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Hortobagyi (Gabriel), M.D., Oral History Interview: Home

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Interview Profile

 

Submitted: 3 July 2014

 

Interview Information:

Five interview sessions: 30 November 2012, 7 January 2013, 23 January 2013, 28 January 2013, 15 March 2013
Total approximate duration: 8 hours 45 minutes
Interviewer: Tacey A. Rosolowski, Ph.D.

 

For supplementary materials:

Please contact, the Historical Resources Center, Research Medical Library:
Javier Garza, MSIS, jjgarza@mdanderson.org

 

 

About the Interview Subject:

Gabriel Hortobagyi, M.D. (b. summer 1946, Sarvoc, Hungary) came to MD Anderson in 1974 as a Fellow in the Department of Developmental Therapeutics.  He joined the faculty of the Breast Medical Service in 1976.  Dr. Hortobagyi’s research has focused on multimodality and adjuvant and neoadjuvant treatments for breast cancer, as well as personalized therapies and gene therapy.  He served as chair of the Department of Breast Medical Oncology until 2012.  He is a professor in that department and heads the Breast Cancer Research Program.  

 

Major Topics Covered:

Personal and educational background

The Department of Developmental Therapeutics; Emil J Freireich, MD

Research: FAC metastatic breast cancer, locally advanced breast cancer, LABC treatment; shift to translational research projects and gene therapy; angiogenesis blocker; 

Breast cancer treatments and service: evolution at MD Anderson

Overview of breast medical oncology: as a field; history of at MD Anderson

The Department of Breast Medical Oncology; history and evolution of at MD Anderson

The Breast Center; history of

Multi-disciplinary teams, evolution of at MD Anderson

Patient centered service, evolution of at MD Anderson

The World Summit Against Cancer

The Breast Cancer Research Group

Leadership and mentoring experiences and principles

Educating breast medical oncologists

Service to organizations and projects in the United States and abroad

Views on MD Anderson presidents

 

Regarding the Transcript and Audio Files

In accordance with oral history best practices, this transcript was intentionally created to preserve the conversational language of the interview sessions.  (Language has not been edited to conform to written prose).

The interview subject was given the opportunity to review the transcript.  Any requested editorial changes are indicated in brackets [ ], and the audio file has not correspondingly altered. 

Redactions to the transcript and audio files may have been made in response to the interview subject’s request or to eliminate personal health information in compliance with HIPAA.


 

Table of Contents

 

Interview Session One: 30 November 2012

 

A Family Escapes to Colombia
Chapter 01 / Personal Background

 

Becoming a Doctor
Chapter 02 / Educational Path

 

A Small Town Offers Good Training
Chapter 03 / Professional Path

 

Choosing to Focus on Cancer
Chapter 04 / Joining MD Anderson/Coming to Texas

  

Inspired by Dr. J Freireich
Chapter 05 / Joining MD Anderson/Coming to Texas

 

Developmental Therapeutics in 1974
Chapter 06 / An Institutional Unit

 

Building Knowledge of Breast Cancer in the Division of Medicine
Chapter 07 / An Institutional Unit

 

Interview Session Two: 7 January 2013

 

Discovering the FAC Regimen for Metastatic Breast Cancer
Chapter 08 / The Researcher

  

Treatment for Locally Advanced Breast Cancer
Chapter 09 / The Researcher

  

A Great Step for MD Anderson: Building Multidisciplinary Teams
Chapter 10 / Building the Institution

  

Adapting LABC Treatment for Stages 2 and 3 Breast Cancers
Chapter 11 / The Researcher

  

From Adriamycin to Molecularly Designed Drugs
Chapter 12 / The Researcher

  

The Breast Cancer Research Group –Bringing Together Clinicians and Basic Scientists
Chapter 13 / The Administrator

  

An Initial Translational Research Project: A Drug to Attack HER2-positive Breast Cancer
Chapter 14 / The Administrator

  

