2021 Honorary Member
Douglas Evans, MD, the epitome of Person-Centered Care
By Doriann Geller, ASTRO Communications
ASTRO has named Douglas Evans, MD, chair of the Department of Surgery and Donald C. Ausman Family Foundation chair at the Medical College of Wisconsin and world-renowned pancreas cancer surgeon as the 2021 Honorary Member. This is the highest honor ASTRO bestows on cancer physicians and researchers who do not quality for Active ASTRO membership.
Dr. Evans took time out of his busy schedule to visit with ASTRO in mid-July 2021. The interview appears here and has been edited for clarity and length.
Q. You were quoted as saying that the idea of medicine came to you late in college, while taking an introduction to medicine course taught by a radiologist, that it was eye opening. And that's when you decided to become a physician. What was it that was eye opening about that course?
A. You know, I really had not thought seriously about medicine. I hadn't really figured out what I wanted to do. The goal was to graduate from college and hope that an epiphany of sorts occurred to me during my senior year. I was a sophomore when I took that introduction to medicine, a class that was actually taught by the dean of the college. It was usually not fully subscribed, so, the dean's office came to our dormitory and said, “This course is going to be fully subscribed. And just to let you know that some of you will just be placed into this course.” The upperclassmen weren't too thrilled about this, so being a sophomore, I was elected. It was a six week immersion, and I worked with just a wonderful man. He was a nuclear medicine physician interested in radio radioiodine uptake by the thyroid gland. This is the late 1970s ― I think Agilent radioiodine was still being used for thyroid cancer at that time. But that was what I focused on. And just being in the hospital and working with someone who really loved his job so much, was intellectually engaged in his job, obviously liked seeing patients but really had an intellectual fascination with the science of medicine…I think that's probably what was so inspiring.
Q. How did your mentors impact your career? And what advice do you have for mentors now to help them in, your words, talent development?
A. Mentoring was not really a term that was used that much when I was in training, and certainly [not in] my early faculty years. When I was a resident and a fellow and early in my career, [there were] people who showed an interest in me, or at least, my interpretation was that they showed an interest in me and wanted to move my career forward. So, Bob Crichlow [MD], who was chair of surgery at Dartmouth when I was a resident, was hell bent on me being a surgical oncologist. And there was just no question that I was going to do a fellowship in surgical oncology. He didn't ever use the term mentoring. But he bought me a plane ticket to go down to MD Anderson to interview. And when I first was hired at MD Anderson, Charles Balch [MD, PhD] was the chair of surgery there [and when he] asked me to be on faculty, really, what I was looking for was opportunity.
Now, young faculty, residents, fellows, want a more structured mentoring environment. One thing we have done here at the Medical College of Wisconsin, under the leadership of Phil Redlich [MD, PhD], and Tracy Wang [MD, MPH] is we've tried to develop the best possible mentoring process for our faculty that exists anywhere in the United States. It's a very structured experience. They have their own mentor within the department. But more than that, we have a mentoring committee, which really gets into the weeds into their career development, you know, their manuscripts, their grant submissions, what their week is like, exactly breaking down their week. I think that it probably is more successful than just providing opportunity, which is what I would say is one of the synonyms for mentoring of the past.
Q. There were people who made a great impact in your life. When you were here in Washington at the DC Children's Hospital, Dr. and Mrs. Randolph ― Dr. Randolph being your senior ― inquired about your family. This kindness made an impression on you. How do you promote that kind of personal connection?
A. Well, you have to realize that that was probably around 1987 and, at that time, surgery was kind of an old school specialty and you spoke when spoken to. Judson Randolph [MD] was one of the most famous pediatric surgeons in the world. When I was at DC Children's, I took care of most of his patients and to have a person of that stature get to know me a little bit and then clearly he had talked about me a little bit at home because his wife knew that we had two daughters at the time, and then to have his wife ask me about my kids … you'd have to go back to old school surgery, when there were no work hour limits. We went into surgery because we loved it and, we didn't oftentimes have those kinds of personal relationships with our attending staff and it certainly was such an impactful rotation for me to get to know Dr. Randolph and then, when at night, sometimes, his wife would come in if they were out to dinner, that opened my eyes to how great the field of medicine really can be.
