Theodore Lawrence, MD, PhD, FASTRO
By Christopher Rose and Eric Gressen
The following interview of Theodore Lawrence, MD, PhD, FASTRO, was conducted on July 1, 2016, by Christopher Rose, MD, FASTRO and Eric Gressen, MD.
Christopher Rose: So, why don’t you tell me, where were you born?
Theodore Lawrence: I was actually born in Queens, New York. Although, I don’t remember since I was only born in a hospital there. I was raised in Port Washington, New York, which is on Long Island.
Christopher Rose: And what did your parents do?
Theodore Lawrence: My father was an engineer and my mother was a schoolteacher. I actually thought about being an engineer for a while. We can talk about that, but I’m glad I wound up where I was.
Christopher Rose: Do you have any siblings?
Theodore Lawrence: Yes, an older brother and a younger brother.
Christopher Rose: And where did you go to high school?
Theodore Lawrence: I went to a high school called Paul D. Schreiber High School, Port Washington High School. Paul D. Schreiber was a superintendent of schools, but most people just called it Port Washington High School. That’s where I was born and raised right through to college. I went to Cornell.
Christopher Rose: Yeah. I see from your CV that you went to Cornell in Ithaca.
Theodore Lawrence: I did.
Christopher Rose: Do you remember anything interesting either from your high school or your college days, which kind of shaped you in to who you are today?
Theodore Lawrence: This is so funny being interviewed like this. I’m just not used to anybody caring about these things. You’re so kind to want to interview me as a historical figure. I still laugh at this whole thing. I think my biggest influence in high school was my high school English teacher, Blaine Bocarde. He was also the adviser of our high school newspaper. He taught me how to write, and it turns out that it’s not that common that people actually learn how to write in high school. He was very rigorous and taught us how to write clearly. I was the editor in chief of my high school newspaper, and so that also got me in to writing and proofreading.
And I have to tell you one more story about high school because it was one of those random events that made a big impression on me. I remember sitting with a close friend of mine, David (who is still my close friend), and we were talking to Mr. Bocarde. We’re talking about student drug use and we made some kind of random comment, like, “I bet that kids use drugs because their parents use drugs.” And so, Mr. Bocarde was just the kind of person, looked at us and said, “Yeah, how do you know that? Who says? Prove it to me!” And that launched us off on doing an enormous survey of all the students in the high school about their drug use and their parents’ drug use. We had to design the questionnaire and figure out how to score it. We had over 1500 students in our high school, so we were not going to score this my hand, plus we thought the students would suspect we could trace their answers if we had hand written score sheets. Our school had a computer that could read key punch cards. We decided we had to figure out how we could turn these cards into answer cards that could be filled in with a number 2 pencil. We consulted a local printer and figured out how to overprint the cards with ink that would make it into a score sheet that could be marked, but that the ink itself would be invisible to the primitive card reader on the computer. Because we were good kids and my mom was the head of the English department, they let us basically shut down the school for an hour to administer the questionnaire. No teachers were in the room so the students would not feel they were being spied on. I can’t quite believe looking back that they let us do this. David’s brother was a computer whiz, who programmed the computer to compile the results from the keypunch cards. And then there was this little matter of statistics to analyze the results; it would have been nice if my friend David and I knew the first thing about them! But his old brother was a statistics major in college, so he taught us about chi-squares and correlations. When we had our analysis, we dedicated an entire issue of our school newspaper to it. One of our friend’s parents had some connection to the New York Times, and told them about it. This led to an article written about us in New York Times as well as several other magazine interviews about these two precocious high school students who did this drug survey.
We decided we should try to write this up for an actual scholarly journal. We submitted it Journal of Psychiatry. That was pretty funny too. We might have though about READING a paper in that journal before writing it. They were so kind; instead of rejecting it out of hand, they carefully explained to us that our data was interesting, but that it would be better if it had an introduction, a methods section, results and a discussion! So this was my first scholarly paper, published from work I did in high school.
This was probably the best educational experience I had in high school, and, in some ways, the best educational experience I have ever had. And all because of a high school teacher who challenged me and said, “Oh yeah, who says?” It was great to have a teacher who challenged you.
Christopher Rose: It’s interesting and I see that your third paper was in Nature, so you obviously were quite precocious and we’ll get to that. Now, you had mentioned that when you went to Cornell initially, you thought you were going to be an engineer. What was that all about?
Theodore Lawrence: Well, I just had enjoyed it. I worked at my father’s office for several summers. This was in the days when no one had personal computers. We’re talking about the late 60s; I was a high school student. And so, IBM had a mainframe computer somewhere in New York. My father worked in Port Washington just half a mile from our house. And so, I spent summers working for him. I would do programming in Basic or in Fortran and I would dial in to this mainframe computer which make the sort of beeping like a fax noise, right? You would attach your phone to this little fax machine and you could have access to a computer. So, I remember writing some programs for him that he used up until that point to do on a slide rule or a big mechanical calculator and really enjoying that. And then saying to my mother at one point, “I want to be an engineer like my father.” And she looked at me and she said, “No, you don’t. You want to be a doctor.” and I guess that influenced me, so there you go. I actually listened to my mother.
Christopher Rose: That’s fascinating. I remember those early modems that you’d put your phone in and you had a little teletypewriter that you could put line commands on.
Theodore Lawrence: Yup. That’s exactly what we had.
Christopher Rose: So, you must have been pretty strong in math I would imagine.
Theodore Lawrence: Yeah. I was reasonably strong. I did well in math and science in high school. I really enjoyed it. I took AP Calculus and AP Chemistry and I enjoyed all that stuff.
