Conversations with the Pioneers of Oncology: Dr. Allen Lichter

Sep 22, 2020

Dr. Hayes interviews Dr. Lichter on his involvement with early breast preservation.

Dr. Daniel F. Hayes is the Stuart B. Padnos Professor of Breast Cancer Research at the University of Michigan Rogel Cancer Center. Dr. Hayes’ research interests are in the field of experimental therapeutics and cancer biomarkers, especially in breast cancer. He has served as chair of the SWOG Breast Cancer Translational Medicine Committee, and he was an inaugural member and chaired the American Society of Clinical Oncology (ASCO) Tumor Marker Guidelines Committee. Dr. Hayes served on the ASCO Board of Directors, and served a 3 year term as President of ASCO from 2016-2018.

 

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

Welcome to JCO's Cancer Stories-- the Art of Oncology, brought to you by the ASCO podcast network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the role of cancer care. You can find all of the shows, including this one, at podcast.asco.org.

Today, my guest on the podcast is Dr. Allen Lichter Dr. Lichter has a long and really storied history in the field of oncology over the last five decades. With his colleagues at the NCI, Drs. David Danforth and Mark Lippman, he was the radiation oncologist PI for one of the four studies that demonstrated that breast preserving therapy was as effective as mastectomy for newly diagnosed breast cancer.

He more or less single-handedly started the Department of Radiation Oncology at the University of Michigan, now considered one of the top programs in the world. He is one of only three radiation oncologists to have been a dean at a major university in the United States, serving as such at the University of Michigan Medical School for eight years.

And he is one of only three radiation oncologists who have been president of ASCO. The others are Sam Hellman, who I've interviewed previously, and our current president, Dr. Lori Pierce, who, by the way, is also from the University of Michigan. And his term was from 1997 to 1999.

Dr. Lichter was born and raised in the Detroit area. He received his undergraduate and his medical degrees at the University of Michigan, after which he completed an internship at a community hospital-- St. Joseph's in Denver-- and then a residency in radiation oncology at the University of California, San Francisco.

Following that, he joined the faculty at Johns Hopkins University, but after two short years there, he moved a few miles south to the National Cancer Institute in 1978, where he was head of the radiation therapy section of the radiation oncology branch. I believe you couldn't have been more than 32 or 33 years old, Allen, at the time. I counted up the years.

He then moved back to Michigan to start the department here, which he chaired for eight years, and then became the dean for eight years. And then he went on to become the Chief Executive Officer of ASCO from 2006 to 2016. In spite of spending the last 20 years of his career as an administrator, Dr. Lichter has authored over 120 peer-reviewed papers. He was the co-editor of Clinical Oncology, one of the major textbooks on oncology, and has really been a leader, especially in radiation oncology, but in cancer in general in this country.

I also want to add he was my boss for eight years when I first moved to University of Michigan, and during which time he was also my next door neighbor here in Ann Arbor. And I got to be his boss for one year-- if anybody could be Allen Lichter's boss-- from my term as ASCO president. Dr. Lichter, welcome to our program.

It's great to be here, Dan.

So a number of questions. I know, first of all, you grew up in Detroit and you went to Cass High School. And while this podcast is supposed to be about the history of oncology, having moved to Ann Arbor, I find the history of Cass High School awfully interesting. Has a number of famous alums, including Diana Ross, Lily Tomlin, Ellen Burstyn, Della Reese, David Alan Grier, Jack White, Alice Coltrane, and-- my guess is, Allen, you don't even know who Big Sean is, but he's a rapper. He's very famous right now for the younger generation.

Any memories from your time there? Did you run into celebrities when you were there? It's quite a place to say you're from, I think.

It's an interesting school, mostly a technical high school, located in downtown Detroit, but with a small college preparatory program that took students from all over the city with a competitive entrance exam. And I don't know what possessed me to get on the Second Avenue bus and ride downtown back and forth every day, but it was a fascinating experience. It takes you out of your normal peer group.

