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Scroll down this page to explore this interview in several ways.

An Interview Profile summarizes this individual’s role, specialization, and contributions to MD Anderson.

A Table of Contents shows the range of topics covered in each interview session: each chapter title links to a chapter summary.

Chapter Summaries describe the specific topics treated in each section; each summary links to the corresponding recording so you can listen to the chapter.

Here is a link to the full transcript so you may browse and search. (link)

 

 

 

 

 

Interview Profile

 

Submitted: 2013

 

Interview Information:

Three interview sessions: 3 January 2013, 12 April 2013, 23 April 2013
Total approximate duration: 5 hours 30 minutes
Interviewer: Tacey A. Rosolowski, Ph.D.
First interviewed in 2004, Lesley Brunet.

 

To supporting materials, please contact:

Javier Garza, MSIS, jjgarza@mdanderson.org

About the Interview Subject:

Radiation oncologist, James A. Cox (b. 16 July 1938, West Virginia) came to MD Anderson in 1988 to serve as Vice President of Patient Care and Physician-in-Chief (’88-’92).  He is a Professor in the Department of Radiation Oncology.  Dr. Cox has been instrumental in advancing the design of clinical trials and in establishing many trials to demonstrate the effectiveness of radiation therapy in combination with chemotherapy and surgery.  Through work conducted both at MD Anderson and with the Radiation Therapy Oncology Group (RTOG), his research has focused on many types of cancer, including lung cancer, lymphomas, esophageal and prostate cancer.  Since 1998, Dr. Cox has been active in developing proton therapy at MD Anderson and opening the Proton Therapy Center in 2006.  He has since worked on trials to compare proton therapy with conventional radiation treatments.  He is also demonstrating the effectiveness of this therapy in reducing patients’ side effects, tumor size, and survival. 

Dr. Cox served as Head of the Division of Radiation Oncology from 1995 to 2010.

 

Major Topics Covered:

Personal and educational background

MD Anderson research culture

Clinical trials: controversy over, ethical issues;

The Radiation Oncology Group

Radiation oncology at MD Anderson; the Division of Radiation Oncology

Research: cancers, body areas, design of clinical trials; effectiveness of proton therapy

The Proton Therapy Center: history of

Regional care centers; sister institutions

MD Anderson presidents and views on growth 

 

A note on transcription and the transcript:

This interview had been transcribed according to oral history best practices to preserve the conversational quality of spoken language (rather than editing it to written standards).

The interview subject has been given the opportunity to review the transcript and make changes: any substantial departures from the audio file are indicated with brackets [ ].

In addition, the Archives may have redacted portions of the transcript and audio file in compliance with HIPAA and/or interview subject requests.

The views expressed in this interview are solely the perspective of the interview subject. They are not to be interpreted as the official view of any other individual or of The University of Texas MD Anderson Cancer Center.


Table of Contents

 

Interview Session One: 3 January 2013

 

Early Memories and a Visual Mind
Chapter 01 / Personal Background

 

Clinical Research in MD Anderson Culture; The Radiation Therapy Oncology Group and Specific Clinical Trials
Chapter 02 / The Researcher

 

An Education Leading to Clinical Study
Chapter 03 / Educational Path

 

Challenges of Clinical Trials: Informed Consent
Chapter 04 / The Researcher

 

The Radiation Therapy Oncology Group
Chapter 05 / The Administrator

 

Radiation Oncology at MD Anderson
Chapter 06 / Overview

 

Leadership Experience
Chapter 07 / The Administrator

 

Interview Session Two: 12 April 2013

 

Early Clinical Studies
Chapter 08 / The Researcher

 

Research Focused on a Range of Body Areas
Chapter 09 / The Researcher

 

Lung Cancer and Uncommon Lymphomas
Chapter 10 / The Researcher

 

Documenting the Benefits of Proton Therapy
Chapter 11 / The Researcher

 

Multidisciplinary Conferences at MD Anderson Lead to More Effective Treatment Plans
Chapter 12 / The Researcher

 

Interview Session Three: 23 April 2013

 

The Regional Care Centers and Sister Institutions

Chapter 13 / Building the Institution

 