The Next Phase of Gene Therapy Research and Funding from the Breast Cancer Research Foundation
Chapter 15 /  The Researcher

 

Interview Session Three: 23 January 2013

 

Studies of Pro-Apoptotic Molecules: Translational Research and Thinking Outside the Box
Chapter 16 / The Researcher

Thinking Outside the Box to Stage the World Summit Against Cancer for a New Millennium
Chapter 17 / Professional Service beyond MD Anderson

 

Therapy to Block Angiogenesis
Chapter 18 / The Researcher

 

A New View of Breast Cancer and Research on HER2 Positive Breast Cancer
Chapter 19 / The Researcher

  

Breast Cancer Service at MD Anderson in the Late Seventies
Chapter 20 / The Administrator

 

The Breast Cancer Service: From Section to Department
Chapter 21 / Building the Institution

 

Interview Session Four: 28 January 2013

  

Creating a Patient-Centered Breast Service
Chapter 22 / MD Anderson Past

 

Regulations on Clinical Trials and New Research Projects in Breast Medical Oncology
Chapter 23 / The Administrator

 

Mentoring, Career Support, and Education in Breast Medical Oncology
Chapter 24 / The Administrator

 

Education in Breast Medical Oncology
Chapter 25 / The Administrator

 

 Interview Session Five: 15 March 2013 

 

A Brief History of Breast Medical Oncology
Chapter 26 / An Institutional Unit

 

An Overview of Research Issues
Chapter 27 / The Researcher

  

Physician Extenders and a View of the Coming Physician Shortage
Chapter 28 / Overview

 

The Evolution of Breast Medical Oncology and the Breast Center
Chapter 29 / An Institutional Unit

  

Stepping Down as Chair of Breast Medical Oncology
Chapter 30 / The Administrator

  

Contributions to International Policy Issues
Chapter 31 / Professional Service beyond MD Anderson

 

The MD Anderson Presidents
Chapter 32 / Key MD Anderson Figures

  

Fostering Collaboration and Collegiality
Chapter 33 / View on Career and Accomplishments

 


 

 

Chapter Summaries

 

 

Interview Session One: 30 November 2012 (listen/read)

 

Chapter 00A
Interview Identifier (listen/read)

 

Chapter 01 (Personal Background)
A Family Escapes to Colombia (listen/read)

 

Topics Covered

  • Personal Background
  • Character, Values, Beliefs, Talents

In this chapter Dr. Hortobagyi describes his childhood Hungary after WW II: the Hortobagyi family was interred in a concentration camp and Dr. Hortobagyi’s father sentenced to three years of hard labor for political differences with the government.  (Dr. Hortobagyi explains that he was assigned to work for a townsman collecting manure for fertilizer.)   When Josef Stalin died in 1953, the family was granted amnesty and released, and Dr. Hortobagyi next explains how in 1954 the family escaped to Colombia, first walking across the Hungarian border to Austria and settling in a refugee camp, then traveling to Genoa, Italy where the family was able to secure passage to South America as refugees from Genoa.  They arrived in Colombia on May 10th, 1957, where Dr. Hortobagyi’s father opened a business in Bogota.

 

Chapter 02 (Educational Path)
Becoming a Doctor (listen/read)

 

Topics Covered

  • Character, Values, Beliefs, Talents
  • Personal Background
  • Professional Path
  • Inspirations to Practice Science/Medicine
  • Influences from People and Life Experiences
  • Professional Values, Ethics, Purpose
  • Professional Practice
  • The Professional at Work
  • Formative Experiences

Here Dr. Hortobagyi sketches his scientific and medical education, beginning with the observation that he never thought of any other profession than medicine even as young person.

Dr. Hortobagyi observes that his mother wanted to be a doctor, but couldn’t because of limits on women’s choices at the time.  She had an impact on his own choice of profession because she gave him books on science and medicine when he was young.