Christopher Rose: So, your mother said you should be a doctor.
Theodore Lawrence: Yup. It’s really funny. Subsequently, when I actually finally started seeing patients as a medical student, I told her about some of the people I was seeing and all of the patients I was seeing, all of sudden, the phone conversations stopped. She finally put together that doctors actually come in contact with sick people. She had never made that connection before. All of sudden, she became worried I was going to catch something. I don’t think she thought this through completely to be honest with you.
Christopher Rose: Well, did you?
Theodore Lawrence: I had really only a very tangential idea. I don’t know what your idea of what being a physician was, but mine was the family pediatrician who was very kind to us and sent us in to the next room. The nurse gave us all the shots, so it seemed like the pretty organized life.
Christopher Rose: I’m afraid that it kind of predates my career as an oncologist. I mean mine was “Not as a Stranger”, Arrowsmith, and The Death of Ivan Ilyich. But on the other hand --
Theodore Lawrence: I’ll have to interview you someday, this will be great.
Christopher Rose: No, no, no. But, yes, so I mean I guess we’ll get to it. So, you went to medical school at Cornell
and --
Theodore Lawrence: I had an career changing experience during college. I didn’t realize this, but there was a man named Zanvil Cohen, who was an MD-researcher at Rockefeller University in New York. I had gone to bar mitzvah class with his son. My mom and his mom had car-pooled us. He must have kept an eye on me because sometime around sophomore year in college, he gave me a call and said, “Would you like to take a look at this place called Rockefeller University where I work?” I thought, “Yeah, it sounds cool.” He drove me in to work with him and it was just an amazing research institute where they were doing this incredible science, which I always been interested in, but never I really imagined a career. I walked around it with my eyes getting bigger and bigger, and I said, “How do you get to do this? What do I need to do?” And so, he said, “You seem to have an aptitude for science. We have just started an MD-PhD program between Cornell Medical School, right across the street, and Rockefeller University. If you’re really interested, go find a lab to work in and see if this is for you.” Without that contact, I don’t know if I would have thought about MD PhD programs. So I wound up applying to, and ultimately going to the Cornell Rockefeller MD PhD program because of Dr. Cohen, because of Zanvil Cohen.
Christopher Rose: Did you do research while you’re still in college, those summers?
Theodore Lawrence: I did. I did an honor’s thesis about changes in intracellular potassium as myocytes fused to form myotubes using electrophysiology. It was a tough project, but I loved being in a laboratory and asking scientific questions that could be answered. I definitely caught the research bug.
Christopher Rose: Did you end up in a lab at Rockefeller before you went to medical school?
Theodore Lawrence: Oh, no. I just toured there. No. The first lab experience I had was at Cornell.
Christopher Rose: I got you.
Theodore Lawrence: I remember going out to laboratories. during my sophomore year, I just wanted to volunteer. I wasn’t going to ask for any money and knocking on every door. I mean everybody was telling me that they didn’t need anybody and getting essentially the last door in this lab building and finally this wonderful person, Tom Podleski, who took me in to his laboratory where I did a project on electrophysiology of developing muscle. I was impaling myotubes with these micropipette electrodes in measuring their electrical potentials in his laboratory.
Christopher Rose: So, it sounds to me, but please confirm that other than a doctor who’s a family doctor giving shots when you thought Rockefeller University that medicine then meant medicine/research a research physician.
Theodore Lawrence: And I had read some books as a kid. I remember reading a book called Great Men of Medicine. Of course, it was great men of medicine. What can you say about of that generation? I’m reading all about Pasteur and Koch and all these people who made these amazing discoveries and thinking about that. I really didn’t put together that I would be a practicing physician even with my family pediatrician back then. I was mainly thinking about research. I was clueless, really.
Christopher Rose: And was the specialization in internal medicine because those were the smart doctors who did research?
Theodore Lawrence: Yes. When I did my MD PhD, all the people who were like me were almost always going in to internal medicine. I had one guy in my MD-PhD class went in to neurology. Somebody else went in to ophthalmology. I don’t think I even knew about radiation oncology. I’ve tried to think about this over the last few years. Did I have any lectures about radiation oncology in medical school? I think the person who taught us about cervix cancer may have been a radiation oncologist, but they may not have been. I may have had no exposure to radiation oncology in medical school. Most of the smart people were going in to internal medicine.
Christopher Rose: How did it work? Did you get the MD PhD and then you did your internship?
Theodore Lawrence: Yes. This was a six-year MD PhD program between Cornell Medical School and Rockefeller University. This was a planned program. So, now, 1974 is when I entered that program and this is only the third year of that program and these programs were really quite new, so they were still working out what these programs were like. But, this was purposely a combined program. In my exit interview for the MD PhD program, I asked the head of the program,” What am I supposed to do next? What do you have in mind for us?” And his answer was “Well, you’re a pretty smart guy, you can figure it out.” I asked, “Why did you even create this program?” “We created this program because we’ve had a lot of smart people just become physicians and go out in to private practice. We figured if we made these free MD PhD programs, in which we actually pay you a small stipend, you wouldn’t have any debt. And maybe you’ll get the research bug in you and you wouldn’t go in to private practice and you’d become an academic, but we didn’t really figured out much beyond that.” That’s what he told me. I guess it worked.
Christopher Rose: It’s fascinating. So, there you are with the MD PhD and you did figure it out. I see that you ended up right after that at the NCI. Did you do an internship there or how did that work?