I met young people-- friends-- from all walks of life, from all corners of the city. And it was a pretty rigorous education. I enjoyed it a great deal. And I played on the golf team.

And it sounds to me like you knew you'd be a doctor then. Your father was a family practice doc in a small community just outside of Detroit. Was that true? Did you plan to go to medical school? Or did you have some epiphany when you were at high school?

No, I never remember a single day not wanting to be a physician. My dad was a general practitioner and really instilled in my brother, and in me, a love of science and a love of medicine. My brother went on to be an ophthalmologist and was chair of the department at the University of Michigan for 34 years, President of the American Academy of Ophthalmology. So my dad and my brother set great examples for me, and into medicine I went.

So I have to tell you, my father was a business man and was disappointed that I was in academics because he never understood why I wasn't generating income. My brother went to work for Eli Lilly. He was a doctor, too. And dad always thought he was doing something productive because he worked for Eli Lilly. So I don't know if your dad was disappointed you went to academics instead of family practice, but--

It was interesting. When I started my residency training, I was certainly confident that I would head into private practice and live a life much like my father did. And when I finished training, I decided I just needed a little more buffing up. I figured I'd go into academics for a couple of years, just to make sure I had a good grounding, and then go into private practice. I love the academic life and stayed there my whole career.

I've been fond of asking previous interviewees-- why'd you choose oncology, and specifically radiation oncology, in your case? What led you to go into this path? Especially 40 years ago-- there wasn't a whole lot of oncology to go into.

Well, you know, I was one of those medical students that loved virtually every rotation, and after that rotation I was going to become a fill in the blank. In my senior year of medical school, we were allowed to take an away elective, and I wanted to explore radiology as a potential field. My brother had a very good friend who was a radiation oncologist at the University of California, San Francisco, and the chance in the early 70s to go to San Francisco-- especially avoiding the Michigan winter-- was very compelling.

So I signed up for the electives, and when I got there, I found that it was six weeks of diagnostic radiology and six weeks of radiation oncology. I hadn't expected that, but what the heck. So I did my six weeks of down in the basement looking at teaching sets, which was really quite inspirational. And I went into radiation oncology.

And after my first day, I called my father and I said, I found what I'm going to do. I'm going into radiation oncology. It was instantly fascinating. I love the camaraderie in the department. I love the blend between the physical exams of patients, the treatment of cancer, the use of very high technology equipment and physics. It just struck me and I never wavered from that point on.

So I've heard you talk about this-- and I'm 10 years behind you and even was true when I trained-- was that there wasn't a whole lot of science in radiation oncology back 40 years ago. And the field has evolved. And there are two things-- one you already hit on, which is it was combined with diagnostic radiology. And the second is it split away from diagnostic radiology to become its own field, and a lot of science.

I've spoken with Saul Rosenberg and Sam Hellman and sort of asked them the same question. Give us just a background of the last 40 years of the evolution of radiation oncology because you had a lot to do with that.

Well, of course, the field grew up, as you point out, inside the broad field of radiology. I always would tell my trainees that when Rankin discovered the X-ray, he forgot to discover the instruction manual. So there was a trial and error learning with this very useful technology, but very dangerous technology over a long period of time.

For quite some period of time, you trained in general radiology. You had some time in diagnostic a little time in therapy, and you went out and could do both. But as I entered the field, it was becoming more and more difficult to learn radiation oncology in just the few weeks that they rotated in from their diagnostic duties.

And I was one of the earliest group of trainees who trained in straight radiation oncology-- no diagnostic training, per se. And the field, as you say, split from diagnostic radiology. Had our own boards. I was amongst the earliest group to take the specialty board in radiation oncology.

And the other thing that was true, certainly back in the late 60s and early 70s, is that so much of the field was experiential-- that is, people wrote papers like, you know, the last 100 patients with cancer of the lung that I treated. And this was valuable, but the need to do rigorous, well-controlled clinical trials was obvious to everyone inside the field.

