and educated me, and gave me a college education all the time working herself. So, I think I gained a work ethic from my mother.
Question: Did you have brothers and sisters?
Dr. Donaldson: No.
Question: But you had your cousins.
Dr. Donaldson: Yes. I grew up with my cousins like siblings.
Question: Did your cousins end up educated and motivated in getting ahead?
Dr. Donaldson: Yes, we all went to school in Oregon. I went the University of Oregon in Eugene, one cousin went to Oregon State in Corvallis, and the other went to Willamette in Salem.
Question: So, in your high school career would somebody have predicted, ‘here is a person who is going to be the head of ASTRO?’
Dr. Donaldson: I think they would have predicted I would have done well, because I was a leader in my class, a class officer, and a popular cheerleader with lots of friends. At U. S. Grant High School in Portland we did not have a ‘most likely to succeed’ award, but 90 percent of the class went on to college and so all my friends were in the Honor Society, high achievers and all went onto college or university.
Question: That was a public high school?
Dr. Donaldson: Yes.
Question: In Portland?
Dr. Donaldson: Yes, it is the school where the movie Mr. Holland's Opus was filmed. Grant High School was very much like the school featured in the film Mr. Holland's Opus.
Question: Do you still keep up with your high school classmates?
Dr. Donaldson: I do. It is quite interesting. The class of ’56 remains very bonded; there are class reunions and events every year, which are well attended. My friends in high school continue to be among my best friends. We communicate with birthday and Christmas cards and more recently via the Internet. I make a point to see my high school friends when I return to Portland even though some of them have moved elsewhere. When I am traveling through a city where one might be, I always call. It is extraordinary that my high school class remains so cohesive.
Question: So it was clear when you were in high school that you would go to college.
Dr. Donaldson: Yes, it was clear.
Question: And was it clear you were going to go to the University of Oregon?
Dr. Donaldson: No. I received a scholarship to Willamette University and almost went there. But it was clear that I was going to go to school in Oregon, as I had never been outside of the state of Oregon. Most Grant High students went to either University of Oregon or Oregon State College.
Question: Did you have to declare your major? At some point, you probably did.
Dr. Donaldson: Well, from the time I was young I knew I wanted to be a nurse. I had done hospital volunteer work at the Multnomah County Hospital in Portland from before the time I was old enough to secure a work permit, as a candy stripper/pink lady. I did volunteer work from about age 13 or 14. Then, when I was 16, I got a work permit and then worked at the hospital as a nurses' aide, which I did all through high school. So there was no question in my mind I wanted to go to nursing school. I entered the University of Oregon in Eugene with the plan to studying pre-nursing, as I intended to be a nurse. At that time girls were expected to be teachers, secretaries or nurses and that is what most high school graduates did.
Question: So the University of Oregon had a nursing program, a four-year nursing program?
Dr. Donaldson: It was a five-term nursing program in Eugene. A year and two-thirds followed by three years at the University of Oregon Nursing School, which was part of the University of Oregon Health Science Center in Portland. So I went to Eugene for almost two years and then moved back to Portland.
Question: It was a five-year program and at the end of it you have a degree?
Dr. Donaldson: Yes, a BS and an RN degree.
Question: Two degrees.
Dr. Donaldson: Yes
Question: Then what happened?
Dr. Donaldson: Well, I graduated from nursing school having had a wonderful time. I then needed a job. Most of my classmates in nursing school – and I'm still good friends with them, too – took their first job in a hospital because that is what young graduates did. About the time when I was in my last year of nursing school, the head of the Department of Surgery at Oregon was a dynamic surgeon named J. Engelbert Dunphy, whom you both will remember because he later chaired the Surgery Department at UCSF. Dr. Dunphy had been trained in Boston and was recruited from Harvard to be the chair of surgery at University of Oregon Medical School, now called Oregon Health and Science University. He brought with him some young surgeons, one of whom was William S. (Bill) Fletcher who had just finished his surgical training. Bill Fletcher's assignment, as an instructor in surgery, was to start a surgical oncology program, including a cancer chemotherapy program. There was a new cooperative group called the Western Cancer Chemotherapy Group who were studying new drugs that included 5 Fluorouracil, Vincristine and Vinblastine, among others, as single agents. At that time there was no specialty of medical oncology; surgeons took care of the cancer patients.
Question: About what year was this?
Dr. Donaldson: The early 1960s. When I graduated from nursing school in 1961, Bill Fletcher needed a nurse to help him as his assistant. So I went to work for him as a research nurse. My job was to organize the tumor board and work as a clinical research associate keeping the flow sheets and data sheets of the experimental drugs. I also worked with Dr. Fletcher in the outpatient clinic. I carried little calipers in my pocket, measuring lumps and bumps and recording weekly tumor size. I prepared the drugs, such as 5 Fluorouracil for intra-arterial and intravenous administration. Bill Fletcher was also doing isolation perfusion in the operating room, so I also worked with him in the OR. I either scrubbed with him or worked as his circulating nurse. And then I worked in the lab with him as well. I helped him in his lab projects and ultimately had my own lab project. It was a study of amelanotic melanoma in hamsters. I transplanted the tumors, watched them grow, and then gave the animals chemotherapy and radiation treatment and recorded the tumor regression.
I worked for Bill Fletcher for several years, during which time he had the idea that perhaps my future should go beyond simply working as his research assistant. His idea was that I should go to medical school. However, I didn't realize that he had that idea because early on he suggested to me that I could be a more useful employee to him if I took some additional classes, including physics because I was running his pump-oxygenator in the operating room. One day he asked me, 'What would you do if the pump broke down?' I wasn't certain what I would do. He then said, 'Well, I think you could be a greater help to me if you take some physics.' So I took physics at Portland State College in a summer school class. But in order to take physics, I had to take trigonometry, a prerequisite to physics, and in order to take trig, I had to take second-year algebra. So ultimately I took a series of courses – at night school or in summer school – to do what Dr. Fletcher had asked me to do, because it was intended to make me into a better employee. Simultaneous with that, Dr. Fletcher also had a license to use radioisotopes in the laboratory. He had gone to Oak Ridge, Tenn., and taken a course to use isotopes in the lab. He was tagging isotopes onto agents and injecting the agents into rats. One day he said, 'You know, if you're going to help me in the lab and you are going to be around radioisotopes, you really need to take organic chemistry.' Well the prerequisite to organic chemistry was inorganic chemistry. I completed these courses in sequence. And then one day after we finished a long experiment, he asked me, 'Why don't you think about going to medical school?' I replied that I couldn’t go to medical school, and he asked why not. I did not realize at the time that I had just fulfilled the premed requirements.
Question: Those were the courses you hadn't had . . .
Dr. Donaldson: Yes, those were the courses I hadn't had in nursing school.
Question: Was he surreptitiously making you do that or was he actually wishing you had that particular knowledge at the time to help him?
Dr. Donaldson: He thought I should go to medical school.
Question: Years before . . .
Dr. Donaldson: Yes. He had the idea; I just didn't realize it. So when he asked, 'Why don't you think about going to medical school?' and I answered 'I can't go to medical school,' he replied 'You just completed the prerequisites,' and I asked, 'I have?' He told me I had. All the while I had been going to school because I was motivated to be a good employee! At any rate, I still thought I couldn't go to medical school and he asked, 'Why can't you go to medical school?' I replied with the four reasons why I thought I couldn’t go to medical school. They were: one, I was too old. The second was I was a girl. The third was I didn't have enough money and the fourth was I wasn't smart enough. He got a little huffy and suggested we talk about this. He then asked, 'Well, how old are you going to be in ten years?' I think I was 24 at the time, and I answered, 'I'll be 34.' And he said how old will you be in ten years if you don’t go to medical school?' Well, 34. And then I said I can't go because I'm a girl. Admittedly, it was a little uncommon for a female to go to medical school, but he had gone to Dartmouth Medical School, finishing at Harvard. He also had gone to Dartmouth for undergraduate studies. Dartmouth was, at that time, an all-male school, and he knew that Dartmouth Medical School was considering taking women into their school. As a strong, Dartmouth alum, having lived in Hanover throughout his own education, he was up to date on Dartmouth’s plans. He replied, 'Dartmouth is looking for women. They are actively recruiting them,' which was, in fact, the case. And so it appeared my gender was no longer an issue in this discussion. The fact that I didn't have any money was a potential problem, but he told me, which was true at that time, 'Well, you can apply for a scholarship, a loan or apply for financial aid'. So although I didn't know how I could afford to go to medical school, he seemed to think the finances wouldn’t be difficult to obtain. And the final reason I said, 'I'm not smart enough.' He pointed out to me that schools like Dartmouth and Harvard, where he had gone to school, had groups of professors that work together on committees called admissions committees. He told me they, in fact, knew the criteria and eligibility necessary for medical school. Furthermore he asked if I thought I knew more than these panels of erudite professors who had spent their entire professional careers educating medical students. ‘Did I know more than they did about who could master the curricula to go to medical school?’ I said, 'No,' and he said, 'Well, this matter is for the admissions committee to decide.' And so the conversation stopped. I had been defeated in this discussion.