Theodore Lawrence: I did a full three years of medicine residency at Stanford. I’m board certified in internal medicine after a full three-year residency. I was initially very nervous about clinical care. The laboratory was so secure for me. I remember finishing my years in the laboratory and people coming up to me at the end of as I was about to get my PhD and ask,” Will you collaborate with me, you’ve got these great skills in electrophysiology?” And I’d say well, “You know, I’m really busy. I’ve already got all these other collaborators. I’m not sure I can have the time to work with you.” Then starting third year medical school, you remember what that’s like, going to the bottom of the bottom and feeling completely incompetent in medicine. It was worse than that. I started my 3rd year of medical school at the end of everyone else’s 3rd year. So I looked really dumb by comparison. Even worse, the people I had entered medical school with and had stayed on were now house officers. I’ll never forget one of my friends sticking his hand in my face on rounds in surgery and almost shouting at me, “What are the 5 indications for a T-tube cholangiogram.” I still don’t know. My one comfort was that the attending, who happened to be a surgical physician scientist, said to this “former” friend, “Be careful son. That man may be your department chair some day.” Well, I never became a chair of surgery, but it did give me some comfort that things could only get better.
After medical school, I matched to Stanford. It was not my first choice; I ranked a couple of very clinical programs above it. But it was clear during the interview process that they actually wanted someone who cared about research. I only did three years of medical school. That’s where our program structured. So, I just did a third year in medical school and then went right in to internship. So those clinical programs were not interested in me, but Stanford really wanted me.
Going to Stanford changed my life. First of all, I am the first and only member of my family to live west of the Hudson River! Secondly, Cornell was very very tough on trainees. They used the “teach by humiliation” method of education. The only thing better than humiliating you in front of a small group, was humiliating you front of a large group. But when I arrived at the Stanford, the chair of medicine (Ken Melmon) said to us, “Call me Ken. We are all doctors here.” Unfortunately, I didn’t really know very much. I had a wonderful co-intern, who is still one of my best friend, and a resident, who saved me, and by the 4th month I had more or less caught up. By the end of internship, I pretty much could keep any patient alive until a real doctor could get there. But I wasn’t really enjoying it because I don’t think I was very good at it.
Another of the major forks in the road of my life was during my PGY II year when I was a resident in medicine in Stanford. I was a resident at the Veteran’s Administration hospital associated with Stanford. I had two interns and three medical students in my team, and I had about 15, 20 patients on my service. At the VA, you were it. Especially after 5:00, you were the chief medical officer of a 250-bed hospital. If you didn’t know it, it wasn’t known. And so, I remember starting the day, and the first patient on rounds arrested and we resuscitated him, and then we admitted about 12 people that day. And then the last patient of the day arrested and we resuscitated him. And there I was writing my notes like 3:00 in the morning thinking to myself, you know, I think I’m a doctor. I think something happened. I think I’m a doctor. Then I realized I really was enjoying clinical medicine. Up until that point, it was 50-50 whether I was just going to be in the laboratory or whether I was going to be in the clinic.
I decided during my PGY-II year at Stanford that I really loved oncology. That had a lot to do with Henry Kaplan and Saul Rosenberg. I remember going to Saturday morning rounds at Stanford and watching these two brilliant people argue with each other over how to take care of a patient in a very gentlemanly way. At least that’s what I saw. I’ll never forget them arguing about cases. Having Dr. Rosenberg go, “Now, Henry” and Dr. Kaplan go, “Now, Saul,” and having them discuss these things. That impressed me that oncology was a rational discipline. People used data. People ran prospective trials, they challenged each other with data and not just with opinion. That’s what really began to hook me into oncology. Of course, it was medical oncology since I was doing medical internship and medical residency program.
Oh, the other thing I just will digress on for one second if it’s okay. Stanford had a three team admitting service on oncology. One was a medical resident with two sub interns. One was a rad onc resident with a medicine intern, and the third was a med onc fellow with a medicine intern. And I randomized as an intern to the rad onc resident who was Ken Russell. Ken was my resident when I was an intern at the end of the year, so this was June. So, by the time, I was a June intern, I was pretty skilled. And I don’t know if you know this, but Ken did his internship in pediatrics. So, we would admit these patients who had cancer and were in septic shock and Ken’s experience had been a year in pediatrics. And so, Ken would be looking for a scalp vein and I’d say, Ken, just go stand in the corner. I don’t know any oncology, but I know septic shock. So, we had a great time working together.
Christopher Rose: That’s fascinating.
Eric Gressen: I hate to make you back up, but any sports or any activities while you’re studying intensely through high school, college and medical school?
Theodore Lawrence: Not really. I was never great in sports. I was never bad in sports, and I was never picked last. I was never told to play right field in elementary school and sneered at. I wouldn’t say I was in any particular sports memories that I would relate. I was just kind of average guy playing on an average team.
Christopher Rose: So, we’ll have to figure out where this slot is in, but Eric reminds me. When did you start singing?
Theodore Lawrence: My younger brother, Fred and I would perform for the relatives when we were little guys. I mean this is pretty much as far back as I can remember. My parents lived on Long Island as I told you. All the other relatives who lived in Queens wanted to know why we were way out in the boonies in the potato farms. I mean Port Washington wasn’t exactly potato farms but it was small town. So they would come out and be entertained by the country folk. So that’s where I first started singing. Now, years ahead, I met my wife towards the end of college. This is in 1973 when we first met. We sang duets on our first date and we both knew about The Kingston Trio. The Kingston Trio was really my older brother Phil’s who really about five years ahead of me, but because of that music had been in the house and Wendy had an older brother as well. We both knew that music, which people really weren’t singing in that in the 70s, but we both knew those songs. So we sang duets together on our first date. Within a few weeks, I knew this is the woman I was going to marry. And she has been the rock of my life. There is no way I could have done any of the things we are going to talk about without her.