Dr. Hortobagyi then notes that he had very good science teachers in middle school and, under the Colombian educational system, had made a commitment to his profession by his senior year in high school.  He talks about his medical education at the Universidad Nacional de Colombia, Bogota (M.D. conferred in 1970).  The Colombian system gave Dr. Hortobagyi an accelerated medical education.  By the time he was a college freshman, he had the equivalent of a clerkship at the University hospital –the only charity hospital in the city and the only one with a real emergency room.  It was a very busy hospital, and during his clerkship in ob/gyn, the delivery room sometimes handled a hundred babies a day. (At times there were two women in a bed.)  By the time he received his M.D., Dr. Hortobagyi had delivered 80-110 babies.  Dr. Hortobagyi also explains that surgery attracted him and that he has a “type A” personality, which is perfect for a surgeon.  He describes his emergency room rotations: 24 hours on, 12 hours off for ten weeks, a system that gave very intensive hands-on training.

 

Chapter 03 (Professional Path)
A Small Town Offers Good Training (listen/read)

 

Topics Covered

  • Character, Values, Beliefs, Talents
  • Personal Background
  • Professional Path
  • Inspirations to Practice Science/Medicine
  • Influences from People and Life Experiences
  • Evolution of Career
  • Professional Values, Ethics, Purpose
  • Professional Practice
  • The Professional at Work
  • Formative Experiences

Dr. Hortobagyi begins this chapter with a brief description of some of the rotations he completed at the University Hospital, then describes his year serving as a doctor to the small town of Pacho to repay the government for tuition support.  (Dr. Hortobagyi describes how the State assessed tuition based on need and merit: by his second year, Dr. Hortobagyi’s tuition was fully covered because of his exemplary performance.)  Pacho is located in the Andes and the tiny town has a 100-bed hospital.  Dr. Hortobagyi saw the results of violent conflict between gangs of emerald smugglers.  He describes treating the victim of a murder attempt.

Dr. Hortobagyi describes treating a woman who was continuously pregnant for eighteen years and had sixteen children.

Dr. Hortobagyi explains that the experiences in Pacho taught him that medicine is an art, not a science.  He gives other examples of caring for patients and describes the organization of the hospital in Pacho, where the generator was turned off at night so Dr. Hortobagyi had to study by candlelight. 

Dr. Hortobagyi describes how he fit into the social life of the small town and how he came to understand how this situation could be comfortable, but ultimately limiting to his professional and intellectual growth.

 

Chapter 04 (Joining MD Anderson/Coming to Texas)
Choosing to Focus on Cancer (listen/read)

 

Topics Covered

  • Character, Values, Beliefs, Talents
  • Personal Background
  • Professional Path
  • Inspirations to Practice Science/Medicine
  • Influences from People and Life Experiences
  • Discovery and Success
  • Human Stories
  • Offering Care, Compassion, Help
  • Patients
  • Cancer and Disease
  • Professional Practice
  • The Professional at Work
  • Evolution of Career
  • Formative Experiences
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care

Dr. Hortobagyi explains that once he felt the limitations of small-town medical practice, he applied for residencies in the U.S., first going to Case Western Reserve University to serve at Saint Luke’s Hospital Cleveland, Ohio (1971-’74).  (He chose Cleveland because of the large Hungarian community, where Hungarian was even spoken at the MacDonald’s.)  At this time he left surgery for a more intellectually stimulating, and began thinking about oncology.  He also notes that on recognizing the more generous resources and education available in the U.S., he had a crisis about whether or not to return to Colombia.

Dr. Hortobagyi describes how oncology was the “wild west of medicine” and offered a field where he could bring together his thinking on hematology and immunology.  He recalls that, during rounds in the early seventies at Saint Luke’s Hospital, physicians would by-pass rooms of patients with solid tumors.  He tells an anecdote about two women with advanced breast cancer who were treated only with morphine.  He found an article on chemotherapy and once he began treating women with chemotherapy, they lived.