It wasn't very long after that when my own research project was up for renewal of its funding. My project at that time was to study Coley’s endotoxins in experimental animals, which produced an immunologic reaction including hyperthermia. It was funded by an agency in New York. Dr. Fletcher pointed out to me the grant was up for renewal, and if I wanted to keep my project going, someone was going to have to defend the grant. The funding agency was scheduled to meet in three weeks, and he said, ' I am operating on that day.' I told him 'I can't go to New York and defend the grant,' and he said, 'Do you want to continue your project?' 'Yes.' 'You are going to have to defend the grant.' And so I said, 'Okay'. So, I went to New York to speak about my research project. As I had never been out of the state of Oregon, Dr. Fletcher suggested I visit his sister who lived in Woodstock, Vt., which is located across the river from Hanover, N.H. Furthermore, he suggested I could stop by and visit Dartmouth, which was exactly what I did. He really had this all preplanned. I was quite naive because what happened was that I was gone for 10 days and I visited eight medical schools these ten days. This was before there was a formal application process. I interviewed at Dartmouth, Harvard, Cornell, Columbia, Hopkins, McGill, Case Western Reserve and Washington University in St. Louis. The day that I went to Hanover was in mid-September. I stayed at the Hanover Inn, a lovely place that looks out onto the Quad and Baker Library. The football team was out practicing; the skies were blue; the sun was shining; the leaves were turning color; it was gorgeous. I sat down on the curb in front of the Hanover Inn and decided I loved Dartmouth.
Question: Was Dartmouth co-ed at that time?
Dr. Donaldson: The undergraduate school was all male; the medical school had taken in two women one year earlier. It was clear to me that Dartmouth was where I wanted to go to school. So I filled out my application, sent it in, and two weeks later, I received a letter in the mail from Dartmouth saying I had been accepted. I called Dr. Fletcher, who at the time was attending the American College of Surgery meeting in San Francisco. I told him 'You'll never guess what has happened. I've just been admitted to Dartmouth,' and he said, 'Terrific. Do you want to go?' I replied 'Yes, but . . .' He asked 'But what?' and I said, 'They want a $50 deposit, a down payment.' He answered, 'The department will cover it.'
Question: So when you were a young girl wanting to go into nursing, you probably didn't have a vision of the actual kind of nursing you might do. How did that transition take place during your nursing training?
Dr. Donaldson: It took place because Bill Fletcher was the chief surgical resident when I was a senior nursing student on my surgical rotation. I loved the operating room. I loved surgery and I was good as an OR nurse. I practiced opening sterile packs and slapping instruments into the palm of one’s hand. I worked hard at being good and stood out in my class. Dr. Fletcher asked for me to be his scrub nurse when he was doing a case, so I knew him. He later offered me a job. I didn't go into hospital nursing like my classmates. I had a unique job opportunity. In fact, I had been advised against taking the research nursing job with Dr. Fletcher. The head of the Nursing Department told me I shouldn't take his job offer because young nursing graduates were supposed to work in a hospital setting doing in-patient floor nursing, in a secure position and gaining much needed experience. But, I didn't follow her advice.
Question: Did Dr. Fletcher have a notion that you would someday be a surgeon? Do you think that was part of his thinking?
Dr. Donaldson: I think he thought that I had an aptitude towards surgery. I have talked to him about this. He is still in Portland, and he remains very much of a mentor to me. This whole story is about a mentor opening a door for a young person.
I often tell this story when I'm talking to young people. It is important to give young people opportunities and to open doors for them because they might just proceed right through if they are well-positioned and prepared. This is the reason I think I feel so strongly about education today. It is one of the most gratifying parts of my job. I am sure that Bill Fletcher thought that I had the potential to do something more than just to be his research assistant. He was the visionary person. It was not me. I had no idea, no scope or vision. Dr. Fletcher was the person who thought this is what I should do and served as a much needed mentor to me throughout my medical school education. I talked to him on the phone regularly. When I thought I was doing poorly in school, I would seek his support. So how did I get into radiation oncology?
Question: Well, not yet. Tell us first about medical school. How was Dartmouth?
Dr. Donaldson: I loved Dartmouth
Question: Did you take up skiing?
Dr. Donaldson: Yes. Dartmouth is interesting. There is not very much to do in Hanover, other than go to school or ski or drink beer, and I did a lot of all three of those things and enjoyed school immensely. I had a wonderful time.
Question: How was it being a woman in one of the first classes of women being at Dartmouth in medical school? Any problems or not?
Dr. Donaldson: All of the students were treated exactly the same, but there weren't many facilities for women. There was no dormitory for women, no locker room or place to change one’s clothes. In Hanover there weren’t many women and not many facilities for women. There were six women in my class. But the medical school didn't have a place to put us, so they gave us a residence which had been the first home of a prior president of Dartmouth, I believe in1783. All the women lived in this house and we had a wonderful time. It was just terrific.
Question: So during medical school you said that sometimes you would speak with Fletcher because you weren't doing so well. What were the things you were doing well in and what were the things that were more difficult?
Dr. Donaldson: I did well in anatomy and in surgery, areas in which I had been mentored. I disliked biochemistry and physiology, as they seemed to require immense memory work. The hardest part of medical school for me was during the first two years, learning how to be a medical student in Hanover. I was slightly older than my classmates and a bit of an outsider because I was the only one from the West Coast. Many of my classmates had gone to Ivy League prep schools. My classmates, in general, didn't know anyone from Oregon, which seemed undiscovered. So, I was novel.
Question: So in medical school, you probably entered thinking, well, the world is my oyster; I can be anything in medicine. It might be surgery; it might be something else. How does that transition eventually?
One question before we get into that, it was a two-year school, so one had to choose where they went for their third and fourth years. Did you have a choice and what made you decide where you went?
Dr. Donaldson: About two-thirds of my class applied to Harvard. The other third applied to other schools. So, most of the class went to Harvard, and the ones that didn't go Harvard went to Cornell, Columbia, McGill or Hopkins. But by this time I was totally entrenched in the class and somewhat of a groupie. Four of the six women in my class applied to Harvard and again when we transferred to Harvard we all lived together in an apartment on Commonwealth Avenue. So I went with the group. But I did what Bill Fletcher said was what I should do. I asked for and followed his advice every step of the way.
Question: So did you have choices when you were in Boston about clinical rotations that you did? Some of them were maybe not choices and some of them were?
Dr. Donaldson: Yes.
Question: Did those choices influence you in some way?
Dr. Donaldson: Yes. Oh, yes, they did. I had my medicine rotation at the Boston City Hospital, a great place. I then did surgery at the Brigham; I did well in surgery, getting an A. This was unusual because it was considered a hard rotation. But, of course, I had worked with Bill Fletcher as his right-arm assistant. He had taught me how to tie knots; he let me do biopsies and taught me to start IVs, so I had gained many surgical skills. Surgery was such fun and seemed natural to me. I wanted to be a surgeon. I wanted to be just like Bill Fletcher. I applied for a surgical house officership at the Brigham, where a surgical internship led to a surgical residency. I was accepted as a surgical house officer at the Brigham, which seemed phenomenal because there had been only one woman before in the Brigham surgical program, Tenley Albright, an Olympic athlete and a wonderful lady. I was thrilled, and I accepted. I was really looking forward to surgery until I had medicine at the Boston City hospital. I then began feeling inadequately prepared in medicine because I didn't really feel as comfortable in medicine. I didn't think I could read EKGs very well, and I didn't think I knew how to manage keto-acidosis very well. Soon I decided that I didn't know enough medicine. So I went to see Dr. Frances Moore, chairman of surgery at the Brigham, and told him that I thought that I needed more training in medicine. I thought I needed a medical internship. He said, 'That will be fine. Just take a medical internship and we'll hold a place for you as a first-year surgical resident.' 'You will?' He said, 'Yes,' and so I applied for a medical internship. I decided to go to the University of Washington in Seattle because there was a very famous internist named Dr. Petersdorf who ran the medicine program. It was a very successful and strong Department of Medicine. So I went off to Seattle, close to Portland and back west. I had a wonderful year as a medicine intern at the University of Washington, loved being a house officer and loved all aspects of medicine: infectious disease, cardiology, renal disease; it was all just terrific. The year was a very good one for me, and at the end I was offered a medicine residency at the University of Washington. As I loved medicine, I accepted the offer. Then I realized I had already accepted a surgical residency in Boston, as well as a medical residency in Seattle.
And so I called Dr. Fletcher and once again asked, 'What should I do?' He asked, 'Well, what do you want to do?' and I said, 'I want to take care of cancer patients, just like you.' Bill Fletcher, visionary that he is, said, 'You know what you should do? You should think about radiotherapy.' Of course, I knew nothing about radiotherapy, and I said to him, 'I can't do radiotherapy.'
Question: What year was this?
Dr. Donaldson: I graduated from Harvard in 1968, and he said, 'Why not radiotherapy?' and I said, 'Isn't radiation all about degradation products and isodose curves? I don't know what those things are.' He replied, 'To be a good radiation therapist, you need to know how to read the area under the curve. You need to know what's on the ordinate and what's on the abscissa, read the curve, and hire a good physicist. That's what you need if you're going to be a good radiation therapist. He told me that what one really needed to be in radiotherapy was to know where the cancer was located and to have the judgment to know when to irradiate and when the patient should undergo surgery and when and how to include radiation with surgery. That would make me a good radiation therapist. He also told me if I was good, I would hire a physicist who would tell me about the area under the curve.
Question: He was mentoring you earlier when you were finishing nursing. Was he obviously exposed in some way, no pun intended, to radiation oncology? Were you aware of that at the time?