Christopher Rose: Yeah. I don’t know, Eric. I mean Ted has an incredibly gifted family of singers including his daughter who is a professional. I guess that’s later on in this, but we have to remember that you’ll have to explain to the people whoever recording this to how you as a family became entertainers, but it’s wonderful.
Theodore Lawrence: We can do that now. It doesn’t take that long.
Christopher Rose: Sure.
Theodore Lawrence: I told you my wife and I love to sing together. We sing in the choir together. When my daughter turned 8, we started seeing as a trio. She was very precocious musically, was very frustrated with the standard xylophone at the age of about 18 months because she couldn’t play Happy Birthday to You because a standard baby xylophone doesn’t have a B flat. We knew something was there right away. She started taking serious piano lessons at second grade, and just really took off, and as Chris mentioned, and has now been a professional freelance musician in Chicago for 10 years. Then when my son turned 8, he also is not only very musical but also had perfect pitch. In retrospect, my kids have told us this - they’ve both taken music education classes - that you’re not supposed to have your 8-year-old and your 10-year-old sing tight harmonies like barbershop quartet. That’s not supposed to happen until they’re significantly older. We didn’t know that. We just said, well let’s sing barbershop quartet, didn’t realize we were scarring our children for life. But they learned those barbershop quartet pieces.
And then we started asking Diana to arrange for us. She was about 10-years-old, and we found out later you’re not supposed to ask your kids to do that until they’re much older. But she would listen to records. One of the first was by an cappella group called the Nylons. I don’t know if either of you ever heard of the Nylons, but she transcribed One Fine Day. I have a recording of that, of the four of us singing. So ever since then, the kids have arranged for us and we sing together at weddings, and we sing in synagogues. It’s been one of the great joys of my life. I get a little teary each time I describe this. I look at the four of us while we’re singing. I think some parents argue with their children, and I get to sing four-part harmony with mine.
Eric Gressen: That’s very nice.
Christopher Rose: It’s astonishing, I have to say Ted. That’s how great you guys are. If you have another job, I think, if this one doesn’t work out at the Cancer Center, but we’ll get to that.
Theodore Lawrence: Well, the funny part is I really am the weak voice in the family. My wife has a beautiful voice, and the kids are professionals. My son is a cantor now in Cleveland. My daughter, I have this image, even when she was in high school, and I think she was even in upper middle school, and putting their hands on their hips say, “Dad, can’t you hear you’re a quarter tone off? Listen. You got to blend. Listen.”
Christopher Rose: So I guess we have to go back to the boring stuff. You decided you would go to oncology and did your mentors both suggest that you spend time in the medical oncology branch at the NCI? How did that happen?
Theodore Lawrence: So I interviewed at a number of programs. I interviewed at Stanford where I probably would have been happy to stay, but at that point I really wanted to combine the lab and the clinic. I thought with all my PhD training, and even though my PhD training was more in sort of cell biology and really was more almost cellular cardiology, a lot of the techniques and concepts fit very well with oncology. But Saul Rosenberg told me that he was not interested in training physician scientists. He wouldn’t really accommodate me. I probably shouldn’t have listened to him because you know there’s a guy name Ron Levy, who was getting started at that point and doing very, very well, and I should have seen what he was permitting and not what he was saying. But in any case, I --
Christopher Rose: You wouldn’t have met Eli?
Theodore Lawrence: I would not have met Eli. I had good interviews at Harvard and good interviews at the NCI. The NCI in particular had really set their program up to pay you decently, and that permitted you to combine the lab and the clinic, and nobody else had created such a good combined program. I had great interviews there, and they were really excited about my background. I had offers at other places, but the NCI seemed like it was a perfect place to go because they had really worked out how to do a combined program. And then I started in med onc. And then in September of my first year, I decided that I would rotate to radiation oncology because I thought every medical oncologist should know something about radiation oncology. I encountered Eli Glatstein, and that changed my life. I always tell people, September 1, 1983, I was a medical oncologist. September 30, 1983, I was a radiation oncologist.
Christopher Rose: What was it?
Theodore Lawrence: It was a combination of things. First of all, it was kind of a bad time in medical oncology at the NCI. It was really interesting to reflect on it. Have you read DeVita’s book, The Death of Cancer?
Christopher Rose: Yes.
Theodore Lawrence: Yeah, and so I only realized it after I read DeVita’s book that there was this real high in the ‘70s that Hodgkin disease and large cell lymphomas had fallen to combination chemotherapy. So when I arrived there in the ‘80s, it was obvious that everybody in the Medicine Branch that all you had to do was pick the right four drugs and you were going to cure all cancers, and you are going to do that by giving people incredibly toxic regimens of chemotherapy. The idea was people weren’t cured because you hadn’t given them enough. I distinctly remember a patient I gave high dose cisplatin to on a trial. I think we gave her 200 mg/M2. of cisplatin, and I put her into renal failure, and I made her colorblind. (We wrote a paper about it. George Wilding was head of the Cancer Center at Wisconsin for many years, and we were onc fellows together. We wound up writing a paper on drug-induced colorblindness.) I put her in a wheelchair. I gave her terrible neuropathies, and I didn’t affect the metastasis that she had one bit.