Head of the Department and the Division of Radiation Oncology

Chapter 14 / The Administrator

 

The Division of Radiation Oncology

Chapter 15 / An Institutional Unit

 

The Division of Radiation Oncology—Strategic Planning and Growth

Chapter 16 / An Institutional Unit

 

The Proton Therapy Center

Chapter 17 / An Institutional Unit

 

Research at the Proton Therapy Center; the Future

Chapter 18 / An Institutional Unit

 

The MD Anderson Presidents

Chapter 19 / Key MD Anderson Figures

 

Contributions to MD Anderson

Chapter 20 / View on Career and Accomplishments

 


Chapter Summaries

 

 

Interview Session One: 3 January 2013 (listen/read)

 

​Chapter 00A
Interview Identifier (listen/read)

 

Chapter 01 (Personal Background)
Early Memories and a Visual Mind (listen/read)

 

Topics Covered

  • Personal Background
  • Character, Values, Beliefs, Talents
  • Funny Stories
  • Portraits

In this Chapter, Dr. Cox talks about childhood memories of West Virginia and Dayton, Ohio, where he recalls blackouts during WWII and his parent’s Victory Garden.  He recalls his early inclination for the sciences and talks about the strongly visual field he ultimately selected as well as some of the visual qualities of his own thinking.  In addition to appreciating Early Renaissance art and Gothic architecture, he admits that he loves women’s fashion, particularly enjoying features of design and proportion. His visual sensibilities focus on structure, he notes.

 

Chapter 02 (The Researcher)
Clinical Research in MD Anderson Culture: The Radiation Therapy Oncology Group; and Specific Clinical Trials (listen/read)

 

Topics Covered

  • The Researcher
  • The Clinician
  • MD Anderson Culture
  • Controversy
  • Research, Care, and Education in Transition
  • MD Anderson History
  • Institutional Politics
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care
  • Critical Perspectives on MD Anderson
  • Professional Practice
  • The Professional at Work
  • On Research and Researchers
  • Research, Care, and Education

In this Chapter, Dr. Cox talks about his focus on clinical research.  He begins by explaining why clinical research has been less appreciated at MD Anderson than laboratory or translational research.  (As an instance of how clinical research can transform a field, he cites studies comparing the effectiveness radiation therapy vs. chemotherapy plus radiation.)  Most clinical studies of radiation therapies were started by the Radiation Therapy Oncology Group (RTOG), and MD Anderson faculty was an important participant in these studies.  Dr. Cox sketches the history of the RTOG, explaining its central role in organizing studies and gathering research statistics for twenty institutions.  Dr. Cox explains that he viewed the RTOG as his laboratory, during his years of administrative service, and he served as senior investigator, though others were more hands-on participants. 

Dr. Cox reflects on his skills in research design, offering as an example these skills, ideas he summarized in “Design and Implementation of Ion Beam Therapy,” a chapter in the book, Ion Beam Therapy: Fundamental Technology, Clinical Applications (Springer, 2011).  He explains what is meant by good research design and lists several factors that contribute to a successful clinical trial. 

Dr. Cox then compares laboratory to clinical studies and notes that, in general, laboratory researchers are more directive in trials, while clinical researchers tend to be more cooperative.  He says that there is a give and take in clinical research that would not be comfortable for most senior laboratory investigators

 

Chapter 03 (Educational Path)
An Education Leading to Clinical Study (listen/read)

 

Topics Covered

  • The Researcher
  • Personal Background
  • Professional Path
  • Inspirations to Practice Science/Medicine
  • Influences from People and Life Experiences
  • Evolution of Career
  • The Researcher
  • Formative Experiences

Here Dr. Cox explains the path that led him to clinical work in radiology.  Dr. Cox became interested in cancer during his second year in medical school, while taking pathology, and he describes his first autopsy of an individual who had died from stomach cancer.  He was fascinated by the cellular destruction and compares it to being “fascinated with a fire.” 

Dr. Cox next talks about the curriculum he followed at the University of Rochester School of Medicine and Dentistry (Rochester, NY) and his year at the Penrose Cancer Hospital in Colorado Springs, where he saw how helpful radiation therapy could be in combination with surgery.  This convinced him to return to U of R to train with Dr. Juan del Regato in radiation oncology. He talks about his shift to the residency program at Penrose, where he became involved in a B-04 trial on breast cancer run by Dr. Bernie Fisher.