Q. In the 1990s, during your time at MD Anderson, their multidisciplinary program began focusing on pancreatic cancer. How did your time there encourage your interest in radiation therapy as part of that disciplinary approach?
A. When I was in this early part of this my second year of fellowship, Dr. Balch asked me if I would stay on as faculty, and he wanted me to focus on pancreas cancer. I had worked on a clinical trial as a fellow with Tyvin Rich [MD], who was the GI radiation oncologist there at the time, and Fred Ames [MD], who was the surgeon. There were a number of medical oncologists who were involved in this, but we said, pancreas cancer has a more aggressive biology than breast and rectal cancer, for example, two diseases which were beginning to be treated with neoadjuvant therapy. Why not consider this for pancreas cancer?
It was really stimulated by a patient we saw soon after a Whipple procedure who already had a liver metastasis. We said, well, the surgery didn't do that patient any good at all. At that time, we knew from the anatomy of the pancreas that patients were very susceptible to local recurrence. Therefore, why not combine infusional 5-FU with radiation done for other disease sites, use that as neoadjuvant therapy. It would provide improved local control and potentially offer a selection bias for patients who would benefit from surgery.
Again, not wanting the treatment to be worse than the disease, if someone undergoes a Whipple procedure and they recur within a year of surgery, say they get a liver metastasis or peritoneal implant within a year of surgery, the surgery clearly did nothing for them. Could we not prevent that by delivering something other than surgery first, allowing a period of observation.
Those patients who will then declare themselves as having early metastatic disease, you may avoid operating on them, which is, when we completed that clinical trial, actually what we found. You could dichotomize the population of patients into those who would benefit from surgery and those who wouldn't and avoid surgery in those patients who wouldn't benefit. We felt strongly that radiation therapy was important too, along with surgery, to prevent local disease control.
It actually goes to the [ASTRO Annual] meeting this year devoted to person-centered care. If you think about pancreas cancer, if a patient is without evidence of recurrence two years after potentially curative treatment for pancreas cancer, then one of the major patents of failure will be local disease recurrence. It's clear that radiation therapy lessens local disease recurrence, but the patient has to survive the gauntlet of liver and peritoneal metastases. That's why it's been difficult to prove an impact of radiation therapy on survival. But for those patients who are destined to develop local recurrence, radiation therapy is tremendously impactful.
The other area where radiation therapy has been important is that here at MCW we have shown probably as well as anyone, that radiation therapy downstages regional lymph node metastases, and survival of node negative patients is superior to node positive patients regardless of how the patient became node negative. If you look at patients who received surgery first, for pancreas cancer, about 70% to 75% of them will be node positive. And there's a tremendous survival advantage for the 25% who are node negative. If you give patients chemotherapy plus radiation prior to surgery, and typically nowadays, it would be two to four months of chemo followed by radiation therapy given in some way, the number of patients who are node positive goes from about 75% down to 35 to 40%. And the patients who are node negative have the same survival of the patients who were node negative without radiation therapy.
So, there is a stage migration with a similar survival advantage. With chemotherapy plus radiation therapy, there is a greater percent of patients who are node negative, those patients have a survival equivalent to the node negative patients. So clearly, there has been a stage migration from node positive to node negative, but the survival impact of being node negative is just the same. So, unfortunately, there are enough patients who are recurring within the first two years, which makes it hard to prove a survival advantage for the entire population for radiation therapy, a complicated mathematical issue, but that's why we and others feel strongly that maximizing survival for operable pancreas cancer will occur with a combination of chemotherapy, radiation therapy and surgery.
Q. You are a proponent of second opinions. I read that you said it sounds very simple, but it took two decades for people to appreciate the importance of combining chemotherapy, radiation and surgery in that order. How does radiation oncology figure into the process of encouraging second opinions?
A. I think it's a complicated situation. Fortunately, with a pancreatic cancer diagnosis, there is a little time. And by that, I mean, there's at least 48 to 72 hours, whereby people can make a few phone calls, just step back and say, where should I go, who should I see? Going to an institution that sees a relatively high volume of a specific disease is probably helpful for the patient. You know, it's not always the surgeon. It's not always the radiation oncologist. But it's really the team of everyone that provides a tremendous amount of supportive care.