Dr. Donaldson: Yes, because Dr. Fletcher had done the early pre-op radiation rectal cancer studies at University of Oregon working with the radiation oncologist whose name was Cliff Allen.
Question: That was a famous study. That was a first.
Dr. Donaldson: Yes. Dr. Fletcher believed in pre-op radiation for rectal cancer because following pre-op radiation, when he would then take his patient for resection, some patients had no viable tumor, so he knew about radiotherapy and he believed in it.
Question: There was a little exposure that you had yourself.
Dr. Donaldson: Yes, I had previously had a laboratory project using radiotherapy in experimental animals.
Question: So now later on Dr. Fletcher was saying to go into radiotherapy, so tell us about that.
Dr. Donaldson: I didn't know where to go for radiotherapy training. Dr. Fletcher told me I should go down to meet his friend, Mal Bagshaw. He and Mal had been on a panel together I believe. So I came down to Stanford to meet Mal Bagshaw. But, the person I was assigned to be interviewed by was Scotte Doggett, and Scotte was the most interesting person I had ever met. When Scotte was interviewing me for a position at Stanford, he asked me my opinion of the best medical internship and residency in the country. I answered that I thought that the Harvard service at the Boston City Hospital was the best training program in medicine in the country. That is where I had taken medicine as a student. Only later did I learn that Scotte had been a house officer on the Harvard service at the Boston City Hospital before he went into radiotherapy, and he also thought it was a great place to train. And then he found out I had been a cheerleader, as had he; he ended our interview by getting up onto the desk and doing a cheer for Stanford. I then decided to come to Stanford! That experience turned out to represent Scotte in his most enthusiastic recruiting mode.
Question: Tell us how you discussed this with Dr. Moore.
Dr. Donaldson: I had to tell him that I decided to go into radiation therapy, which I did. I wrote him a letter and told him. I never got any feed back.
So, my going into radiation oncology was not because I was visionary; it was Bill Fletcher's vision. At that time the world of radiation oncology was very small with some foreign medical graduates and a few stand-out personalities but not very many. Dr. Fletcher thought the world of radiation oncology needed more surgically oriented physicians.
Question: So at that time you knew a lot about surgery and you knew some about medicine, but you probably knew relatively less of radiation oncology. So deciding to come here was basically an act of faith.
Dr. Donaldson: It is what Bill Fletcher told me I should do.
Question: And you knew he would be probably right.
Dr. Donaldson: He advised me and I followed his advice all the way along.
Question: So who was in your residency class with you?
Dr. Donaldson: In the class ahead of me were Ron Thompson, Joe Kraut, Eli Glatstein and other luminaries, including Karen Fu. Karen had actually had a year of radiation oncology training in Toronto, but she entered the class at Stanford with me. She was one year ahead of me in experience and one year smarter than me; she could do chi-squares in her head, and I did them on a slide rule. Karen was a great role model for me and we became very good lifelong friends.
Question: You started here in the summer of '69? Was that right?
Dr. Donaldson: Yes.
Question: With Karen?
Dr. Donaldson: Yes.
Question: And anybody else in your class?
Dr. Donaldson: Tom Barclay and Dick Borrison,
Question: Sarah, before you came, I was here six months as a visiting professor, and it was a fun place in those days. There were TGIF parties every Friday. Tell us about them.
Dr. Donaldson: Well, I'll tell you about my first TGIF party. It was notable. There were TGIFs regularly, and the first week of my residency, there was a departmental party for the new residents. It was at the home of one our therapists, Irene Davidson, who lived in downtown Palo Alto. We were all supposed to go to the departmental party, especially the new residents. I was uncomfortable about going to this party because I didn't have a date, and I didn’t want to go by myself. So I orchestrated a way that I wouldn't have to go to the party by myself. I invited the department nurse, Renee Doyle and her husband, as well as a medical student on service who was John Salzman, to come to my house beforehand for a drink. I made martinis and then all four of us went together to Irene's house. We arrived about an hour and a half late, and all the food was gone. But by that time there was dancing in the dining room; everyone was having a wonderful time. When I walked in the front door all of a sudden John was someplace else and Renee was gone, and I was standing by myself in the entryway. Eli Glatstein came up and said, 'Well Sarah, would you like to dance?' and I said, 'Well, sure.' So I ended up going onto the dance floor with Eli. We were dancing, and all of a sudden Eli walked off the dance floor. He just left. And again, I was by myself, standing there among a group of people all of whom had somebody to dance with, and I was standing by myself. So I quickly hurried off the dance floor. And as I did, I slipped on a spilled drink; I was going at quite a clip, as a matter of fact, and when I slipped and fell, I slid on my bottom from the middle of the dining room dance floor, all the way across the room, out the exit, into the entry way where there was a huge floor to ceiling mirror. I slid parallel to the mirror until I landed abruptly on a giant, black shoe. As I looked up next to the body extending from the black shoe, I saw Bob Stewart, a junior faculty and such a nice man. And Bob said, 'Dr. Kaplan, I'd like you to meet one of our new residents.' I was sitting on Dr. Kaplan’s foot! I jumped up, terribly embarrassed, and asked 'Dr. Kaplan, would you like to dance?' He said, 'Sarah, I'll take a rain check.' I was so mortified that I went directly home. That was my introduction to the department and the first time I met Henry Kaplan, sitting on his shinny black shoe!
Question: Let me ask you this. You've authored hundreds of papers. What was the first radiation oncology paper that had your name on it?
Dr. Donaldson: The paper that is most memorable to me was a paper that I wrote with Henry Kaplan. I worked very hard on that paper. It was a study of infections in asplenic patients. In our Hodgkin’s disease laparotomy series, many patients developed infections. I was aware that young children who had their spleens removed for hematologic disease before the age of two had a high incidence of overwhelming pneumococcal infections. And so I was interested in this problem. We had a six-month rotation when the radiotherapy residents took care of all the inpatients on the clinical research center. Many of these patients developed overwhelming infections, meningitis and bacteremia. So I wrote a paper about infections in splenectomized patients. I worked hard to get this paper as perfect as it could be, perhaps after 20 revisions or so. I then gave my ‘perfect product’ to Dr. Kaplan. Subsequently, the draft was returned to me, looking like a blood bath. Dr. Kaplan wrote his comments in red ink. My paper was all red. Every page was red; it was impossible to see any white paper. My perfect draft was covered with red corrections. That paper went through 23 additional revisions before it was accepted for publication.
Question: Before you sent it in?
Dr. Donaldson: Yes, that was what it was like to write with Henry Kaplan. He was a true perfectionist.
Question: How did you develop your interest in pediatrics?
Dr. Donaldson: Well, at that time there was no pediatric oncology service, as there was no specialty called pediatric oncology. The radiation oncologist or the pediatric surgeon took care of the children with cancer. When I was chief resident, it was my responsibility to take the inpatient, new patient consultations. When the pediatricians needed a child to be assessed, I would get the call and was asked to decide about management. Eventually I learned a little about pediatric oncology, but there was no subspecialty called pediatric radiation oncology. At the end of my residency, a very troubled time in America because of The Vietnam War, the youth of America were very much at unrest. Young people were protesting the war, writing graffiti on walls and acting out. We all wanted a change. We didn’t want to be told what to do, we didn’t want to take any more exams and we were tired of being regimented. I wanted to travel. So I decided I wanted to go abroad to find an experience away from America. As there was no official pediatric radiation therapy subspecialty, I had an idea that maybe I could do pediatric radiation therapy. So I told Dr. Kaplan that I wanted to go to England and do specialty training in pediatrics. Dr. Kaplan replied, ‘No.’ He told me if I wanted to specialize in pediatrics, I should go to Institut Gustave Roussy (IGR) in Villejuif, outside of Paris, where there was an established pediatric service. He told me to talk to Malcolm. Mal had taken his sabbatical at IGR, and he agreed that if I wanted to do pediatric radiation therapy, I needed to train with Dr. Odile Schweisguth who was sort of the queen mother of pediatric oncology in all of Europe. So, I went off to see the world and work in France. Really, I knew very little about pediatrics.
Question: And you were in France for one year?
Dr. Donaldson: Yes, I was there for a year. It was a wonderful year; it was, perhaps, the most difficult year of my life. It was hard because, although I thought I knew French, when I arrived I didn't know any useful French. I knew no conversational French. No one was there to roll out a red carpet. The French were not particularly nice to an American. Survival was difficult. I needed to learn to survive. In fact, I ate chicken every day for six months because I didn't know how to ask for anything other than “poulet,” the French word for chicken.
Question: So after six months or so you integrated into the system and were able to take care of patients and so forth . . .
Dr. Donaldson: I was never very good at taking care of patients, but I could talk to children because in French there is a formal and an informal version of the language. When talking to a child, you speak in the informal, familiar form. I never mastered the formal, proper form of the language. But I did make friendships and became good friends with some colleagues from the hospital, with whom I went skiing and on bicycle rides. All in all, I had a very rewarding experience in France. One lesson from Dr. Kaplan was, 'The way to learn French is to get a French boyfriend. You need a French boyfriend.' So I found a French boyfriend who was a ski instructor and I came back from my Christmas skiing holiday speaking much better French, but it was all the familiar, informal form; it was not the formal form.
Question: Did it improve your skiing as well?