 

Chapter 04 (The Researcher)
Challenges of Clinical Trials: Informed Consent (listen/read)

 

Topics Covered

  • Institutional Processes
  • Institutional Mission and Values
  • Ethics
  • Ethics
  • Professional Values, Ethics, Purpose
  • Professional Practice
  • The Professional at Work
  • The Administrator
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care

Dr. Cox explains that, while in his residency at Penrose, he became interested in the issues involved when obtaining the collaboration of patients in a study.  He then discusses informed consent at length, describing the issues involved and making reference to the Tuskegee syphilis case as a summary of the ethical issues at play.  To demonstrate his ideas about informed consent, Dr. Cox describes a trial on cancer of the esophagus.  While patients treated with radiation or surgery had some results, pairing chemotherapy with radiation therapy has such profound results that they “couldn’t ethically continue the trial.” 

Dr. Cox explains that the Data Safety Monitoring Committee makes recommendations to stop any trial that is not ethically sound.  Dr. Cox talks about several cases in which trials were conducted without any informed consent, and talks about the ethical and philosophical issues involved.  He notes that informed consent was not a prominent issue until the 1970s, though now Institutional Review Boards are “out of hand.”

 

Chapter 05 (The Administrator)
The Radiation Therapy Oncology Group (listen/read)

 

Topics Covered

  • The Researcher
  • Overview
  • Definitions, Explanations, Translations
  • Understanding Cancer, the History of Science, Cancer Research  
  • Devices, Drugs, Procedures
  • Activities Outside Institution
  • Beyond the Institution
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care
  • Business of Research

Dr. Cox begins this Chapter with a brief history of the ROTG, founded in the late sixties, after several individuals running clinical trials created centers to gather statistics and manage trial operations.  In the late sixties, the NCI gave instructions and funds to draws the disparate centers together.  Dr. Cox became involved in 1978 or ’79 and soon became vice chair for research strategy.  He lists the areas of research the ROTG followehypoxic desensitizers and hypothermia; chemotherapy; and fractionization. He explains that he evaluated the results of studies.  He speaks about an MD Anderson study treating cancer of the cervix with a combination of radiation and chemo.

Dr. Cox describes how technologies of radiation therapy have evolved and how this evolution has been influenced by the NCI’s interest.  (Dr. Cox feels the NCI has a prejudice in favor of chemotherapy, thus making less money available for radiation and surgery, even today.)

 

Chapter 06 (Overview)
Radiation Oncology at MD Anderson (listen/read)

 

Topics Covered

  • Overview
  • Definitions, Explanations, Translations
  • The Researcher
  • The Clinician
  • Information for Patients and the Public         
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Controversy
  • Portraits

           

Dr. Cox briefly describes how radiation is used to kill cancer cells and mentions a few of the first studies to investigate its effects.

Dr. Cox then talks about the Dr. Gilbert Fletcher’s role in developing radiation therapy and its use at MD Anderson.  He discusses the challenges Dr. Fletcher faced during this time when surgeons believed that the best treatment was to surgically remove cancer.  Dr. Fletcher eventually convinced the MD Anderson community that radiation therapy could be successfully combined with surgery for positive patient outcomes.  Dr. Cox talks about the attitudes of several surgeons: Dr. William MacComb, Dr. Richard Jesse, and Dr. J. Ballantyne.

Dr. Cox describes Dr. Fletcher’s strong will, his unique form of genius, and his honesty even about toxicities of radiation levels.  He notes that MD Anderson people “had great affection for him.”

 

Chapter 07 (The Administrator)
Leadership Experience (listen/read)

 

Topics Covered

  • Professional Values, Ethics, Purpose
  • MD Anderson Culture
  • The MD Anderson Brand, Reputation
  • Military Service
  • Professional Path
  • MD Anderson Culture
  • MD Anderson Mission and Values

Dr. Cox reviews the experiences that led to the many leadership roles he has held during his career. He begins by noting that when he entered the military under the Berry Plan, there was a shortage of career people in radiation oncology and, at the age of thirty two, he became Head of the Radiation Oncology Service at Walter Reed Hospital, though he had served in administrative roles in smaller arenas.