And then I saw her again with Eli, and Eli said, “We can treat that with an e-beam,”. My high dose cisplatin did nothing for that, and that little e-beam made it go away. I went, oh my gosh, look at what you can do with radiation therapy. Then Dr. DeVita that same month gave a Cancer Center Grand Rounds to the NCI, he had this introductory slide that surgeons cure 150,000 patients a year. Radiation oncologists cure 75,000 patients a year. Medical oncologists cure 15,000 patients a year. So I’m starting to think, did I pick the wrong career? Then I rotated with Eli who was so excited about every case. Every case was something we could learn from, someone we could help, someone we could think about a protocol for, and I was so –
Christopher Rose: We’ll get to this -- I don’t know whether it’s a tightrope, but this dual paths that you walk between bench work in chemo-radiation interaction and/or second messenger radiation interaction, and the work you’ve done in liver. But it sounds like up to this day you’re really excited about using directed energy to deal with I guess what’s called these days, oligometastatic disease.
Theodore Lawrence: Yes. But it didn’t start back then. The other influence I had was Jim Mitchell, who is radiation biologist, and I spent a year in his laboratory at the end of residency. He was just a terrific teacher, very supportive, and a wonderful cell biologist. And then Al Fornace who is at Georgetown now, who was a super molecular biologist right at the dawn of molecular biology. There was also guy named Angelo Russo, whom a lot of people don’t know, who was a wonderful biochemist. The three of them, Mitchell and Russo and Fornace, stimulated me on the research side to think about how you develop molecularly targeted radiation sensitizers, all in the presence of Eli’s very, strong clinical hand. It was a wonderful experience, and really got me excited that this is the right field I mean both from the laboratory side and clinical side.
Christopher Rose: With this very strong background, it probably was a seller’s market for you in terms of your first job. How did you end up at Michigan? What was it? Your next mentor I guess, but tell us that story?
Theodore Lawrence: So Michigan, this was the first place interviewed at. Everyone said there was this guy named Lichter who had just left the NCI. He and I overlapped by a year but I actually didn’t know him. He spent a year in the laboratory, and that was my first clinical year. So I think I must have just barely met him but I wouldn’t say I really knew him in the NCI. But everybody spoke very highly of him. Eli said, “I know it’s the Midwest, and I know you spent your whole life on the coasts, but Allen is building this really great department in Michigan, and you have to at least interview there.” So I interviewed here, and this department was in a vertical ascent phase. Dick Fraass Randy Ten Haken and Dan McShan had come here already, and, along with Allen, were developing something called 3D treatment planning. There was a small laboratory program (just 2 scientists) but it was clear that they were inventing a new and better way of doing radiation therapy. And I think I had good training at the NCI, but what was going on at Michigan in 3D planning just made my eyes pop out of my head.
And then Allen offered me a lot of resources to start up a lab. Combined with the 3D planning, it just seemed like a great opportunity. I came home to Eli and said this is it. I want to take this job. Eli said, “You can't do that. You just can't go to one job and interview and take it. You got to interview at some more places than that.” So I interviewed at University of Arizona. Bob Cassidy was there, and Jeff Trent was in the laboratory there, and it was a very good program. I interviewed with Ralph Weichselbaum at the University of Chicago. Ralph is brilliant, one of the smartest people in our field with a real eye for the important problems in oncology. And he also has a terrific sense of humor. I felt very fortunate I was getting offers from essentially every place. But the offer at Michigan was just stronger by 50 percent, and there was a palpable feeling of excitement here that this was a new department. It was really ground level opportunity and that I was going to get a chance to shape it. So in the end it really wasn’t a hard choice because of those factors, because of the excitement and plus the resources.
Eric Gressen: You had family at that point or were you just starting out?
Theodore Lawrence: Okay. Yes. By that time I had my second child. So we had Diana, my daughter, was six months to go in my internal medicine residency. That was 1983, and then my son was born in 1985. So we moved here in ’87, and my son was not quite 2 yet, and my daughter was about 4.
Eric Gressen: Perfect timing.
Theodore Lawrence: Yes. But I have to say though that as I drove from my residency-fellowship at NCI in Washington DC to the house we had purchased that used to be part of a farm, I wondered what I was doing here in the Midwest. I was a little nervous about it. You know this was just a flyover state for me, and what was life going to be like? Part of what convinced me to come here is I had a friend all the way from grade school. Actually, the one I did the drug survey with was a professor here. He said this was a great place to raise a family, and then they have a fantastic deli here called Zingerman’s. Zingerman ships all over the country so I figured a nice Jewish boy from Long Island that my friend says that you can live here and they have great deli, I think it’ll work. That permitted me to come here.
Christopher Rose: That’s great.
Theodore Lawrence: The first few years were kind of tough because I was trying to establish a laboratory. The clinical area I decided to focus on was GI and in, particular, liver tumors. Everybody thought I needed a psychiatrist because nobody was using the radiation therapy to treat liver cancer. I had a great colleague, and this gets to who my mentors were. So I have two incredible mentors. One of course one was Allen Lichter on the clinical side, and then the other is a guy named William (Bill) Ensminger, who really understood translational research. So I really needed two mentors for my career and I was fortunate enough to find two spectacular mentors.
Christopher Rose: Bill was a resident in medicine at the BI. He was my resident at the BI.
Theodore Lawrence: Oh, my gosh, that’s so cool. I didn’t know that.
Christopher Rose: Yeah. Bill was great. He is such a wonderful man.
Theodore Lawrence: He was into regional therapy. He was one of few medical oncologists who thought that local control meant anything because he was interested in controlling liver metastasis. So I couldn’t have found a better mentor, and most medical oncologists will often say, it’s all systemic. Who cares about local control? But Bill really got translational research and cared about local control.