Dr. Donaldson: It improved my skiing, but it did nothing for my use of the formal form of French. I well remember when I came back from the Christmas holiday and went to the morning conference, I arrived early. Professor Tubiana, director of the Institut Gustave Roussy, a very formal man, was one of the first people to arrive, and he said, 'Bonjour, Sarah,' and I replied 'Bonjour, monsieur, speaking in the same informal French I had been using all Christmas holiday. This was not appropriate for the professor. I continued to make mistakes like that; I never mastered the language appropriately.
Question: What were the options presented to you at the end of that year?
Dr. Donaldson: Well, I got homesick for America and I wanted to come home. I wrote to Malcolm, and he invited me to come back to Stanford. My opportunity was to start an oncology program, along with a pediatrician named Dan Wilbur.
Question: I know him. I talked to him yesterday.
Dr. Donaldson: Dan Wilbur had trained at Stanford and had gone to MD Anderson in Houston, to run their pediatric oncology service. At the time I was returning from France, Dan was being recruited from Houston back to Stanford, to start a pediatric oncology service. At that time there was no specific person from the radiotherapy faculty to take care of children. That became my job, to return and work with Dan Wilbur and to start a pediatric oncology program.
Question: Some time in there you went to MD Anderson, didn't you?
Dr. Donaldson: Yes, I did. I took an elective rotation as a resident, and that is how I first met Dan Wilbur, because he was in Houston at that time. While at the MD Anderson hospital, I worked as a pediatric oncology fellow.
Question: Dan left here in late '77 or something like that? I was just having a discussion with him about his career yesterday on the phone, but you have some number of years of overlap with him.
Dr. Donaldson: Yes.
Question: So you helped develop, with Dan, pediatric oncology.
Dr. Donaldson: We worked together.
Question: So was anybody else in the country doing pediatric oncology at that time?
Dr. Donaldson: Radiotherapy?
Question: Yes.
Dr. Donaldson: Omar Hustu was at St. Jude, Dan D'Angio was at Memorial and Melvin Tefft had worked in Boston, along with Dr. D'Angio.
Question: This is out of sequence – When did Board exams require demonstrating some knowledge of pediatric radiation oncology? It must not have been then.
Dr. Donaldson: When I first took the Boards, we did not have seven or eight different oral exams the way we have now. We had three examiners and they examined every area. One of my three examiners was Luther Brady, and he asked me an orbital rhabdomyosarcoma question, a retinoblastoma staging question, and a prostate lymph node question.
Question: There's so much we could talk about here.
Question: What are your hobbies? Do you do anything outside of medicine besides cheerleading?
Dr. Donaldson: On one of my sabbaticals, in the mid 1980s, one of the female residents invited me to go to an exercise class with her. We joined a health club in downtown Palo Alto. Ultimately she stopped going to the gym, but I continued going and taking a walking class. That walking class grew into a cohesive group of women that have been walking together for the last 20 years or so. The “walkers” have become a strong support group, and we have also walked around the world together. We have been to Italy, France, Spain, Mexico and British Columbia – walking, hiking, kayaking, biking and always doing exercise. So I would say in my spare time I do outdoors activities with women that I met a long time ago through a fitness center.
Question: People want to be modest, but don't be modest about awards and honors. What sorts of things have you been honored with?
Dr. Donaldson: The most meaningful honor for was to be a trustee and then the president of the American Board of Radiology. I loved being an ABR trustee, because it was an opportunity to make a real and lasting contribution in education. That was a wonderful experience; I got to know a lot of diagnostic radiologists and physicists, and I loved being an ABR trustee. I went through leadership within the ABR system and that was pretty wonderful because I became the first female president of the ABR. That was quite memorable.
Question: You were also the first female president of ASTRO.
Dr. Donaldson: I was. It was fun. It wasn't as much work at that time as it is now. It was lots of fun. We had a great staff including Fran Glica, Nick Croce and John Curry. They provided great administrative assistance.
Question: What other honorary professorships or medals have you received?
Dr. Donaldson: Most recently I received the Gold Medal from the American College of Radiology. I have a Gold Medal from ASTRO and the Janeway Medal from the American Radium Society. I have also been honored be being a member of the Institute of Medicine.
Question: I see favorite sayings as one of the items on the list. Any favorite sayings?
Dr. Donaldson: My favorite saying is from Ralph Waldo Emerson. ‘Nothing great was ever achieved without enthusiasm.’
Question: That's great. Have you ever done sabbaticals? You did a year in France. Have you done others?
Dr. Donaldson: The year in France was actually a fellowship. I’ve had two sabbaticals. On my first sabbatical I went to London and spent my time at St. Bartholomew’s Hospital and the Hospital for Sick Children at Great Ormond Street. It was wonderful. On my second sabbatical I worked with Charlotte Jacobs to develop the infrastructure for a clinical cancer center. We designed the building that is our current Clinical Cancer Center working on the final phases of the blue prints for the building and working with the architects and contractors. We also built a cancer program. We established a clinical trials office and an outreach program. So I feel a real responsibility for this facility, our cancer program and our cancer center.
Question: How many papers have you written yourself and with residents? Anything at this moment being worked on?
Dr. Donaldson: That is a timely question because, actually, I have a draft on my desk of a paper on pediatric Hodgkin’s disease that I intend to read this evening. I think it is very important when I have a good idea to give it to a resident. I learned that lesson from Ted. When Ted came down for his sabbatical at Stanford, one of the things he said afterwards is that when you want to get a project done, give it to a resident.
Question: Oh, that's the way to do it. They get the authorship, and you get the paper back. Do you have any plans to retire?
Dr. Donaldson: Not immediately.
Question: Good. Just wondered.
Dr. Donaldson: I told Dr. Hoppe that when it is clear I need to retire, he must tell me so. I am a little fearful that I might not recognize when I am no longer making a contribution. He promised me he would alert me when the time is right for me to retire, if I don’t recognize this myself.
Question: You had a major role in clinical trials in the United States, particularly in the pediatric field. Can you tell us a little bit about how you got introduced to clinical trials and how it grew and how you grew in it?
Dr. Donaldson: I think it started before the collaborative groups were established, and there I credit Henry Kaplan. As a resident I saw an 18-month-old baby from Brazil who had wide spread Hodgkin’s disease. This was in 1969 when the standard curative treatment was high-dose extended field radiation for pathologically staged children. The dose of 44 Gy total lymphoid radiation did not seem appropriate for this baby, and I didn't know what to do. Dr. Kaplan suggested we give him a smaller radiation dose and combine it with six cycles of MOPP chemotherapy. At that time MOPP chemotherapy was being investigated by Vince DeVita for adults with relapsed Hodgkin’s disease. We gave the baby 15 Gy total lymphoid radiation followed by six cycles of MOPP. He survived. Two years later I saw another child, a 4 year old who also had advanced stage Hodgkin’s disease. We treated him in the same way, and Dr. Kaplan said, 'I think you should write a protocol.' This was long before IRBs and all the regulations we have today. I wrote a protocol using low-dose radiation and six cycles of MOPP, and that became our first pediatric clinical trial at Stanford. This study later evolved into our second pediatric Hodgkin’s disease protocol using low-dose radiation and MOPP/ABVD, which carried with it less chemotherapy related complications of sterility and less leukemia. The national cooperative groups then got excited about this approach of combined modality therapy for children using low-dose radiation and combination chemotherapy because it provided curative therapy with minimal acute and long-term toxicity. I think I got involved into the national cooperative groups by way of the Intergroup Rhabdomyosarcoma Study Group (IRSG). Early on I was part of an NCI review committee and was asked to site visit what was then called the Intergroup Rhabdomyosarcoma Study Group. I was an extremely critical site visitor. The PI of the group at that time was Dr. Hal Maurer who went on to be department chairman and dean and now is chancellor at University of Nebraska. He is a wonderful and very smart man. He invited me to become a member of the IRSG and gave me the task of solving all the problems I had criticized as a site visitor! That particular cooperative group has been extraordinarily productive and is a very cohesive group. They have completed a series of sequential studies from IRS-I to II to III to IV to V and now they are undertaking risk adapted studies that represent continuity in a series of studies in sarcoma spanning nearly 40 years. The cure rate for children with rhabdomyosarcoma has escalated with improved multidisciplinary care, improved staging and imaging, and with each sequential study. So my experience in the cooperative group setting has been very gratifying.
Question: Do you think the merger of the two main pediatric groups, POG and CCG, has been beneficial?
Dr. Donaldson: No, I don't think it has been beneficial. It was helpful to have competition between the two groups. Competition is healthy. We were always trying to be more novel and innovative than the other group. With one large group it is an enormous challenge to arrive at consensus. Often one ends up compromising, and then you don't necessarily have the best outcome. So, I don't think the merger has been helpful.
Question: Any final comment?
Dr. Donaldson: No. Thank you for interviewing me.
Question: Thank you, Sarah. This has been great.
This conversation with Sarah Donaldson, MD, FASTRO, David Larson, PhD, MD, FASTRO, and Theodore Phillips, MD, FASTRO, was conducted on September 28, 2008.
Question: Can you tell us where you were born, Sarah?
Dr. Donaldson: I was born in Portland, Ore.
Question: And who were your parents and what did they do?
Dr. Donaldson: For as long as I can remember, my mother and father, Isabel and Laurance, worked. They divorced when I was young, and I grew up living with a single working mother. We lived next door to my aunt, uncle and two cousins, so I grew up with my aunt and uncle serving as surrogate parents and my cousins like siblings. So, in fact, I was an only child, but I was not brought up as one because I spent most of my waking day with my cousins.