Dr. Cox offers comments on the qualities of MD Anderson and why he has stayed at the institution so many years, noting that it offers “the best cancer care anybody can get.”

 

Interview Session Two: 12 April 2013 (listen/read)

 

Chapter 00B
Interview Identifier (listen/read)

 

 

Chapter 08 (The Researcher)
Early Clinical Studies (listen/read)

Topics Covered

  • The Researcher
  • Overview
  • Definitions, Explanations, Translations
  • MD Anderson Culture
  • On Research and Researchers
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care
  • Professional Practice
  • Patients, Treatment, Survivors
  • Healing, Hope, and the Promise of Research
  • On Research and Researchers

Dr. Cox begins the discussion of his research career with his residency.  He explains that hypotheses in clinical research derive from the care of patients.  Survival is the “immutable endpoint” that determines whether a treatment is successful, but survival does not tell you why a treatment is successful.  Early in his career, Dr. Cox developed an approach to determine why treatments succeed, though he observes that many of the questions he asks about patterns of failure are irrelevant from other perspectives (e.g. medical oncology).

Dr. Cox describes studies done in the 70s with lung cancer to determine why treatments failed.  When he became involved in the Radiation Therapy Oncology Group (RTOG) his style of designing studies influenced the group.  All of the ROTG studies during his ten years with the group used survival as the endpoint.  Returning to his residency years, Dr. Cox talks about his studies of cancer of the breast and cervix.  Dr. Cox notes that his view of clinical trials was strongly influenced by his mentor, Dr. Juan del Regato.

 

Chapter 09 (The Researcher)
Research Focused on a Range of Body Areas 
(listen/read)

Topics Covered

  • The Administrator
  • The Researcher
  • Professional Practice
  • The Professional at Work
  • Overview
  • Definitions, Explanations, Translations
  • On Research and Researchers
  • The History of Health Care, Patient Care

Dr. Cox summarizes the range of research he administered on fractionation while involved with the RTOG: lung cancer, head and neck cancers, cervix and brain.  He also discusses the key importance of adding chemotherapy to patients’ treatment regimens to get the best results. 

Dr. Cox next explains that while he was Chair of the RTOG he was able to move combined treatments forward in the NCI and other organizations.  He explains why the NCI is biased toward chemotherapy.  He also comments on NCI politics is influencing how gynecologic cancers will be investigated.

Dr. Cox next comments on other cancer studies he oversaw during the period when he was Vice President for Patient Care under Dr. Charles LeMaistre [Oral History Interview]. 

 

Chapter 10 (The Researcher)
Lung Cancer and Uncommon Lymphomas (listen/read)

Topics Covered

  • The Researcher
  • Discovery and Success
  • Patients
  • Patients, Treatment, Survivors
  • Healing, Hope, and the Promise of Research
  • The Scientist at Work
  • Overview
  • Definitions, Explanations, Translations
  • Devices, Drugs, Procedures
  • Understanding Cancer, the History of Science, Cancer Research

Dr. Cox describes the research he undertook when left the position of Vice President for Patient Care and returned to his full-time faculty position, beginning with his new role as “the lymphoma person.”  He explains the lymphoma trials that combined radiation and chemotherapy and that resulted in a successful response as well as a genetic translocation that will give rise to a genetic marker.  He notes studies of radiation and chemotherapy in uncommon lymphomas.

Dr. Cox next explains how he was involved in teasing out the natural history of unusual lymphomas to understand them as distinct cancers.  He uses testicular lymphoma as an example, describing how this cancer is treated with both radiation and chemotherapy.  Patients with this cancer were rarely cured before this approach was developed with this treatment, the cancer is eliminated in 50% of cases.  Dr. Cox conducted this work between 1992 and 2000.