Christopher Rose: You’ll be interested to know that when he was back at the BI, he always talked about metastasis in terms of locks and keys, seed and soil. I think that when he started doing that work with infusion, it was natural because that was how he thought about the disease. He read the stuff by Garth Nicolson and by Josh Fidler by then and it really came into his thinking I think. Fascinating. So tell us what it was like at Michigan in those days. You’re right it was -
Theodore Lawrence: I skipped one of your questions. I had some really cool co-residents when I was at the NCI I should mention. So Dino Stea, Baldassarre Stea and I were co-residents. He’s now the chair at the Arizona. Dino was great. Dino had love of life, really very Italian, good food, took work seriously, but understood how to enjoy life. You can't say joie de vivre for someone who’s Italian, right? What’s the equivalent in Italian? I don’t know. But Dino is wonderful, and then Gillies McKenna was a year ahead of me. And Gillies, I wouldn’t say was really a mentor but has been kind of a role model for again trying to do translational research and showed me that it could be done. Steve Hahn was a couple of years behind me. I wouldn’t say I knew Steve well then but I knew of him and the good work that he did.
Christopher Rose: So tell us what it was like in Michigan in those days and how it happened that when Allen became the dean that you took over there.
Theodore Lawrence: There are two good stories. Developing the liver program was really interesting. Allen was very good at telling me that we had this amazing 3D planning tools. And for Allen he loved being able to place beams from any orientation. It’s probably hard to remember a day where we didn’t have 3D planning, but back in the mid-80s, late ‘80s, all beams were constrained to the axial plane. You couldn’t use non-coplanar beam. But with 3D planning, these things that Fraass, and Ten Haken, and McShan were inventing you could, and Allen loved that. Allen had amazing sense of 3D and putting beams in from weird angles, and I liked that. But the part about 3D planning that I loved was how you could quantify things. I loved dose-volume histograms.
The idea that you could calculate, you could break the liver up into 2000 voxels and calculate the dose to each, and then actually quantify the volume of that organ that was getting a dose. Randy Ten Haken was and still is own of my closest colleagues and we’re now starting our 30th year of collaboration. Our big idea was that we would design protocols in which the dose of radiation was based on the maximum safe dose we thought we could give based on the dose-volume histogram, based on quantifying how much of the liver was getting how much dose. And so we began with a prospective trial in which we treated 79 patients, nine of whom got radiation-induced liver disease, and we looked at all our dose volume histograms. I’ll never forget these were all printed out on ink pens on paper printers, and we spread out the 79 DVHs on the floor, with some of the 70 without complications over on the right and the nine with complications over here on the left. What was different about the DVHs on the left compared to the DVHs on the right? Randy came up with a scheme for organizing them and for using them as input for normal tissue complication probability models based on actual data. You know it just been that Emami volume using the Lyman model to estimate NTCP based on the opinions of experienced clinicians. But we had data. I look back at everything I’ve done in my life, and that was probably the most exciting thing I’ve ever worked on because I felt nobody had ever understood this before. Nobody was quantifying dose-volume histograms and what’s the maximum safe dose? I felt like I was on a mountain. You are looking out on a valley that no one had seen before. It was amazing, coming up with a model based on data and then designing a new trial prospectively testing that model. It was exciting stuff and having colleagues to work with, and then at the same time trying to run a laboratory, getting help from people on trying to develop the first chemotherapeutic radiation sensitizers and then ultimately targeted therapy, and molecularly targeted radiation sensitizers. So that was fabulous, and over the first 10 years I got to develop both those programs with a lot of help from other people. And then by about 10 years in, I thought that I had enough ideas and desires to organize a department.
I went to Allen, and I said, Allen, you’ve been the world’s greatest boss, but I’ve been interviewing for jobs. I’ve been offered the job of being chair of radiation oncology at Vanderbilt, and I think I’m going to go. Allen had been chair for 13 years, he was in good health and was widely respected chair here, and said to me, “Well, you know Ted, I’ve thinking about stepping down in the next few years - he said this to me - I would like to keep you here. I think you should be the chair of this department, so I’ll step down.” Isn’t that an amazing story?
Christopher Rose: He loved Michigan. He loves Michigan eh?
Theodore Lawrence: He stepped down to keep me here. I’ve never heard a story like that in academia. So then, he was president of ASCO during that year, and as he finished that year, the dean here stepped down, and they asked him to be interim dean, which he was able to do because he wasn’t a chair, and then he did such a great job, and he became dean. So he did not become dean and open up the chair position for me. He stepped down to permit to be chair here, which opened up the opportunity for him to become dean here - amazing story.
Christopher Rose: Most remarkable. You know I want to try and save some time so we could talk forever about -- and we’ll get to the part about what’s like to run -- well why don’t we do that now? So you were the chairman of the radiation oncology department for how many years before you were asked to run the whole Cancer Center?
Theodore Lawrence: 18 years. Starting February last year, I became Cancer Center director, which is a very interesting job. I hate to use clichés but it really is herding cats.
Christopher Rose: Do you have time to continue? I know you’re still highly interested in liver radiation. Do you have time to continue your laboratory work as well with your colleagues?
Theodore Lawrence: I have on a more modest scale. I have one postdoc now whom I directly mentoring. I managed over the years to trick three post docs into staying with me, two of whom are assistant professors and one is an associate professor. And so as far as the lab is concerned now, I only have this one postdoc I really supervise directly. And then for the others I meet for three or four hours a week with everybody and go over data. And I help people write papers and help them write grants, but I don’t really primarily run a laboratory anymore.
Christopher Rose: So from your perch as the head of the Cancer Center there at Michigan is cancer therapeutics, research, teaching, and taking care of patients alive and well in this new era?