Question: Was there something about your upbringing that said study hard, get educated, get ahead?
Dr. Donaldson: Yes, that message came from my mother. My mother was an extraordinarily hardworking, educated lady with a degree in education, who grew up during the depression. She worked hard to balance the finances. I remember she kept a huge ledger of what she spent and how to allocate the money she had to keep a household going on her wages during the war, World War II. She brought me up, raised and educated me, and gave me a college education all the time working herself. So, I think I gained a work ethic from my mother.
Question: Did you have brothers and sisters?
Dr. Donaldson: No.
Question: But you had your cousins.
Dr. Donaldson: Yes. I grew up with my cousins like siblings.
Question: Did your cousins end up educated and motivated in getting ahead?
Dr. Donaldson: Yes, we all went to school in Oregon. I went the University of Oregon in Eugene, one cousin went to Oregon State in Corvallis, and the other went to Willamette in Salem.
Question: So, in your high school career would somebody have predicted, ‘here is a person who is going to be the head of ASTRO?’
Dr. Donaldson: I think they would have predicted I would have done well, because I was a leader in my class, a class officer, and a popular cheerleader with lots of friends. At U. S. Grant High School in Portland we did not have a ‘most likely to succeed’ award, but 90 percent of the class went on to college and so all my friends were in the Honor Society, high achievers and all went onto college or university.
Question: That was a public high school?
Dr. Donaldson: Yes.
Question: In Portland?
Dr. Donaldson: Yes, it is the school where the movie Mr. Holland's Opus was filmed. Grant High School was very much like the school featured in the film Mr. Holland's Opus.
Question: Do you still keep up with your high school classmates?
Dr. Donaldson: I do. It is quite interesting. The class of ’56 remains very bonded; there are class reunions and events every year, which are well attended. My friends in high school continue to be among my best friends. We communicate with birthday and Christmas cards and more recently via the Internet. I make a point to see my high school friends when I return to Portland even though some of them have moved elsewhere. When I am traveling through a city where one might be, I always call. It is extraordinary that my high school class remains so cohesive.
Question: So it was clear when you were in high school that you would go to college.
Dr. Donaldson: Yes, it was clear.
Question: And was it clear you were going to go to the University of Oregon?
Dr. Donaldson: No. I received a scholarship to Willamette University and almost went there. But it was clear that I was going to go to school in Oregon, as I had never been outside of the state of Oregon. Most Grant High students went to either University of Oregon or Oregon State College.
Question: Did you have to declare your major? At some point, you probably did.
Dr. Donaldson: Well, from the time I was young I knew I wanted to be a nurse. I had done hospital volunteer work at the Multnomah County Hospital in Portland from before the time I was old enough to secure a work permit, as a candy stripper/pink lady. I did volunteer work from about age 13 or 14. Then, when I was 16, I got a work permit and then worked at the hospital as a nurses' aide, which I did all through high school. So there was no question in my mind I wanted to go to nursing school. I entered the University of Oregon in Eugene with the plan to studying pre-nursing, as I intended to be a nurse. At that time girls were expected to be teachers, secretaries or nurses and that is what most high school graduates did.
Question: So the University of Oregon had a nursing program, a four-year nursing program?
Dr. Donaldson: It was a five-term nursing program in Eugene. A year and two-thirds followed by three years at the University of Oregon Nursing School, which was part of the University of Oregon Health Science Center in Portland. So I went to Eugene for almost two years and then moved back to Portland.
Question: It was a five-year program and at the end of it you have a degree?
Dr. Donaldson: Yes, a BS and an RN degree.
Question: Two degrees.
Dr. Donaldson: Yes
Question: Then what happened?
Dr. Donaldson: Well, I graduated from nursing school having had a wonderful time. I then needed a job. Most of my classmates in nursing school – and I'm still good friends with them, too – took their first job in a hospital because that is what young graduates did. About the time when I was in my last year of nursing school, the head of the Department of Surgery at Oregon was a dynamic surgeon named J. Engelbert Dunphy, whom you both will remember because he later chaired the Surgery Department at UCSF. Dr. Dunphy had been trained in Boston and was recruited from Harvard to be the chair of surgery at University of Oregon Medical School, now called Oregon Health and Science University. He brought with him some young surgeons, one of whom was William S. (Bill) Fletcher who had just finished his surgical training. Bill Fletcher's assignment, as an instructor in surgery, was to start a surgical oncology program, including a cancer chemotherapy program. There was a new cooperative group called the Western Cancer Chemotherapy Group who were studying new drugs that included 5 Fluorouracil, Vincristine and Vinblastine, among others, as single agents. At that time there was no specialty of medical oncology; surgeons took care of the cancer patients.
Question: About what year was this?
Dr. Donaldson: The early 1960s. When I graduated from nursing school in 1961, Bill Fletcher needed a nurse to help him as his assistant. So I went to work for him as a research nurse. My job was to organize the tumor board and work as a clinical research associate keeping the flow sheets and data sheets of the experimental drugs. I also worked with Dr. Fletcher in the outpatient clinic. I carried little calipers in my pocket, measuring lumps and bumps and recording weekly tumor size. I prepared the drugs, such as 5 Fluorouracil for intra-arterial and intravenous administration. Bill Fletcher was also doing isolation perfusion in the operating room, so I also worked with him in the OR. I either scrubbed with him or worked as his circulating nurse. And then I worked in the lab with him as well. I helped him in his lab projects and ultimately had my own lab project. It was a study of amelanotic melanoma in hamsters. I transplanted the tumors, watched them grow, and then gave the animals chemotherapy and radiation treatment and recorded the tumor regression.
I worked for Bill Fletcher for several years, during which time he had the idea that perhaps my future should go beyond simply working as his research assistant. His idea was that I should go to medical school. However, I didn't realize that he had that idea because early on he suggested to me that I could be a more useful employee to him if I took some additional classes, including physics because I was running his pump-oxygenator in the operating room. One day he asked me, 'What would you do if the pump broke down?' I wasn't certain what I would do. He then said, 'Well, I think you could be a greater help to me if you take some physics.' So I took physics at Portland State College in a summer school class. But in order to take physics, I had to take trigonometry, a prerequisite to physics, and in order to take trig, I had to take second-year algebra. So ultimately I took a series of courses – at night school or in summer school – to do what Dr. Fletcher had asked me to do, because it was intended to make me into a better employee. Simultaneous with that, Dr. Fletcher also had a license to use radioisotopes in the laboratory. He had gone to Oak Ridge, Tenn., and taken a course to use isotopes in the lab. He was tagging isotopes onto agents and injecting the agents into rats. One day he said, 'You know, if you're going to help me in the lab and you are going to be around radioisotopes, you really need to take organic chemistry.' Well the prerequisite to organic chemistry was inorganic chemistry. I completed these courses in sequence. And then one day after we finished a long experiment, he asked me, 'Why don't you think about going to medical school?' I replied that I couldn’t go to medical school, and he asked why not. I did not realize at the time that I had just fulfilled the premed requirements.
Question: Those were the courses you hadn't had . . .
Dr. Donaldson: Yes, those were the courses I hadn't had in nursing school.
Question: Was he surreptitiously making you do that or was he actually wishing you had that particular knowledge at the time to help him?
Dr. Donaldson: He thought I should go to medical school.
Question: Years before . . .
Dr. Donaldson: Yes. He had the idea; I just didn't realize it. So when he asked, 'Why don't you think about going to medical school?' and I answered 'I can't go to medical school,' he replied 'You just completed the prerequisites,' and I asked, 'I have?' He told me I had. All the while I had been going to school because I was motivated to be a good employee! At any rate, I still thought I couldn't go to medical school and he asked, 'Why can't you go to medical school?' I replied with the four reasons why I thought I couldn’t go to medical school. They were: one, I was too old. The second was I was a girl. The third was I didn't have enough money and the fourth was I wasn't smart enough. He got a little huffy and suggested we talk about this. He then asked, 'Well, how old are you going to be in ten years?' I think I was 24 at the time, and I answered, 'I'll be 34.' And he said how old will you be in ten years if you don’t go to medical school?' Well, 34. And then I said I can't go because I'm a girl. Admittedly, it was a little uncommon for a female to go to medical school, but he had gone to Dartmouth Medical School, finishing at Harvard. He also had gone to Dartmouth for undergraduate studies. Dartmouth was, at that time, an all-male school, and he knew that Dartmouth Medical School was considering taking women into their school. As a strong, Dartmouth alum, having lived in Hanover throughout his own education, he was up to date on Dartmouth’s plans. He replied, 'Dartmouth is looking for women. They are actively recruiting them,' which was, in fact, the case. And so it appeared my gender was no longer an issue in this discussion. The fact that I didn't have any money was a potential problem, but he told me, which was true at that time, 'Well, you can apply for a scholarship, a loan or apply for financial aid'. So although I didn't know how I could afford to go to medical school, he seemed to think the finances wouldn’t be difficult to obtain. And the final reason I said, 'I'm not smart enough.' He pointed out to me that schools like Dartmouth and Harvard, where he had gone to school, had groups of professors that work together on committees called admissions committees. He told me they, in fact, knew the criteria and eligibility necessary for medical school. Furthermore he asked if I thought I knew more than these panels of erudite professors who had spent their entire professional careers educating medical students. ‘Did I know more than they did about who could master the curricula to go to medical school?’ I said, 'No,' and he said, 'Well, this matter is for the admissions committee to decide.' And so the conversation stopped. I had been defeated in this discussion.