Dr. Cox then explains that he always saw cancer as more than one disease: he explains what it means to understand this at the molecular and cytogenetic level, eventually resulting in diagnoses being rendered by biochemical, molecular or genetic findings.  He notes that his work at MD Anderson was tightly linked to his work with the RTOG.  He continues, explaining that he returned to work with lung cancer in the late nineties.  He mentions that lung cancer still has the highest death rate among all cancers, though mortality from lymphoma is increasing and Dr. Cox explains this is largely attributed to environmental chemicals.  He explains the “modest progress” that he and the lung group at MD Anderson have made combining drugs, radiation, and surgery.  Dr. Cox explains his work using prophylactic cranial irradiation to decrease the risk of brain metastasis from small cell carcinoma and notes that studies were also done to determine if this irradiation increased the risk for neuropsychological complications.  

 

Chapter 11 (The Researcher)
Documenting the Benefits of Proton Therapy (listen/read)

 

Topics Covered

  • The Researcher
  • Overview
  • Definitions, Explanations, Translations
  • Devices, Drugs, Procedures
  • Healing, Hope, and the Promise of Research           
  • Discovery and Success
  • On Research and Researchers

Dr. Cox explains a difficulty with proton therapy: the advantages can be seen on paper and modeled by computer, but “we don’t yet have the evidence that people want.”  He describes the kinds of treatment advantages that proton therapy provides, particularly the reduction of toxicity.

Dr. Cox explains a study showing that proton therapy avoided toxicity in treatment of 15 patients with cancer of the tongue, then describes the next step of this research: to demonstrate the differences between two dimensional and three dimensional, conformational therapy.  He explains that proton therapy offers these advantages because the beam can be targeted to hit very isolated structures.

 

Chapter 12 (The Researcher)
Multidisciplinary Conferences at MD Anderson Lead to More Effective Treatment Plans (listen/read)

Topics Covered

  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Institutional Mission and Values
  • Institutional Processes
  • MD Anderson Culture
  • The Clinician
  • Patients
  • On Care

Dr. Cox notes that proton therapy treatment focuses heavily on lung cancer and lists other cancers being studied, explaining that the study of esophageal cancer puts all the modalities together.  This leads Dr. Cox to talk about the Tumor Board and Thoracic Conference –weekly multi-disciplinary meetings where specialists from different disciplines discuss cases and treatment options for patients.  He explains that surgical techniques have improved so much that surgery is now also being integrated into the treatment modalities.  He then describes the history of the conferences, which go back to the earliest years of MD Anderson and have proliferated through the entire institution.  Dr. Cox describes how these meetings educated everyone, e.g. by having specialists from a wide range of fields talk to a radiologist, a pathologist, or someone conducting research on molecular markers.  (He acknowledges that attendees are self-selected).

Dr. Cox affirms that the multi-disciplinary meetings have affected the culture of MD Anderson: Multi-disciplinary care is a hallmark of MD Anderson care.  He explains that that the salary pool on which compensation is based at the institution insures that there is no economic incentive behind treatment decisions.  “We function as a team” for all patients.

Dr. Cox explains that not everyone embraces multi-disciplinarity and that, in the past, MD Anderson faculty who worked on the disease sites tended to talk only to one another.  When he brought in the RTOG, the multi-disciplinary focus has a definite impact on the institution.  Dr. Cox closes this section by noting some other multi-disciplinary organizations and by explaining that MD Anderson may not be helped by some of the NCI’s recent decisions on how to restructure cooperative groups.

 

Interview Session Three: 23 April 2013 (listen/read)

 

Chapter 00C
Interview Identifier (listen/read)

 

 

Chapter 13 (Building the Institution)
The Regional Care Centers and Sister Institutions (listen/read)

Topics Covered

  • Beyond the Institution
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Fiscal Realities in Healthcare
  • The MD Anderson Brand, Reputation
  • Institutional Mission and Values
  • Institutional Processes
  • Devices, Drugs, Procedures
  • Critical Perspectives on MD Anderson
  • Patients
  • MD Anderson History

Dr. Cox gives an overview of issues involved in setting up regional care centers and sister institutions. He begins by noting that Radiation Oncology backed away from involvement in MD Anderson-Banner because of concerns that MD Anderson would have no hand in quality control for patient care.  He next talks about setting up the first regional care center in Bellaire (1998/99): the regional care centers were originally established to provide radiation therapy. 