If you look at our results, especially with operable pancreas cancer, I suspect that we don't do surgery any better than it's done at many other institutions. But we have tremendous support. We have everyone from nurses to technicians to nurse practitioners and PAs, and because we see a large volume of patients with pancreas cancer, they've seen just about every little problem that the patient can develop. They can get solved quickly when they're a tiny problem, and people can get back on track.
I think for the delivery of neoadjuvant or adjuvant therapy, radiation therapy is ― and this is a surgeon speaking ― a bit of an art form. I've always been lucky to work with really great radiation oncologists. The radiation oncologist we have here Bill Hall [William Hall, MD] and Beth Erickson [MD, FASTRO] are tremendously devoted to their patients. And, and similarly, our medical oncologists are extremely devoted so that all the supportive measures are delivered to the patients all the time and I think that makes a huge difference with regard to the safety of surgery, and the eventual and the eventual outcomes.
We actually have a full time psychologist that works in our pancreas program. This has been my dream for years. This stems from my kids. My kids were really good athletes, and our oldest daughter was a really good college volleyball player. She developed a health issue early in her junior year. The coaching staff desperately wanted her back for her senior year, and one of the things they did is put one of the sports psychologists on to work with her during her recovery and eventual rehab. It made a huge difference. I firmly believe that they had an interest in her, not just her ability to play volleyball. They were taking a normal person who was dealing with a life changing event. And they were trying to make that better. And I always thought that's exactly what we're dealing with pancreas cancer, that these are normal people dealing with life altering events, and why shouldn't we do the same thing that good college athletic teams, and every single pro team does.
Q. The theme of this year’s Annual Meeting is advancing person-centered care. Over the years, when you look back, how do you feel your career has advanced person-centered care?
The paradigm of radiation therapy for operable pancreas cancer is exactly person centric. Because without radiation therapy, a percentage of those patients will clearly have an increased risk for local recurrence. But it's hard to identify who those patients are at the very beginning, so we include radiation therapy. But with regard to my general approach to medicine, maybe I can tell you another story.
In 1998, my mother-in-law developed a glioblastoma multiforme. I brought her down to Houston and she received her care at MD Anderson, but we took care of her from diagnosis until death. She lived about a year. At that time, our kids were ― I think our oldest was in ninth. So, we had ninth grade, eighth grade and sixth grade. My wife, who was a schoolteacher, took a leave of absence to take care of her mom. Before she died, she had significant problems with seizures, and there would be times ― invariably, it would occur in the middle of the night or on weekends ― when she would be seizing. I would be treating her ― I could give IM injections and everything at home ― and my treatments weren't working. I would want to get a hold of one of the neuro-oncologists, and it was hard to get a hold of them.
I said, from that point on, I have to be more accessible to my patients, because the problems that they may have will not occur Monday through Friday, nine to five. So, from that time on, I gave my cell phone to my patients and their families. And, you know, no one abuses that ― no one at all. I don't talk about this much, because right now there's such an emphasis on work-life balance, and basically detaching yourself from work.
But the other alternative is what I call work-life integration ― basically integrating work into your life so that it's never really an interruption. And I can tell you, after my kids saw me struggle getting a doctor on the phone to manage my mother-in-law, there was never an issue with me missing anything. Before that, if I maybe missed a birthday, or I maybe missed my anniversary, or I was in the operating room and missed a baseball game, there might have been a little frustration. After we took care of their grandmother and they saw me struggling to get help on a Saturday night, they never said anything to me. But I knew that they thought, “We're never going to complain about him missing anything. Because he is taking care of someone else, someone's grandmother, someone's wife.”
Now I probably get two or three calls every weekend. It never is an interruption. I'm not advocating that doctors should do this. I'm just saying that one way to make life simple and at the same time fulfilling and fun is to integrate medicine with your personal and family life.
Q. Congratulations on being selected ASTRO’s Honorary Member. And thank you for your time today.
A. Thanks. And bye.
---Dr. Evans will be honored during the Awards Ceremony on Tuesday, October 26, during the 63rd ASTRO Annual Meeting in Chicago.