It wasn't very long after that when my own research project was up for renewal of its funding. My project at that time was to study Coley’s endotoxins in experimental animals, which produced an immunologic reaction including hyperthermia. It was funded by an agency in New York. Dr. Fletcher pointed out to me the grant was up for renewal, and if I wanted to keep my project going, someone was going to have to defend the grant. The funding agency was scheduled to meet in three weeks, and he said, ' I am operating on that day.' I told him 'I can't go to New York and defend the grant,' and he said, 'Do you want to continue your project?' 'Yes.' 'You are going to have to defend the grant.' And so I said, 'Okay'. So, I went to New York to speak about my research project. As I had never been out of the state of Oregon, Dr. Fletcher suggested I visit his sister who lived in Woodstock, Vt., which is located across the river from Hanover, N.H. Furthermore, he suggested I could stop by and visit Dartmouth, which was exactly what I did. He really had this all preplanned. I was quite naive because what happened was that I was gone for 10 days and I visited eight medical schools these ten days. This was before there was a formal application process. I interviewed at Dartmouth, Harvard, Cornell, Columbia, Hopkins, McGill, Case Western Reserve and Washington University in St. Louis. The day that I went to Hanover was in mid-September. I stayed at the Hanover Inn, a lovely place that looks out onto the Quad and Baker Library. The football team was out practicing; the skies were blue; the sun was shining; the leaves were turning color; it was gorgeous. I sat down on the curb in front of the Hanover Inn and decided I loved Dartmouth.
Question: Was Dartmouth co-ed at that time?
Dr. Donaldson: The undergraduate school was all male; the medical school had taken in two women one year earlier. It was clear to me that Dartmouth was where I wanted to go to school. So I filled out my application, sent it in, and two weeks later, I received a letter in the mail from Dartmouth saying I had been accepted. I called Dr. Fletcher, who at the time was attending the American College of Surgery meeting in San Francisco. I told him 'You'll never guess what has happened. I've just been admitted to Dartmouth,' and he said, 'Terrific. Do you want to go?' I replied 'Yes, but . . .' He asked 'But what?' and I said, 'They want a $50 deposit, a down payment.' He answered, 'The department will cover it.'
Question: So when you were a young girl wanting to go into nursing, you probably didn't have a vision of the actual kind of nursing you might do. How did that transition take place during your nursing training?
Dr. Donaldson: It took place because Bill Fletcher was the chief surgical resident when I was a senior nursing student on my surgical rotation. I loved the operating room. I loved surgery and I was good as an OR nurse. I practiced opening sterile packs and slapping instruments into the palm of one’s hand. I worked hard at being good and stood out in my class. Dr. Fletcher asked for me to be his scrub nurse when he was doing a case, so I knew him. He later offered me a job. I didn't go into hospital nursing like my classmates. I had a unique job opportunity. In fact, I had been advised against taking the research nursing job with Dr. Fletcher. The head of the Nursing Department told me I shouldn't take his job offer because young nursing graduates were supposed to work in a hospital setting doing in-patient floor nursing, in a secure position and gaining much needed experience. But, I didn't follow her advice.
Question: Did Dr. Fletcher have a notion that you would someday be a surgeon? Do you think that was part of his thinking?
Dr. Donaldson: I think he thought that I had an aptitude towards surgery. I have talked to him about this. He is still in Portland, and he remains very much of a mentor to me. This whole story is about a mentor opening a door for a young person.
I often tell this story when I'm talking to young people. It is important to give young people opportunities and to open doors for them because they might just proceed right through if they are well-positioned and prepared. This is the reason I think I feel so strongly about education today. It is one of the most gratifying parts of my job. I am sure that Bill Fletcher thought that I had the potential to do something more than just to be his research assistant. He was the visionary person. It was not me. I had no idea, no scope or vision. Dr. Fletcher was the person who thought this is what I should do and served as a much needed mentor to me throughout my medical school education. I talked to him on the phone regularly. When I thought I was doing poorly in school, I would seek his support. So how did I get into radiation oncology?
Question: Well, not yet. Tell us first about medical school. How was Dartmouth?
Dr. Donaldson: I loved Dartmouth
Question: Did you take up skiing?
Dr. Donaldson: Yes. Dartmouth is interesting. There is not very much to do in Hanover, other than go to school or ski or drink beer, and I did a lot of all three of those things and enjoyed school immensely. I had a wonderful time.
Question: How was it being a woman in one of the first classes of women being at Dartmouth in medical school? Any problems or not?
Dr. Donaldson: All of the students were treated exactly the same, but there weren't many facilities for women. There was no dormitory for women, no locker room or place to change one’s clothes. In Hanover there weren’t many women and not many facilities for women. There were six women in my class. But the medical school didn't have a place to put us, so they gave us a residence which had been the first home of a prior president of Dartmouth, I believe in1783. All the women lived in this house and we had a wonderful time. It was just terrific.
Question: So during medical school you said that sometimes you would speak with Fletcher because you weren't doing so well. What were the things you were doing well in and what were the things that were more difficult?
Dr. Donaldson: I did well in anatomy and in surgery, areas in which I had been mentored. I disliked biochemistry and physiology, as they seemed to require immense memory work. The hardest part of medical school for me was during the first two years, learning how to be a medical student in Hanover. I was slightly older than my classmates and a bit of an outsider because I was the only one from the West Coast. Many of my classmates had gone to Ivy League prep schools. My classmates, in general, didn't know anyone from Oregon, which seemed undiscovered. So, I was novel.
Question: So in medical school, you probably entered thinking, well, the world is my oyster; I can be anything in medicine. It might be surgery; it might be something else. How does that transition eventually?
One question before we get into that, it was a two-year school, so one had to choose where they went for their third and fourth years. Did you have a choice and what made you decide where you went?
Dr. Donaldson: About two-thirds of my class applied to Harvard. The other third applied to other schools. So, most of the class went to Harvard, and the ones that didn't go Harvard went to Cornell, Columbia, McGill or Hopkins. But by this time I was totally entrenched in the class and somewhat of a groupie. Four of the six women in my class applied to Harvard and again when we transferred to Harvard we all lived together in an apartment on Commonwealth Avenue. So I went with the group. But I did what Bill Fletcher said was what I should do. I asked for and followed his advice every step of the way.
Question: So did you have choices when you were in Boston about clinical rotations that you did? Some of them were maybe not choices and some of them were?
Dr. Donaldson: Yes.
Question: Did those choices influence you in some way?
Dr. Donaldson: Yes. Oh, yes, they did. I had my medicine rotation at the Boston City Hospital, a great place. I then did surgery at the Brigham; I did well in surgery, getting an A. This was unusual because it was considered a hard rotation. But, of course, I had worked with Bill Fletcher as his right-arm assistant. He had taught me how to tie knots; he let me do biopsies and taught me to start IVs, so I had gained many surgical skills. Surgery was such fun and seemed natural to me. I wanted to be a surgeon. I wanted to be just like Bill Fletcher. I applied for a surgical house officership at the Brigham, where a surgical internship led to a surgical residency. I was accepted as a surgical house officer at the Brigham, which seemed phenomenal because there had been only one woman before in the Brigham surgical program, Tenley Albright, an Olympic athlete and a wonderful lady. I was thrilled, and I accepted. I was really looking forward to surgery until I had medicine at the Boston City hospital. I then began feeling inadequately prepared in medicine because I didn't really feel as comfortable in medicine. I didn't think I could read EKGs very well, and I didn't think I knew how to manage keto-acidosis very well. Soon I decided that I didn't know enough medicine. So I went to see Dr. Frances Moore, chairman of surgery at the Brigham, and told him that I thought that I needed more training in medicine. I thought I needed a medical internship. He said, 'That will be fine. Just take a medical internship and we'll hold a place for you as a first-year surgical resident.' 'You will?' He said, 'Yes,' and so I applied for a medical internship. I decided to go to the University of Washington in Seattle because there was a very famous internist named Dr. Petersdorf who ran the medicine program. It was a very successful and strong Department of Medicine. So I went off to Seattle, close to Portland and back west. I had a wonderful year as a medicine intern at the University of Washington, loved being a house officer and loved all aspects of medicine: infectious disease, cardiology, renal disease; it was all just terrific. The year was a very good one for me, and at the end I was offered a medicine residency at the University of Washington. As I loved medicine, I accepted the offer. Then I realized I had already accepted a surgical residency in Boston, as well as a medical residency in Seattle.
And so I called Dr. Fletcher and once again asked, 'What should I do?' He asked, 'Well, what do you want to do?' and I said, 'I want to take care of cancer patients, just like you.' Bill Fletcher, visionary that he is, said, 'You know what you should do? You should think about radiotherapy.' Of course, I knew nothing about radiotherapy, and I said to him, 'I can't do radiotherapy.'
Question: What year was this?