Dr. Cox explains that for thirty years the treatment plans for all MD Anderson patients are created by way of a peer-review process that insures high quality care and results.

Dr. Cox next lists some other satellite centers and describes the lessons learned about recruitment and competition from within the communities.  He concludes that, in general, the quality of the care centers has stood the test of time and paved the way for medical oncology and laboratory services to be offered at the sites as well.  He summarizes the convenience that the care centers offer to patients. Next he describes the financial and administrative relationships between the care centers and MD Anderson.  Dr. Cox then comments on the sister institutions in Orlando, Florida and Madrid, Spain, noting the importance of quality control and oversight of faculty for the success of such initiatives.

 

Chapter 14 (The Administrator)

Head of the Department and Division of Radiation Oncology (listen/read)

Topics Covered

  • The Administrator
  • Professional Practice
  • The Professional at Work
  • Building/Transforming the Institution
  • Definitions, Explanations, Translations
  • Technology and R&D 

Dr. Cox explains his dual role as Head of the Department and Division of Radiation Oncology, first discussion his Departmental goals of expanding the faculty and creating a strong and highly specialized department. He also notes that the department was technologically out of date when he took over, and he explains the upgrades he introducea modern system for treatment planning, a CT simulator, and the transition from 2-D to 3-D treatments.  The department next combined 3-D treatment planning with computer assisted treatment planning to refine patient protocols.  Dr. Cox explains how the Department established a dosimetry school as the program grew.  The Department next developed intensity modulated radiation therapy.

 

Chapter 15 (An Institutional Unit)
The Division of Radiation Oncology (listen/read)

Topics Covered

  • Controversy
  • Institutional Politics
  • Obstacles, Challenges
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Growth and/or Change
  • Leadership

Dr. Cox describes challenges that he faced in developing the Division of Radiation Oncology.  a change in attitude toward buying new equipment greatly helped move the Division forward. He describes a communication gap that existed with Ken Hogstrum, Chair of the Department of Radiation Physics (who focused on education over patient care and research), a problem resolved when Dr. Cox removed him.  Dr. Cox describes some of the changes that took place as Dr. Hogstrum and a number of his supporters left, emphasizing that the individuals recruited to replace them shared his goals of developing the technological base of the Division as well as the ‘research portfolio,’  which went from effectively no research to over a million dollars of research funding.  Dr. Cox ends this Chapter with comments on his administrative approach.

 

Chapter 16 (An Institutional Unit)
The Division of Radiation Oncology—Strategic Planning and Growth (listen/read)

Topics Covered

  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Growth and/or Change
  • Institutional Processes
  • MD Anderson Culture
  • Leadership

Dr. Cox summarizes the growth of the division between ’97 and 2007, when he retirefrom seventeen to fifty full-time faculty and from 240 to 600 patients seen per day.  He notes that the Division made a lot of money for the institution and achieved a high level of credibility from good planning.  He sketches the yearly strategic planning meetings the Division held each year, noting that the main goal of all planning was to ensure that the Division was the best in all areas.  He explains that a second goal was to create a supportive environment for everyone, and believes that they were successful in achieving that.  At the end of this Chapter, Dr. Cox offers reasons for the separation of Departments within the Division of Radiation Oncology.

 

Chapter 17 (An Institutional Unit)
The Proton Therapy Center (listen/read)

Topics Covered

  • Overview
  • Definitions, Explanations, Translations
  • The Researcher
  • The Clinician
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Growth and/or Change
  • Obstacles, Challenges
  • The Business of MD Anderson
  • Discovery and Success
  • MD Anderson Mission and Values
  • Technology and R&D 
  • Devices, Drugs, Procedures
  • Industry Partnerships
  • Beyond the Institution

Dr. Cox notes that the use of intensity-modulated radiation therapy was a starting point for thinking about how advanced technology could be used to concentrate radiation beams on a tumor.  The idea to construct a Proton Therapy Center began in 1998, when Dr. Cox spoke to John Mendelsohn about the possibility, and Dr. Mendelsohn then went to the UT System.  Though the University of Texas System would not fund it, Leon Leach [Oral History Interview, Dan Fontaine and others were enthusiastic and looked for other funding sources.  Dr. Cox explains what created the enthusiasm for proton therapy, given the absence of any studies to confirm its benefits or advantages over other types of therapy.  Dr. Cox believes that his credibility in the institution spurred the administration to embrace the idea.