And so the field did become much more scientific. Never quite much as medical oncology, and part of that is because devices are treated differently at the FDA than drugs. Drugs you have to prove through scientific investigation that the agent is safe and effective. And then you can release it for patient use.

For devices, you just have to prove that it basically doesn't kill anybody. And you can get an approval of a device and often get a billing code for the device. So the approval comes, and then you're supposed to do the science.

Well, a lot of people, at that point, they're just too busy using the technology, then, to actually step back and do the science. And, of course, if you spent a lot of money for a piece of technology, to do the science to find out that wasn't a very wise investment is not in your self-interest.

So our science lagged behind. I think it is certainly catching up, but it's still, in fact, in many cases, has a ways to go.

I have enormous respect for our colleagues in the FDA on the devices side, and their hands are tied a bit. But I liken some of what they do to being like underwriter's laboratory. If you plug it in, it doesn't blow up, so they approve it.

Yes. It's a little more than that, but you're right. And so much of the device approvals are based on a predicate of a similar device. And it goes from A to B to C and finally, you know, years down the road, the equipment and its use and its underlying structure is so different from the original device that was approved years ago that you rely on, at every step of the way, it really has-- there's been a lot of scrutiny about changing that, and I think over time it will change.

You know, historically, it's interesting, by what you just said-- some of the first prospective randomized trials in all of medicine were radiation versus nil to the chest wall with breast cancer. To my knowledge, streptomycin versus nil for tuberculosis was the first, but then a whole series of radiation versus nil.

But who would you give credit in the United States-- I would give part credit to you with the work you did with Drs. Lippman and Danforth. Probably one of the first randomized trials in radiation in this country.

Well, you're correct that the first chest wall radiation trial started in Manchester, England in 1948. And at that point, doing randomized trials-- giving some patients the therapy and other patients observing or giving them a placebo-- that was not in widespread use in medicine. And over time, those types of trials began to become more common.

I think in radiation oncology, our big advance was becoming part of the national co-operative group system, where many of the co-operative groups-- maybe all of them-- had a radiation oncology committee. And our studies were often integrated with surgical care or combined modality care with chemotherapy. And so we began a series of very important studies in breast cancer and lung cancer.

The pediatric group did many, many trials that involved plus or minus radiation. I don't know that there's any specific person I'd give credit to, but it was the movement inside the field to join our other oncology colleagues in testing things rather than just doing observational work.

You know, in that regard, let's circle back to your work at the NCI. That must've taken a fair amount of organizational and political skills to mount a breast preserving therapy, just at the NCI. The data that breast preserving therapy was safe was just beginning to be reported. The randomized trials in other places were ongoing. Give us some story there, how the three of you got that going and how you ran that.

Well, of course, virtually everything at the NCI, from a clinical standpoint, is a clinical trial. Patients aren't treated there, just as going to their community hospital. You come to the NCI-- the travel is paid for, the care is paid for, et cetera, based on your agreement to enter into a study.

At the time that I went to the NCI, the NSABP was doing their very large trial of lumpectomy versus mastectomy under Bernie Fisher's direction. My concerns were twofold. Number one-- this was being done at many, many centers around the country, and one could, I think, logically ask the question whether the quality of that care was going to be uniformly high enough to truly test breast preservation therapy. And secondly, I believed-- and many of us believed at the time-- that a boost to the tumor bed was quite important as part of having a low rate of local recurrence, and the NSABP study did not use the boost. They just treated the whole breast and stopped.

And I said, you know, let's do a trial where it's done at a single institution, where the quality is going to be absolutely top notch, where we're going to use a boost and all of the technical tricks that we knew how to do this, just in case the NSABP study didn't come through. We'd have a backup. If both of them were negative, we could forget about lumpectomy and radiation, but if the NSABP was negative, we'd have this.

As it turned out, the NSABP study, as you know, was positive, established for sure the equivalence of preservation therapy, and our study was sort of a little caboose at the end of the train. But that's OK. It confirmed what Ernie and colleagues confirmed very emphatically.