Dr. Donaldson: I graduated from Harvard in 1968, and he said, 'Why not radiotherapy?' and I said, 'Isn't radiation all about degradation products and isodose curves? I don't know what those things are.' He replied, 'To be a good radiation therapist, you need to know how to read the area under the curve. You need to know what's on the ordinate and what's on the abscissa, read the curve, and hire a good physicist. That's what you need if you're going to be a good radiation therapist. He told me that what one really needed to be in radiotherapy was to know where the cancer was located and to have the judgment to know when to irradiate and when the patient should undergo surgery and when and how to include radiation with surgery. That would make me a good radiation therapist. He also told me if I was good, I would hire a physicist who would tell me about the area under the curve.
Question: He was mentoring you earlier when you were finishing nursing. Was he obviously exposed in some way, no pun intended, to radiation oncology? Were you aware of that at the time?
Dr. Donaldson: Yes, because Dr. Fletcher had done the early pre-op radiation rectal cancer studies at University of Oregon working with the radiation oncologist whose name was Cliff Allen.
Question: That was a famous study. That was a first.
Dr. Donaldson: Yes. Dr. Fletcher believed in pre-op radiation for rectal cancer because following pre-op radiation, when he would then take his patient for resection, some patients had no viable tumor, so he knew about radiotherapy and he believed in it.
Question: There was a little exposure that you had yourself.
Dr. Donaldson: Yes, I had previously had a laboratory project using radiotherapy in experimental animals.
Question: So now later on Dr. Fletcher was saying to go into radiotherapy, so tell us about that.
Dr. Donaldson: I didn't know where to go for radiotherapy training. Dr. Fletcher told me I should go down to meet his friend, Mal Bagshaw. He and Mal had been on a panel together I believe. So I came down to Stanford to meet Mal Bagshaw. But, the person I was assigned to be interviewed by was Scotte Doggett, and Scotte was the most interesting person I had ever met. When Scotte was interviewing me for a position at Stanford, he asked me my opinion of the best medical internship and residency in the country. I answered that I thought that the Harvard service at the Boston City Hospital was the best training program in medicine in the country. That is where I had taken medicine as a student. Only later did I learn that Scotte had been a house officer on the Harvard service at the Boston City Hospital before he went into radiotherapy, and he also thought it was a great place to train. And then he found out I had been a cheerleader, as had he; he ended our interview by getting up onto the desk and doing a cheer for Stanford. I then decided to come to Stanford! That experience turned out to represent Scotte in his most enthusiastic recruiting mode.
Question: Tell us how you discussed this with Dr. Moore.
Dr. Donaldson: I had to tell him that I decided to go into radiation therapy, which I did. I wrote him a letter and told him. I never got any feed back.
So, my going into radiation oncology was not because I was visionary; it was Bill Fletcher's vision. At that time the world of radiation oncology was very small with some foreign medical graduates and a few stand-out personalities but not very many. Dr. Fletcher thought the world of radiation oncology needed more surgically oriented physicians.
Question: So at that time you knew a lot about surgery and you knew some about medicine, but you probably knew relatively less of radiation oncology. So deciding to come here was basically an act of faith.
Dr. Donaldson: It is what Bill Fletcher told me I should do.
Question: And you knew he would be probably right.
Dr. Donaldson: He advised me and I followed his advice all the way along.
Question: So who was in your residency class with you?
Dr. Donaldson: In the class ahead of me were Ron Thompson, Joe Kraut, Eli Glatstein and other luminaries, including Karen Fu. Karen had actually had a year of radiation oncology training in Toronto, but she entered the class at Stanford with me. She was one year ahead of me in experience and one year smarter than me; she could do chi-squares in her head, and I did them on a slide rule. Karen was a great role model for me and we became very good lifelong friends.
Question: You started here in the summer of '69? Was that right?
Dr. Donaldson: Yes.
Question: With Karen?
Dr. Donaldson: Yes.
Question: And anybody else in your class?
Dr. Donaldson: Tom Barclay and Dick Borrison,
Question: Sarah, before you came, I was here six months as a visiting professor, and it was a fun place in those days. There were TGIF parties every Friday. Tell us about them.
Dr. Donaldson: Well, I'll tell you about my first TGIF party. It was notable. There were TGIFs regularly, and the first week of my residency, there was a departmental party for the new residents. It was at the home of one our therapists, Irene Davidson, who lived in downtown Palo Alto. We were all supposed to go to the departmental party, especially the new residents. I was uncomfortable about going to this party because I didn't have a date, and I didn’t want to go by myself. So I orchestrated a way that I wouldn't have to go to the party by myself. I invited the department nurse, Renee Doyle and her husband, as well as a medical student on service who was John Salzman, to come to my house beforehand for a drink. I made martinis and then all four of us went together to Irene's house. We arrived about an hour and a half late, and all the food was gone. But by that time there was dancing in the dining room; everyone was having a wonderful time. When I walked in the front door all of a sudden John was someplace else and Renee was gone, and I was standing by myself in the entryway. Eli Glatstein came up and said, 'Well Sarah, would you like to dance?' and I said, 'Well, sure.' So I ended up going onto the dance floor with Eli. We were dancing, and all of a sudden Eli walked off the dance floor. He just left. And again, I was by myself, standing there among a group of people all of whom had somebody to dance with, and I was standing by myself. So I quickly hurried off the dance floor. And as I did, I slipped on a spilled drink; I was going at quite a clip, as a matter of fact, and when I slipped and fell, I slid on my bottom from the middle of the dining room dance floor, all the way across the room, out the exit, into the entry way where there was a huge floor to ceiling mirror. I slid parallel to the mirror until I landed abruptly on a giant, black shoe. As I looked up next to the body extending from the black shoe, I saw Bob Stewart, a junior faculty and such a nice man. And Bob said, 'Dr. Kaplan, I'd like you to meet one of our new residents.' I was sitting on Dr. Kaplan’s foot! I jumped up, terribly embarrassed, and asked 'Dr. Kaplan, would you like to dance?' He said, 'Sarah, I'll take a rain check.' I was so mortified that I went directly home. That was my introduction to the department and the first time I met Henry Kaplan, sitting on his shinny black shoe!
Question: Let me ask you this. You've authored hundreds of papers. What was the first radiation oncology paper that had your name on it?
Dr. Donaldson: The paper that is most memorable to me was a paper that I wrote with Henry Kaplan. I worked very hard on that paper. It was a study of infections in asplenic patients. In our Hodgkin’s disease laparotomy series, many patients developed infections. I was aware that young children who had their spleens removed for hematologic disease before the age of two had a high incidence of overwhelming pneumococcal infections. And so I was interested in this problem. We had a six-month rotation when the radiotherapy residents took care of all the inpatients on the clinical research center. Many of these patients developed overwhelming infections, meningitis and bacteremia. So I wrote a paper about infections in splenectomized patients. I worked hard to get this paper as perfect as it could be, perhaps after 20 revisions or so. I then gave my ‘perfect product’ to Dr. Kaplan. Subsequently, the draft was returned to me, looking like a blood bath. Dr. Kaplan wrote his comments in red ink. My paper was all red. Every page was red; it was impossible to see any white paper. My perfect draft was covered with red corrections. That paper went through 23 additional revisions before it was accepted for publication.
Question: Before you sent it in?
Dr. Donaldson: Yes, that was what it was like to write with Henry Kaplan. He was a true perfectionist.
Question: How did you develop your interest in pediatrics?
Dr. Donaldson: Well, at that time there was no pediatric oncology service, as there was no specialty called pediatric oncology. The radiation oncologist or the pediatric surgeon took care of the children with cancer. When I was chief resident, it was my responsibility to take the inpatient, new patient consultations. When the pediatricians needed a child to be assessed, I would get the call and was asked to decide about management. Eventually I learned a little about pediatric oncology, but there was no subspecialty called pediatric radiation oncology. At the end of my residency, a very troubled time in America because of The Vietnam War, the youth of America were very much at unrest. Young people were protesting the war, writing graffiti on walls and acting out. We all wanted a change. We didn’t want to be told what to do, we didn’t want to take any more exams and we were tired of being regimented. I wanted to travel. So I decided I wanted to go abroad to find an experience away from America. As there was no official pediatric radiation therapy subspecialty, I had an idea that maybe I could do pediatric radiation therapy. So I told Dr. Kaplan that I wanted to go to England and do specialty training in pediatrics. Dr. Kaplan replied, ‘No.’ He told me if I wanted to specialize in pediatrics, I should go to Institut Gustave Roussy (IGR) in Villejuif, outside of Paris, where there was an established pediatric service. He told me to talk to Malcolm. Mal had taken his sabbatical at IGR, and he agreed that if I wanted to do pediatric radiation therapy, I needed to train with Dr. Odile Schweisguth who was sort of the queen mother of pediatric oncology in all of Europe. So, I went off to see the world and work in France. Really, I knew very little about pediatrics.
Question: And you were in France for one year?
Dr. Donaldson: Yes, I was there for a year. It was a wonderful year; it was, perhaps, the most difficult year of my life. It was hard because, although I thought I knew French, when I arrived I didn't know any useful French. I knew no conversational French. No one was there to roll out a red carpet. The French were not particularly nice to an American. Survival was difficult. I needed to learn to survive. In fact, I ate chicken every day for six months because I didn't know how to ask for anything other than “poulet,” the French word for chicken.
Question: So after six months or so you integrated into the system and were able to take care of patients and so forth . . .