 

Chapter 05 (Joining MD Anderson/Coming to Texas)
Inspired by Dr. J Freireich (listen/read)

 

Topics Covered

  • Portraits
  • Joining MD Anderson
  • Personal Background
  • Professional Path
  • Inspirations to Practice Science/Medicine
  • Influences from People and Life Experiences
  • Funny Stories
  • Character, Values, Beliefs, Talents

Dr. Hortobagyi recounts how, early in his second year of his residency, he attended an American Cancer Society conference in Columbus, Ohio, where he heard Dr. Emil (J) Freireich give a talk.  Dr. Hortobagyi notes that no one was talking about curing cancer in the early seventies, and he describes how inspiring it was to hear Dr. J Freireich state that he believed it was possible to cure the disease.

Dr. Hortobagyi explains that hearing this talk inspired him to apply for a fellowship at MD Anderson.  He wrote to J Freireich, who approved hired him without even speaking with him.

Dr. Hortobagyi confesses his love of automobiles and tells an anecdote about buying his first car –a blue Dodge Challenger-- with no money and no credit.

Dr. Hortobagyi tells how he loaded his belongings in his car and drove down to Houston, despite the fact that everyone told him, “Nobody goes to Texas.”  On arriving, he immediately went to the hospital and introduced himself to the head of the Breast Service, George Blumenschein.

 

Chapter 06 (An Institutional Unit)
Developmental Therapeutics in 1974 (listen/read)

 

Topics Covered

  • MD Anderson History
  • Institutional Politics
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Understanding the Institution
  • Personal background
  • Character, Values, Beliefs, Talents
  • Personal Background
  • The Researcher
  • Understanding the Institution
  • MD Anderson Culture
  • Evolution of Career
  • This is MD Anderson
  • Education at MD Anderson
  • On Research and Researchers
  • On Education

Dr. Hortobagyi talks about his fellowship in Developmental Therapeutics (DT, ’74 – ’75), beginning with a discussion of the “serious political split” between the Division of Medicine, which focused on patient care to the near-complete exclusion of research, and Developmental Therapeutics, which focused closely on research.  Though Dr. Hortobagyi was interested in breast cancer, Developmental Therapeutics had no access to breast cancer patients, handled via the Division of Medicine, and the head of the Fellowship Program, Ken McCready, assigned him to the leukemia service.  Dr. Hortobagyi describes his busy days on this service, then recounts how he was assigned to Developmental Therapeutics’ Outpatient Service.  Dr. Hortobagyi describes the influence of Anthony Burgess (head of the Outpatient Clinic) and Jeffrey Gottlieb (Chief of Solid Tumors in Developmental Therapeutics). 

Dr. Hortobagyi describes his interest in singing.  He sang with the Cleveland Symphony while living in Ohio and he auditioned for the Houston Symphony Chorale and sang with them until 1979.  He then explains that he was married in 1976 to Agnes, whom he met on a date arranged by his sister. 

Dr. Hortobagyi describes some of the research he conducted while in the Department of Developmental Therapeutics.  Dr. Jordan Gutterman recruited him to work on immunotherapy research using BCG (Bacillus Calmette-Guérin).  He describes DT as a “tornado of intellectual activity” that nonetheless left him little time for innovation and creative thinking.

Dr. Hortobagyi states that his Fellowship in Developmental Therapeutics prepared him with the basic concepts of clinical research. He describes specific lessons he learned and compares his experience with the more structured training programs offered today. 

 

Chapter 07 (An Institutional Unit)
Building Knowledge of Breast Cancer in the Division of Medicine (listen/read)

 

Topics Covered

  • The Researcher
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care
  • MD Anderson History
  • Mentoring
  • Leadership
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Discovery, Creativity and Innovation
  • Professional Practice
  • The Professional at Work
  • Personal Reflections, Memories of MD Anderson
  • MD Anderson Past
  • The Researcher
  • Understanding the Institution
  • Multi-disciplinary Approaches
  • Institutional Mission and Values
  • MD Anderson Past
  • This is MD Anderson

Dr. Hortobagyi explains that he was focused almost exclusively on breast cancer when he finished the first year of his fellowship in Developmental Therapeutics, at which point he shifted to the Division of Medicine (’75 – ’76).  He sketches his research projects: preoperative chemotherapy for breast cancer; clinical trials for adjuvant treatment of breast cancer; developing a database of breast cancer patients.  He also describes the vacuum of knowledge about breast cancer among the four leaders of the breast service at that time, noting the main question in his mind, “Who was I going to learn from?” 