Actually, there's an interesting article in the JCO written by Ian [INAUDIBLE] and his colleagues, about six months ago, that he preluded when he won the award your last year as CEO at ASCO. Was it your award? I can't remember.

Yes.

But anyway-- yeah. And in which, he designated the term I hadn't heard before of statistical fragility. And he made the point that many single prospective randomized trials are positive and the subsequent ones are not. And I give you and, of course, the Italians and the Brits also ran similar trials. It's nice to have four trials that all show the same thing. There's no statistical fragility in this observation.

Yes, well, the NSABP trial was 1,800 patients. Our trial was about 240. We weren't going to change the world, but it was at least comforting to me that we had this trial coming along just in case.

The other academic success that I give you credit for and would love to hear more about it is that you're interested in CT planning, which I think, really, was the forerunner, now, of stereotactic radiation and I would call precision radiation, as opposed to just blasting an organ and hoping you hit the cancer.

And I think, really, a lot of that you brought when you started the department here. But how did you get interested in that?

When I went to the NCI, my first day there, they took me on a tour of the department and we walked by a room with a locked door. I said, what's in there? And they said, oh that's our CT scanner, but we never use it. So I said, well, let me see it.

And, you know, this was an EMI 5005. This was one of the early scanners. It was a body scanner, but it had a fairly small aperture. You could not get a lot of Americans into this machine. And I said, well, why don't we start scanning some patients. As long as-- does anybody know how to use this thing? Yes? OK, let's start scanning some patients.

And it didn't take long to recognize that this was a machine that was almost tailor made to do radiation therapy planning. It gave you the contour of the patient's surface. It showed you the inside of the patient. It showed you the tumor in most settings.

And remember, at that time we were facing radiotherapy treatment planning on plain x-rays taken on the simulator where, for example, when you treated the prostate, you never saw the prostate. You knew where the pubis was. You knew where the rectum was. You knew where the bladder was. And you knew the prostate had to be in there somewhere, but you never saw it.

When we started to CT scan the pelvis in prostate cancer patients, there was the prostate in all its anatomic glory. And so we began to plan on this. And then it became pretty clear that if you took these slices and stacked them back up, like if you took a loaf of bread and it was laying out on the table as individual slices and stacked the slices back up, you could rebuild the three dimensional picture of the loaf.

We decided that that might be a good thing to do with CT scans. And that's when I went to Michigan, and that's when we brought together some terrific physicists and brilliant programmers and spent a lot of money on a roomful of computers and began to do three dimensional reconstruction. And that led to a transformation in radiation therapy from a two dimensional specialty to a three dimensional specialty.

And you could start firing at the tumor from cross sections from different directions. We didn't have to be in the actual plane, et cetera, et cetera, et cetera. And then we put a multi-leaf on the aperture, and so you could shape the field in real time. And it just went from there.

So I have to tell you, when I was a first year fellow at Sidney Farber Cancer Institute, and I saw a patient who had received chest wall radiation-- not at our institution, by the way, not even in Massachusetts. She'd come from one of the other states. And basically, they had just stood her up in front of the machine and turned it on, as far as I could see.

And the amount of normal tissue damage that she had suffered from this was incredible. And I called your friend, Jay Harris, and said, is this what we do here? He said, no way. Had me come down-- he showed me the beginnings of their CT planning and that sort of thing. I didn't know [INAUDIBLE] at the time, but then I learned later, mostly because of your doing.

There were a number of outstanding institutions that were involved in this, and a lot of the inspiration for this came from some of the work that Sam Hellman was writing about, in terms of how we might better use imaging. So it was a team effort across the whole specialty.

By the way, you bring up Dr. Hellman. We just lost Eli Glatstein in the last few months. I'll give you an opportunity to say some nice things about him. I know that you worked with him, and he was a giant in the field.