Dr. Cox next sketches the partnership between public and private sources created to fund the initiative, with Hitachi as the vendor.  He notes that his wife, Dr. Ritsuko Komaki, served as a mediator to help MD Anderson people deal with cross-cultural issues that arose during negotiations with Hitachi.  He then explains what they requested in the design of the proton source and the challenges that arose as Hitachi dealt with their specifications, noting in particular how difficult it was to get three computer systems to work together.

 

Chapter 18 (An Institutional Unit)
Research at the Proton Therapy Center; the Future (listen/read)

Topics Covered

  • Overview
  • Definitions, Explanations, Translations
  • The Researcher
  • The Clinician
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Growth and/or Change
  • Obstacles, Challenges
  • The Business of MD Anderson
  • Discovery and Success
  • Technology and R&D 
  • Devices, Drugs, Procedures
  • Beyond the Institution
  • Controversy
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care
  • Patients
  • Discovery and Success

Dr. Cox notes that the Proton Therapy Center project was started in May 2003.  Since 2006, when the first patient was treated, 4400 patients have been seen, with virtually all patients involved in research studies.  Dr. Cox explains that there is a master protocol for studying increasing dosages and the degree to which normal tissue is spared.  Specific protocols have been created to compare proton therapy and intensity-modulated radiation therapy on non-small cell lung cancer and for cancer of the esophagus.  Next Dr. Cos explains the reasons why individuals question the value of proton therapy. Some are anti-technology.  Some admit that it looks valuable on paper, but question whether the effects are real; some say that, in principle, there is value, but there are too many technical uncertainties to warrant going ahead with it.  Others accurately state that no randomized trials have been conducted to definitely prove that proton therapy is superior to x-rays.  These studies are underway now.  Dr. Cox says that the main benefits are fewer side effects for the patient.  In some cases physicians are able to deliver higher doses of radiation, which may result in better tumor control.  Dr. Cox says that all of these objections make it difficult to get papers accepted in journals so good results can be demonstrated.

Dr. Cox affirms that the Proton Therapy Center has been very successful.  The Center is also in the process of expanding uses for patients, so proton therapy will be part of treatment for many diseases and stages of disease.  He anticipates that eventually 20% of MD Anderson patients will be treated with proton therapy.  He explains how patients are identified for proton therapy (curative uses, rather than palliative).  The Proton Therapy Center will be upgrading certain functions, taking advantages of developments Hitachi has recently made.

Dr. Cox observes that the regional care centers have not referred as many patients for proton therapy as he would have expected and that they would like to treat even more patients.  As the Chapter closes, explains that the original investors pulled out of the project and MD Anderson owns 51% of the interest in the Center.

 

Chapter 19 (Key MD Anderson Figures)
The MD Anderson Presidents (listen/read)

Topics Covered

  • Critical Perspectives on MD Anderson
  • Portraits
  • Personal Background
  • MD Anderson in the Future

Dr. Cox begins with observations about Charles LeMaistre, who recruited him to serve as Vice President of Patient Care, “a good title, bad job,” as he says.  Cr. Cox explains that he and Dr. LeMaistre had very different orientations toward MD Anderson administration.  Dr. LeMaistre was interested in issues related to the UT System, Dr. Cox says, then explains why he believes that Dr. LeMaistre didn’t fully understand what was going on at the institution. 


Dr. Cox says that during Dr. LeMaistre’s  tenure, the institution was on the verge of greatness, but couldn’t take the next step because many faculty were “living in silos.”

Dr. Cox next talks about John Mendelsohn, who was very aware of what was going on in the institution (at least during the first years).  He then turns to Ronald DePinho, whom he admires for his grand aims and desire to change the institution in a major way.  He offers his view of the Moon Shots Program, which he sees advancing team science, though he has no expectation that is will eliminate the cancers at which the various sub-programs are aimed.