Dr. Hortobagyi provides background on how George Blumenschein became head of the breast service, though he knew little about breast cancer, then provides a sketch of Blumenschein and of Nylene Eckles [M.D., Ph.D), who headed the service for many years.

Dr. Hortobagyi lists other individuals connected to the breast service who did teach him about breast cancer, despite the lack of immediate mentorship.  Dr. Hortobagyi then describes how he organized biweekly case-review meetings for everyone involved in breast cancer to “bring together the discipline.”  He explains that it took ten to fifteen years before everyone felt there was a benefit to this multi-disciplinary review of cases.  He also describes the process required to encourage specialists to open up to other specialists.  He also reflects on what enabled him to get people to work together.

 

 

Interview Session Two: 7 January 2013 (listen/read)

 

Chapter 00B
Interview Identifier (listen/read)

 

Chapter 08 (The Researcher)
Discovering the FAC Regimen for Metastatic Breast Cancer (listen/read)

 

Topics Covered

  • The Researcher
  • MD Anderson History
  • The Researcher
  • Discovery and Success
  • Patients
  • Cancer and Disease
  • This is MD Anderson
  • Understanding the Institution
  • Institutional Mission and Values
  • Healing, Hope, and the Promise of Research
  • Overview
  • Definitions, Explanations, Translations
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care

In this chapter, Dr. Hortobagyi describes his research into drug combinations for the treatment of breast cancer.  He begins by stating that no one discovers anything new in science, but rather integrates and builds on knowledge created by others.

Dr. Hortobagyi says MD Anderson was an exciting place when he arrived in 1974, and the field was progressing.  He also notes that the original pioneers were at the peaks of their careers or retiring, making room for new researchers.  He summarizes philosophical differences between the Division of Medicine and Developmental Therapeutics, noting that the latter had visionary leaders who provided a unique environment for innovation.  “Cancer was no longer a disease with no hope.“

Dr. Hortobagyi sets the context for his research by explaining that, at the time, important drugs had been discovered and needed a champion.  His mentors were looking at chemotherapeutic agents, and he put them together and explored what would become the FAC combination treatment.  Dr. Hortobagyi provides an overview of the drugs included in the regimen (Fluororacil, Adriamycin, Cyclophosphamide) and explains how they were selected and why that combination proved effective.  The FAC regimen is still one of the most effective treatments against metastatic breast cancer.

 

Chapter 09 (The Researcher)
Treatment for Locally Advanced Breast Cancer (listen/read)

 

Topics Covered

  • The Researcher
  • Discovery and Success
  • Patients
  • Cancer and Disease
  • This is MD Anderson
  • Understanding the Institution
  • Institutional Mission and Values
  • Healing, Hope, and the Promise of Research
  • Overview
  • Definitions, Explanations, Translations
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care

Dr. Hortobagyi explains that at the same time that he was working on the FAC regimen (Fluorouracil, Adriamycin, Cyclophosphamide), he was also influenced by one of his mentors, Jordan Gutterman, who was experimenting with immunotherapy.  Dr. Hortobagyi added BCG (Bacillus Calmette-Guérin) to the FAC regiment.  Though unsuccessful, this study opened a new path, as it revealed that a patient’s baseline immune status determined her responsiveness to chemotherapy.  Dr. Hortobagyi explains how this observation led him to look at locally advanced breast cancer (LABC), a disease that required extensive surgery and radiation for little effect on patient survival.  (MD Anderson was seeing 300-400 cases per year and still sees many more cases than other cancer institutes: Dr. Hortobagyi explains what causes this disease and why it is so much more prevalent in the South.)  Dr. Hortobagyi also observes that medical oncology was not respected in the seventies, but in the case of LABC, they relented.  Studies were begun using the FAC regimen for LABC and also inflammatory breast cancer.  The multidisciplinary regimen involved the drug regimen, surgery, then chemo therapy.  Dr. Hortobagyi explains that 90% of patients had an objective response, with 10% showing a complete response.  Patients were less disfigured and showed a much greater survival rate.