Theodore Lawrence: I think so. I have had to contract my clinic unfortunately so I only have half a day a week of clinic. I only have a few patients under treatment at any one time. But I still want to keep my hand in. I just love patient care. It’s the one time of the week where I only answer patient related pages. There are some administrative days where you get through the whole day and you look at your calendar and you say did I actually do anything today? What actually happened today? You know with the clinic. You get to the end of the clinic and you know you helped some people that day. It’s still the most consistently rewarding part of what I do. But I’m trying to still keep in touch with everything. I don’t know if I’m going to be able to stay chair and Cancer Center director forever. I probably will need to give up one of these positions at some point but I’m still assessing that.
Christopher Rose: So Eric has some other things here he wants us to cover. When you travel around, you’ve been a visiting professor, what interesting things did you see at other places which were different than Michigan, the same as, what have you learned from other departments?
Theodore Lawrence: Yes. I think different departments organize their lives in their different ways. I learn from each place I visit. For instance, I had a great time being visiting professor at Stanford a number of years ago when Rich Hoppe was chair. They arranged the whole day to include my talk with their presentations so as to bring the department together. He and Sarah Donaldson arranged a wonderful visit that included meeting one of my favorite internal medicine attendings when I had been a resident there I’ve had some great visits in the Harvard programs. Bill Shipley and Anthony Zietman were wonderful welcoming hosts and the residents asked such great questions. I would say that many of the faculty I interviewed with feel it is difficult to carry out all of the patient care they are charged with and still do good research. I feel like the one thing that I’ve tried to do for the faculty at Michigan is try to build a little bit more time for research so that we can keep pushing the field ahead.
I mean I don’t want to compare our program to others. There are a lot of great programs. I think our physics program, led by Randy Ten Haken and James Balter, is strong. Our biology program is strong, led by Al Rehemtulla and Yi Sun. Our clinical research work is strong as well. We’ve tried to grow more. Reshma Jagsi is my deputy chair, has opened up the whole area of public policy to try to build strength in health services research as well.
But maybe I can say that Michigan has done a good job compared to the other programs I visited at trying to give the opportunity for residents to have experience from topflight people in all three areas. This is an important factor, I think that leads to about 2/3 of our residents going into academics. One of the best parts of my job is seeing our residents grow into outstanding faculty who go on to do great things either in our department or elsewhere.
Christopher Rose: So you talked about keeping radiation oncology strong, and of course we forgot and missed all of your activities with political radiotherapy both with ASTRO and with the Radiation Oncology Institute. What are your reflections?
Theodore Lawrence: I do want to talk about that because I think that first of all, how did I even get involved in ASTRO? I do want to mention Steve Leibel, unfortunately he passed away, and Jay Harris. They called me out of the blue in 1994, and it was some sort of fluke because Jay was supposed to be head of the Scientific Program Committee for the Annual meeting after Steve Leibel, but Jay was elected president of ASTRO. But they plucked me from where I would say was relative obscurity and asked me to be head of the ASTRO Scientific Program Committee. That was an amazing thing for me. I’ve always been deeply indebted to the two of them for giving me that opportunity because it really changed my life.
Some of my best experiences in this whole field have been all the people I’ve gotten to meet, because of this great field, because of what ASTRO means and has done and being involved in the Program Committee for five years. I was the last person to do five years. Everybody decided that was too much punishment. I would have gone for a sixth year, except Allen Lichter asked me to be head of the ASCO Program Committee because he was elected president of ASCO that year. So then that led to Chris -- I’m trying to remember- Chris you called me up, didn’t you? You asked me to run for president.
Christopher Rose: Yes.
Theodore Lawrence: I know it was Dave Larson who asked me to run for the Board, and I said, wow that would be great. About two hours later you called me up and asked me to run for president. That was even better! And you told me don’t feel bad if you lose. You’re from the Midwest. Midwesterners always lose. Don’t feel bad about it. But, remarkably, I won. It’s been a wonderful experience.
Then one of the best things I was able to do in ASTRO was help to found the Radiation Oncology Institute. You really got it started Chris. I think you are the major player in the year before me who set it up, but sometimes it takes a couple of tries to roll that rock up the hill. I will always be grateful for having had that opportunity that you started.
Eric Gressen: Any other contributions at ASTRO or ASCO that you want to mention?
Theodore Lawrence: Well, I was on the Board of Directors at ASCO. That was great fun to do that. I think the other thing that has been satisfying most recently is I gotten more involved in AACR and I’ve tried to build some bridges between AACR and ASTRO. Some individual bridges were being built, but I got the opportunity to work within the AACR with Margaret Foti. She and the Board of AACR supported creating a new Working Group, the Radiation Sciences and Medicine Working Group, within AACR. The whole purpose is to advocate for and advertise the science of radiation and cancer biology and the scientific basis of radiation medicine. We now have a couple of hundred members. I was the founding chair of this committee and still I’m chair of this committee for another year. That’s been very satisfying. I don’t think that would happen without my ASTRO experience. Technical developments will continue to be important in our field, and they have been a big part of my own career, but developing therapies based on the biology of cancer has got to be important too. I think our field is now embracing both, although the technical still seems to dominate.
Someone told me that I’m the youngest gold medal winner. Is that true? I don’t know if that’s --
Christopher Rose: I think that that’s probably true. You are 10 years younger than the people who are next from above. So I mean at this point I was about to say you’re still a young man. You are young but this thing needed to be done now. But I mean you still have a lot of juice left in the orange. What do you think the future is going to bring my friend?