The reason I was attracted down to the NCI is that this little short pudgy guy, Eli Glatstein, was recruited from Stanford by Vince Devita to come and run the radiation oncology branch. It was a pretty interesting time. There were five of us with Eli. All five of us became department chairs after our time at the NCI.

He was just a phenomenal individual. He gave you a lot of rope. You could either hang yourself, or you could do the work you wanted to do. And we accomplished a lot.

The other thing that I remember-- so I went to the NCI 1978. 1980, Eli said to me-- he handed me a piece of paper. I said, what's this? He says, it's an application form to join ASCO. You need to join ASCO.

So I said, OK. That's not typically what radiation oncologists do, but I'll join. He sponsored me. And then he said, I'm going to see if I can't get you on a committee. And he did. I was on early Grants Award Committee. We handed out five or six young investigator grants.

And I became chair of that committee. And then they said, well, you know, you did a nice job. We're going to put you on another committee, and way led to way. It was entirely because of Eli that I got introduced to ASCO and became such an important part of my life.

He was a giant and will be sorely missed by all of us. And that's a perfect segue into my last question, which is changing gears completely, and that is your career at ASCO. Give us some ideas of what ASCO was like in the late 70s and how it has evolved-- principally, I mean, I know that's a whole hour long discussion, but I think you've had such a huge footprint in the society-- and what you saw changed, and the important changes.

You know, ASCO was founded in 1964. There were no oncologists in 1964. There were doctors who were treating cancer-- some of them with surgery, some of them with radiation, some of them with these very early, highly toxic drugs. And so the society was formed.

And it specifically says, when you read the early writings about this by the founders, that this was not a society of what they called chemotherapeutists. It was a society of physicians who wanted to treat cancer. They brought together all of the clinical specialties.

I like to joke that the most interesting thing is that the medical oncologists forgot to found the American Society of Medical Oncology. They're the only specialty in medicine that doesn't have a specifically focused society just for them. They used ASCO, and to this day, it remains that way.

And so I got involved. And the leaders of ASCO in the 70s and 80s and into the 90s, espousing how wonderful their multidisciplinary work was. And they used to have annual member meetings at the ASCO annual meeting. And the board would sit up on the dais, and the peanut gallery would ask questions.

So I raised my hand, and I walked to the microphone, and I said, you know, it's great how you extol the multidisciplinary nature of the society. But I look at the dais, and I see the 12 members of the board of ASCO, and they're all medical oncologists. You are not practicing what you preach.

And I sat down, and they mumbled a few things. And then the next thing I knew, darn it, they created board slots for a surgeon, a radiation oncologist, and a pediatric oncologist. And then they said, all right, big mouth, now that you held our feet to the fire, we're going to run you for the board. And I did get elected to the board, and then, eventually, got elected president.

And then when they needed a CEO in 2006, they asked me if I was interested, and I interviewed for the job and then moved to Washington and then Alexandria and did that for 10 years. It was really-- you know, I say that I have been involved with two great organizations during my career-- the University of Michigan Medical School, and the American Society of Clinical Oncology. And to have the privilege of leading both of those organizations was just truly amazing.

Well, there are many more things we could talk about, but for our listeners, you should know there's an Allen Lichter Visionary Leadership Award and Lectureship held at every annual meeting now. And for those of you who attend meetings at our headquarters in Alexandria, you'll notice you're sitting in the Allen S. Lichter conference center.

Those weren't done by accident, by the way. They were done because of my guest today and all of the contributions he's made, not just oncology, frankly, but in my opinion, to medicine in general. As a dean, I know many of the things you've done, which we don't have time to get into.

So on behalf of our listeners, and behalf of myself, and behalf of all the patients who have benefited through your work through the years, thanks so much, Allen. [INAUDIBLE]

Dan, it was great being with you. Thanks for talking to me.

Until next time, thank you for listening to this JCO's Cancer Stories-- The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts, or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories-- The Art of Oncology podcast is just one of ASCO's many podcasts. You can find all the shows at podcast.asco.org.