 

Chapter 10 (Building the Institution)
A Great Step for MD Anderson: Building Multidisciplinary Teams (listen/read)

 

Topics Covered

  • Critical Perspectives on MD Anderson  
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Institutional Mission and Values
  • MD Anderson Past
  • Controversy
  • On Research and Researchers
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care
  • Professional Practice
  • The Professional at Work
  • Collaborations
  • The Administrator
  • On Research and Researchers
  • The Healthcare Industry
  • Fiscal Realities in Healthcare
  • Beyond the Institution
  • Global Issues –Cancer, Health, Medicine

Dr. Hortobagyi begins this chapter by stating that, in 1975, he was disillusioned by the lack of collegiality at MD Anderson, and so he invited individuals from many disciplines (including Developmental Therapeutics) to discuss cases, explain, their different perspectives on treatment, and collectively determine the best combination and order of measures.  Slowly, he notes, they were able to build mutually respectful teams.  He describes some of the clinical trials that emerged from the collaborations.  Dr. Hortobagyi affirms that this interdisciplinary work represents one of the greatest steps forward at the institution, one that created team work twenty years before the creation of the official multidisciplinary breast center.

Dr. Hortobagyi next explains that, in the seventies some leaders at MD Anderson considered randomized clinical trials immoral because they would withhold from some patients therapies believed to be more effective than what was in existence.  Dr. Hortobagyi himself believes that clinical trials are an important tool for medical science.  He sketches the development of thought regarding ethics and randomized trials and explains other reasons why physicians do not believe that randomized trials are necessary.  He observes that that oncology is “light years ahead” of the rest of medicine in accepting their value.  He tells a story that demonstrates how radiology does not see the benefit; he also notes that there are no controlled trials comparing, for example, proton therapy to conventional electron beam therapy.  He sees a similar situation with the treatment options for prostate cancer, and states that it is “tragic” that there is a lack of evidence-based information for major decisions.  Dr. Hortobagyi then compares the laboratory research scenario to the complex challenges characterizing clinical investigation of living human systems.  He states that much of what physicians do has no basis in fact.  He goes on to talk about the economic impact that such decisions can have.  He compares the $1000 one might spend on adjuvant therapy to the $200,000 one can spend on a full regimen of neoadjuvant treatment, surgery, and chemo, noting that his group has done cost-benefit studies to insure the money on these treatments is well spent.

Dr. Hortobagyi points out that very expensive treatments cannot always be exported to other institutions.  Randomized trials provide a way of determining how effective treatments are at each cost level and therefore provide a logical way of seeing incremental benefit.  This provides a sound basis for making decisions on which treatment methods to adopt for the greatest public benefit.

Dr. Hortobagyi explains that he is not a “purist” who insists that every point be demonstrated through randomized trials.  He advocates the identification of basic questions and treatment options in each specialty and a strategy of comparing them via Comparative Effectiveness Research methods.