Theodore Lawrence: Yeah. I think that our field has got a tremendous future. One of our biggest recent advances is stereotactic body radiation, but I have somewhat mixed feelings about SBRT. I don’t want to suggest to turn into ablationist. It puts us in the same playing field as the people who do radiofrequency and microwave ablation. I think there is a lot more biology and a lot more we can do with radiation therapy so I’m excited with SBRT but I don’t want our field to overuse SBRT. I also love having 20, or 25, or 30 fraction treatments because you get to know patients. I’m a little afraid with the ablationist approach that it’s so procedural. They’re sort of in and out. But having said that, it’s a tremendous advance, and I think the biology of our field is getting stronger and stronger particularly with targeted therapies and with immunotherapy.
And as I said above, I continue to feel that we should advance the physics. When I look at my own contributions even though I’ve had a laboratory, I still think my -- if I’ve had any contributions, they are stronger in the physics and the clinical side than they have been in the laboratory. But I do think the laboratory day is coming especially with immunotherapy and with molecularly targeted therapies. Another important area is the development of molecular biomarkers using large data sets. OncotypeDx has been around for a while, and I now see people in our field using these techniques to develop predictive biomarkers for the efficacy of radiation. We need to have a cadre of people who understands how to use these molecular markers to optimize radiation therapy. I think we have a lot to offer in those areas. It’s an exciting time by continuing to build in all of our strength plus I’m very excited to see more and more radiation oncologists getting involved in public policy issue. I went into medicine, Chris probably you and I are roughly the same age thinking that physicians, we could control our own destiny. And of course, we’ve learned that’s not the case. So having radiation oncologists in the middle of public policy, which I see happening more and more is also extremely important.
Christopher Rose: Any favorite sayings?
Theodore Lawrence: Yes, yes. I had a couple. I’m glad you asked me that. I love a quote from Linus Pauling that I use with my trainees all the time which is “In order to have good ideas, you have to have a lot of ideas.” Then the skill is to get rid of the ideas that aren’t good ideas as fast as you can. I’m constantly encouraging people to have ideas but then what’s the quickest way to disprove that hypothesis so you can move on to the next idea. Another way I say this to my residents, “Ideas are cheap. Data is expensive.” I may have made that up. I don’t remember hearing that one, but has served me well in my career.
Christopher Rose: Anything we forgot?
Theodore Lawrence: Another saying that has helped me in my life is “Never confuse malevolence with incompetence.” Because you know sometimes someone does something to you and you think that they purposely hurt you, and in fact it just turned out they didn’t know what they were doing.
Christopher Rose: Well, it’s good to remain optimistic and sunny. Anything else that we forgot, this was a joy for me. I don’t know if --
Theodore Lawrence: One more thing I would like to say is that I never planned my career. Some people, especially young people say, “My plan is that in three years I’m going to do this, and in five years I’m going to do that.” I never planned my career. I just tried to take whatever opportunities were offered to me, and make the most of them.
Eric Gressen: Well, this was an excellent interview. We’re going to start interviewing more and more younger doctors. I think we’re also going to be sending everybody information ahead of time because you were very much on the ball and you knew the pace that we were doing. So we don’t always extend the spreadsheet of what you should discuss but this was great. I love your tangents. They made a very interesting interview. I couldn’t be happier in how this turned out.
Theodore Lawrence: One last thing before we go. I made one note. Four chairs have come from our department. It’s your trainees. When you get to our age, it’s your trainees, you’re the proudest of. So to Jim Bonner and Rich Zellars, our current chair is Jim at UAB and Rich now at University of Indiana, both were my residents, worked in my laboratory, and Carolyn Sartor who was chair at University of North Carolina for several years (and, sadly recently passed away) and then Spring Kong who came here out of her residency was chair at the Georgia Regents University for several years. I’m proud of all my trainees but there is nothing more satisfying when you see people come from your program and succeed.
Christopher Rose: Then of course there’s Laura Dawson who is giving you a run for the money in liver.
Theodore Lawrence: I am so proud of her. You know if we have one more minute, I will tell you a nice story about her.
Christopher Rose: Four.
Theodore Lawrence: Laura Dawson is one of my best stories. As you know she’s Canadian and she came here as a fellow. She looked at me the first week and said, “You are stark raving mad. You are treating these patients with liver metastasis or with these big hepatocellular cancers. What are you doing? These are people who should be going to hospice.” Now, the student has exceeded the master.
Christopher Rose: I don’t know, Ted. I’m not sure.
Theodore Lawrence: I’m so proud of her because she has pushed the field forward. Likewise, Mary Feng, who is now at UCSF, has moved the field ahead too and is now a Vice-Chair at UCSF. Her husband, Felix, came into our program after coming to Michigan as a resident in diagnostic radiology. He has done a brilliant job in understanding the drivers of prostate cancer, and is also a Vice Chair at UCSF. There are too many residents (and faculty) to talk about, and I am afraid by mentioning some that I make an error by leaving out others. So I apologize in advance! And we have some terrific people who are early in their career: I can’t wait to see what they do!
Christopher Rose: Well, this was a real joy for me, Ted. Thank you so much.
Theodore Lawrence: So kind to choose me to do this, and to listen to me regale you with my life for all this time. It’s very, very kind.
Eric Gressen: We might interview you again in 20 years as you only look three to five years ahead. So that would be great too.
Theodore Lawrence: You are so kind to do this and to honor me by choosing me to interview.
Eric Gressen: Well, you’re well-worth the interview and I think it went great. So thank you so much, Ted. And Chris thanks for doing the bulk of the work since you knew Ted so well.
Christopher Rose: It was easy. He is truly one of the most humble people who has no right to be. It’s been great. We’ll see you in September guys.