Dr. Donaldson: I was never very good at taking care of patients, but I could talk to children because in French there is a formal and an informal version of the language. When talking to a child, you speak in the informal, familiar form. I never mastered the formal, proper form of the language. But I did make friendships and became good friends with some colleagues from the hospital, with whom I went skiing and on bicycle rides. All in all, I had a very rewarding experience in France. One lesson from Dr. Kaplan was, 'The way to learn French is to get a French boyfriend. You need a French boyfriend.' So I found a French boyfriend who was a ski instructor and I came back from my Christmas skiing holiday speaking much better French, but it was all the familiar, informal form; it was not the formal form.
Question: Did it improve your skiing as well?
Dr. Donaldson: It improved my skiing, but it did nothing for my use of the formal form of French. I well remember when I came back from the Christmas holiday and went to the morning conference, I arrived early. Professor Tubiana, director of the Institut Gustave Roussy, a very formal man, was one of the first people to arrive, and he said, 'Bonjour, Sarah,' and I replied 'Bonjour, monsieur, speaking in the same informal French I had been using all Christmas holiday. This was not appropriate for the professor. I continued to make mistakes like that; I never mastered the language appropriately.
Question: What were the options presented to you at the end of that year?
Dr. Donaldson: Well, I got homesick for America and I wanted to come home. I wrote to Malcolm, and he invited me to come back to Stanford. My opportunity was to start an oncology program, along with a pediatrician named Dan Wilbur.
Question: I know him. I talked to him yesterday.
Dr. Donaldson: Dan Wilbur had trained at Stanford and had gone to MD Anderson in Houston, to run their pediatric oncology service. At the time I was returning from France, Dan was being recruited from Houston back to Stanford, to start a pediatric oncology service. At that time there was no specific person from the radiotherapy faculty to take care of children. That became my job, to return and work with Dan Wilbur and to start a pediatric oncology program.
Question: Some time in there you went to MD Anderson, didn't you?
Dr. Donaldson: Yes, I did. I took an elective rotation as a resident, and that is how I first met Dan Wilbur, because he was in Houston at that time. While at the MD Anderson hospital, I worked as a pediatric oncology fellow.
Question: Dan left here in late '77 or something like that? I was just having a discussion with him about his career yesterday on the phone, but you have some number of years of overlap with him.
Dr. Donaldson: Yes.
Question: So you helped develop, with Dan, pediatric oncology.
Dr. Donaldson: We worked together.
Question: So was anybody else in the country doing pediatric oncology at that time?
Dr. Donaldson: Radiotherapy?
Question: Yes.
Dr. Donaldson: Omar Hustu was at St. Jude, Dan D'Angio was at Memorial and Melvin Tefft had worked in Boston, along with Dr. D'Angio.
Question: This is out of sequence – When did Board exams require demonstrating some knowledge of pediatric radiation oncology? It must not have been then.
Dr. Donaldson: When I first took the Boards, we did not have seven or eight different oral exams the way we have now. We had three examiners and they examined every area. One of my three examiners was Luther Brady, and he asked me an orbital rhabdomyosarcoma question, a retinoblastoma staging question, and a prostate lymph node question.
Question: There's so much we could talk about here.
Question: What are your hobbies? Do you do anything outside of medicine besides cheerleading?
Dr. Donaldson: On one of my sabbaticals, in the mid 1980s, one of the female residents invited me to go to an exercise class with her. We joined a health club in downtown Palo Alto. Ultimately she stopped going to the gym, but I continued going and taking a walking class. That walking class grew into a cohesive group of women that have been walking together for the last 20 years or so. The “walkers” have become a strong support group, and we have also walked around the world together. We have been to Italy, France, Spain, Mexico and British Columbia – walking, hiking, kayaking, biking and always doing exercise. So I would say in my spare time I do outdoors activities with women that I met a long time ago through a fitness center.
Question: People want to be modest, but don't be modest about awards and honors. What sorts of things have you been honored with?
Dr. Donaldson: The most meaningful honor for was to be a trustee and then the president of the American Board of Radiology. I loved being an ABR trustee, because it was an opportunity to make a real and lasting contribution in education. That was a wonderful experience; I got to know a lot of diagnostic radiologists and physicists, and I loved being an ABR trustee. I went through leadership within the ABR system and that was pretty wonderful because I became the first female president of the ABR. That was quite memorable.
Question: You were also the first female president of ASTRO.
Dr. Donaldson: I was. It was fun. It wasn't as much work at that time as it is now. It was lots of fun. We had a great staff including Fran Glica, Nick Croce and John Curry. They provided great administrative assistance.
Question: What other honorary professorships or medals have you received?
Dr. Donaldson: Most recently I received the Gold Medal from the American College of Radiology. I have a Gold Medal from ASTRO and the Janeway Medal from the American Radium Society. I have also been honored be being a member of the Institute of Medicine.
Question: I see favorite sayings as one of the items on the list. Any favorite sayings?
Dr. Donaldson: My favorite saying is from Ralph Waldo Emerson. ‘Nothing great was ever achieved without enthusiasm.’
Question: That's great. Have you ever done sabbaticals? You did a year in France. Have you done others?
Dr. Donaldson: The year in France was actually a fellowship. I’ve had two sabbaticals. On my first sabbatical I went to London and spent my time at St. Bartholomew’s Hospital and the Hospital for Sick Children at Great Ormond Street. It was wonderful. On my second sabbatical I worked with Charlotte Jacobs to develop the infrastructure for a clinical cancer center. We designed the building that is our current Clinical Cancer Center working on the final phases of the blue prints for the building and working with the architects and contractors. We also built a cancer program. We established a clinical trials office and an outreach program. So I feel a real responsibility for this facility, our cancer program and our cancer center.
Question: How many papers have you written yourself and with residents? Anything at this moment being worked on?
Dr. Donaldson: That is a timely question because, actually, I have a draft on my desk of a paper on pediatric Hodgkin’s disease that I intend to read this evening. I think it is very important when I have a good idea to give it to a resident. I learned that lesson from Ted. When Ted came down for his sabbatical at Stanford, one of the things he said afterwards is that when you want to get a project done, give it to a resident.
Question: Oh, that's the way to do it. They get the authorship, and you get the paper back. Do you have any plans to retire?
Dr. Donaldson: Not immediately.
Question: Good. Just wondered.
Dr. Donaldson: I told Dr. Hoppe that when it is clear I need to retire, he must tell me so. I am a little fearful that I might not recognize when I am no longer making a contribution. He promised me he would alert me when the time is right for me to retire, if I don’t recognize this myself.
Question: You had a major role in clinical trials in the United States, particularly in the pediatric field. Can you tell us a little bit about how you got introduced to clinical trials and how it grew and how you grew in it?
Dr. Donaldson: I think it started before the collaborative groups were established, and there I credit Henry Kaplan. As a resident I saw an 18-month-old baby from Brazil who had wide spread Hodgkin’s disease. This was in 1969 when the standard curative treatment was high-dose extended field radiation for pathologically staged children. The dose of 44 Gy total lymphoid radiation did not seem appropriate for this baby, and I didn't know what to do. Dr. Kaplan suggested we give him a smaller radiation dose and combine it with six cycles of MOPP chemotherapy. At that time MOPP chemotherapy was being investigated by Vince DeVita for adults with relapsed Hodgkin’s disease. We gave the baby 15 Gy total lymphoid radiation followed by six cycles of MOPP. He survived. Two years later I saw another child, a 4 year old who also had advanced stage Hodgkin’s disease. We treated him in the same way, and Dr. Kaplan said, 'I think you should write a protocol.' This was long before IRBs and all the regulations we have today. I wrote a protocol using low-dose radiation and six cycles of MOPP, and that became our first pediatric clinical trial at Stanford. This study later evolved into our second pediatric Hodgkin’s disease protocol using low-dose radiation and MOPP/ABVD, which carried with it less chemotherapy related complications of sterility and less leukemia. The national cooperative groups then got excited about this approach of combined modality therapy for children using low-dose radiation and combination chemotherapy because it provided curative therapy with minimal acute and long-term toxicity. I think I got involved into the national cooperative groups by way of the Intergroup Rhabdomyosarcoma Study Group (IRSG). Early on I was part of an NCI review committee and was asked to site visit what was then called the Intergroup Rhabdomyosarcoma Study Group. I was an extremely critical site visitor. The PI of the group at that time was Dr. Hal Maurer who went on to be department chairman and dean and now is chancellor at University of Nebraska. He is a wonderful and very smart man. He invited me to become a member of the IRSG and gave me the task of solving all the problems I had criticized as a site visitor! That particular cooperative group has been extraordinarily productive and is a very cohesive group. They have completed a series of sequential studies from IRS-I to II to III to IV to V and now they are undertaking risk adapted studies that represent continuity in a series of studies in sarcoma spanning nearly 40 years. The cure rate for children with rhabdomyosarcoma has escalated with improved multidisciplinary care, improved staging and imaging, and with each sequential study. So my experience in the cooperative group setting has been very gratifying.
Question: Do you think the merger of the two main pediatric groups, POG and CCG, has been beneficial?
Dr. Donaldson: No, I don't think it has been beneficial. It was helpful to have competition between the two groups. Competition is healthy. We were always trying to be more novel and innovative than the other group. With one large group it is an enormous challenge to arrive at consensus. Often one ends up compromising, and then you don't necessarily have the best outcome. So, I don't think the merger has been helpful.
Question: Any final comment?
Dr. Donaldson: No. Thank you for interviewing me.
Question: Thank you, Sarah. This has been great.