 

Chapter 11 (The Researcher)
Adapting LABC Treatment for Stages 2 and 3 Breast Cancers 
(listen/read)

 

Topics Covered

  • The Researcher
  • Discovery and Success
  • Professional Practice
  • The Professional at Work
  • Cancer and Disease
  • Understanding the Institution
  • Controversy
  • Overview
  • Definitions, Explanations, Translations
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care

Dr. Hortobagyi begins by explaining that the LABC (Locally Advanced Breast Cancer) treatment involved six months of chemotherapy, surgery, radiation, and treatment with hormonal Herceptin.  His group then decided to expand the regimen to stage two and stage three tumors and they designed a national clinical trial comparing the regimen with a protocol that performed the surgery first.  Dr. Hortobagyi explains that new regimen offered advantages even though the effects on the tumor were not statistically greater than with surgery first.  He points out that it was not possible to do a randomized trial at MD Anderson in the seventies, and so the process of clearly demonstrating the regimen’s value was greatly prolonged.  To explain why surgery was the last to participate in randomized trials, Dr. Hortobagyi mentions that a 1980 conference in Tuscon brought the discussion to a head when Dr. Chuck [Charles] Moertel (a proponent) debated the issue with Dr. J Freireich (an opponent).  It was clear that most of the oncology community in the country supported randomized trials and that MD Anderson had to evolve.  The NCI became involved and spoke to institution leadership about the need to initiate such trials and the culture of the institution changed accordingly.

 

Chapter 12 (The Researcher)
From Adriamycin to Molecularly Designed Drugs (listen/read)

 

Topics Covered

  • The Researcher
  • Discovery and Success
  • Devices, Drugs, Procedures
  • Discovery, Creativity and Innovation
  • Professional Practice
  • The Professional at Work
  • On Research and Researchers
  • The History of Cancer Research and Care

Dr. Hortobagyi explains that he was the first to introduce Adriamycin into adjuvant therapy, responding to the fact that many patients were referred to the breast service after surgery (though MD Anderson surgeons were not referring patients to them).  Adriamycin was combined with the FAC therapy and accepted as a standard of care by the 1990s.  MD Anderson was also the first institution to report that Taxol was just as effective as Adriamycin when used in the FAC regimen and it was acceptedas a new standard.  His group then worked with Taxotere, which was demonstrated effective.  Research in the eighties was frustrating and his group tested about forty drugs, with little to show for it.  He talks about the process of drug development and notes that the community ran out of ideas for a time. 

During this same period there was a move to more molecularly designed chemicals as well as the discovery of oncogenes, tumor suppressor genes, and a burst of enthusiasm for the human genome project.  This fertile scenario led to the development of the major targeting agents such as Herceptin.

 

Chapter 13 (The Administrator)
The Breast Cancer Research Group –Bringing Together Clinicians and Basic Scientists (listen/read)

 

Topics Covered

  • The Researcher
  • Beyond the Institution
  • Institutional Mission and Values
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care
  • Professional Practice
  • The Professional at Work
  • Collaborations
  • Controversy
  • MD Anderson Culture

Dr. Hortobagyi explains that frustrations with research motivated him to accept a 1990 invitation from Dr. James Cox [Oral History Interview] to pull together a comprehensive group to study breast cancer.  The Breast Cancer Research Group linked radiologists, surgeons and other specialists, as well as basic researchers interested in the disease. This request came at a time that the administration wanted to enhance the quality of research and to make it more collaborative and translational.  Dr. Hortobagyi also notes the growing suspicion, at the time, that basic scientists would spend their time doing research for its own sake, without necessarily linking their research questions or discoveries to patient care.  He explains that the process for awarding grants prevented scientists from taking bold steps or thinking outside the box.  Dr. Hortobagyi describes the challenges of getting the specialties to work together.  He describes setting up talks with luminary scientists and researchers –for only very low turnout.  Laboratory scientists communicate differently than clinical specialists, he notes.  Their days are also organized very differently, which made it difficult to find a time when everyone could gather.  In addition, the institution offered no incentives for communication across specialty lines –and he says this is still true. He offers observations on Dr. Ronald DePinho’s support of basic scientists.