 

Chapter 20 (View on Career and Accomplishments)
Contributions to MD Anderson (listen/read)

Topics Covered

  • Contributions
  • Activities Outside Institution
  • Career and Accomplishments
  • The MD Anderson Brand, Reputation
  • The Researcher
  • Institutional Mission and Values
  • Portraits
  • Personal Reflections on MD Anderson

Dr. Cox talks about his contributions to MD Anderson: he spurred clinical research and therefore contributed to the care of patients.  Administratively he believes he helped foster collegiality across departments and division, making faculty comfortable with multi-disciplinary work styles.

Dr. Cox recalls that Gilbert Fletcher set a very high standard for radiation oncology at MD Anderson.  Dr. Cox says that he has contributed to maintaining that stature, one that differs from any other cancer center in the world.

Original Profile

Submitted by: Tacey A. Rosolowski, Ph.D.

Date revised: 3 July 2014

This interview of radiation oncologist, Dr. James A. Cox (b. 16 July 1938, West Virginia) was conducted over three sessions in the early part of 2013 (approx. duration, 5:30).  (Dr. Cox was first interviewed in 2004 by Lesley Brunet.)  Dr. Cox came to MD Anderson in 1988 to serve as Vice President of Patient Care and Physician-in-Chief (’88-’92).  From ’95 to 2010 he served as Head of the Division of Radiation Oncology.  He is also a Professor in the Department of Radiation Oncology and holds the Hubert L. and Olive Stringer Distinguished Chair in Oncology in Honor of Sue Gribble Stringer.   Since 1998, Dr. Cox has been active in developing proton therapy at MD Anderson, and the sessions take place in Dr. Cox’s office at the Proton Therapy Center located south of MD Anderson’s main campus, on Old Spanish Trail.  Tacey A. Rosolowski, Ph.D. serves as interviewer.

Dr. Cox received his AB in Chemistry and Biology in 1960 from Kenyon College, Gambier, OH, and in 1965 was awarded his M.D. from the University of Rochester School of Medicine and Dentistry, Rochester, NY.  He undertook Fellowships in Clinical Oncology and Therapeutic Radiology at Penrose Cancer Hospital, Colorado Springs, CO (‘63-‘64), then interned at the University of Chicago Pritzker School of Medicine in Chicago, Illinois (’66-’69).  A final clinical fellowship in Therapeutic Radiology took him to the Institut Gustave-Roussy in Villejuif, France (’69-’70).  In 1974, after holding serving as assistant professor on the faculty in Radiology at Georgetown University Hospital in Washington, D.C., Dr. Cox took up a position as Associate Professor in teh Department of Radiology at the Medical College of Wisconsin, Milwaukee, Wisconsin. He became a full professor in 1977.  In 1985, Dr. Cox joined the Department of Radiation Oncology at Columbia University College of Physicians and Surgeons in New York, where he stayed until 1988, when Dr. Charles LeMaistre recruited him to come to MD Anderson to serve as Vice President of Patient Care and Physician-in-Chief (’88-’92).  He also served as Chair of the Department of Radiation Oncology and Head of the Division of Radiation Oncology (’95-2010).  Through work conducted both at MD Anderson and with the Radiation Therapy Oncology Group (RTOG), Dr. Cox has been instrumental in advancing the design of clinical trials and in establishing many trials to demonstrate the effectiveness of radiation therapy in combination with chemotherapy and surgery.  His research has focused on many types of cancer, including lung cancer, lymphomas, esophageal and prostate cancer.  Since the opening of the Proton Therapy Center in 2006, he has worked on trials to compare proton therapy with conventional radiation treatments.  He is also demonstrating the effectiveness of this therapy in reducing patients’ side effects, tumor size, and survival. 

In this interview, Dr. Cox talks speaks at length about his commitment to clinical trials as a means of improving patient care, covering many issues such as biases against clinical trials, ethical dimensions of such studies, and the specific studies he has conducted with conventional and with proton therapy.  He also gives insight into the development of the Department and Division of Radiation Oncology, which was technologically behind the times when he assumed leadership.  He discusses the development of the Proton Therapy Center and the role of radiation oncology in establishing regional care centers that have expanded MD Anderson’s reach.