 

Chapter 14 (The Administrator)
An Initial Translational Research Project: A Drug to Attack HER2-positive Breast Cancer (listen/read)

 

Topics Covered

  • The Researcher
  • Professional Practice
  • The Professional at Work
  • Collaborations
  • On Research and Researchers
  • On Pharmaceutical Companies and Industry
  • Industry Partnerships
  • Devices, Drugs, Procedures
  • The Business of MD Anderson
  • Portraits

In this chapter, Dr. Hortobagyi talks about his first experience with translational research. He explains that while leading the Breast Cancer Research Group, he identified individuals with a collaborative mindset (Robert Bast, Gordon Mills, Mien Chie Hung [Oral History Interview]) and undertook translational research for the first time.  They had success addressing resistance to chemotherapy with gene therapy, but the field progressed and the results were not competitive.  Combining forces with Mien Chie Hung, they then used the gene product E1-A to kill cells specific to HER2-positive breast cancer. The procedure worked, but they lacked resources to take the product to the drug phase.

Dr. Hortobagyi then explains that, at the time, individuals and institutions had little understanding about the legal issues attached to intellectual property and about raising money for development.

Dr. Hortobagyi explains that John Mendelsohn changed the Development Office and helped fund drug development. He also hired legal expertise so the intellectual property of individuals and the institution would be protected.  Dr. Hortobagyi sketches the costs of drug development, noting that one can only develop a drug by partnering with industry and one “can’t do that without going to bed with the devil.”

 

Chapter 15 (The Researcher)
The Next Phase of Gene Therapy Research and Funding from the Breast Cancer Research Foundation (listen/read)

 

Topics Covered

  • The Researcher
  • Professional Practice
  • The Professional at Work
  • Collaborations
  • On Research and Researchers
  • Devices, Drugs, Procedures
  • Business of Research
  • Philanthropy, Fundraising, Donations, Volunteers
  • Understanding Cancer, the History of Science, Cancer Research

In this chapter, Dr. Hortobagyi describes the next phase of his gene therapy research.  He begins by explaining that the funding organization, the Breast Cancer Research Foundation, was started by Evelyn Lauder when she was diagnosed with breast cancer.  Dr. Hortobagyi and others were asked to be scientific advisors.   The Foundation brought together powerful women who raised a great deal of money, a lot of which came to MD Anderson.  The gene therapy project was also funded by a SPORE grant.  Dr. Hortobagyi sketches the state of the gene therapy projects.  He explains why it was difficult to secure NCI funding for the E1-A project then discusses why it is so difficult to deliver a gene product.  He tells the story of a University of Pennsylvania project in which some children died from gene therapy, an event that helped turn the NCI away from funding this kind of research.  He then describes how the Breast Cancer Research Foundation uses different criteria than the NCI to award money to high-risk projects.  The BCRF is now funding such areas of research as cancer vaccines, early genetic screening, the development of targeted agents, and diagnostic tests. 

 

 

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

 

Chapter 00C
Interview Identifier (listen/read)

 

Chapter 16 (The Researcher)
Studies of Pro-Apoptotic Molecules: Translational Research and Thinking Outside the Box (listen/read)

 

Topics Covered

  • The Researcher
  • Discovery, Creativity and Innovation
  • Professional Practice
  • The Professional at Work
  • On Research and Researchers
  • The History of Cancer Research and Care
  • The Administrator
  • Beyond the Institution
  • Career and Accomplishments
  • Institutional Mission and Values
  • Discovery, Creativity and Innovation
  • Patients, Treatment, Survivors
  • The History of Cancer Research and Care
  • The History of Health Care, Patient Care
  • Global Issues –Cancer, Health, Medicine 

In this chapter, Dr. Hortobagyi talks about two related studies of pro-apoptotic proteins (which instruct cancer cells to commit suicide) and reflects on the kind of creative thinking that leads to great discoveries.  He begins by explaining how he and Dr. Mien Chie Hung decided to submit a “truly different” proposal to the Breast Cancer Research Foundation (BCRF), one based on the observation that a gene product from Adenovirus-5 and E1A could cause HER2 positive cancer cells to commit suicide.  This research proposal was partially funded by the BCRF and also by a SPORE grant.  This gene therapy successfully transformed HER2 positive cancer from the most difficult to the easiest disease treated and has been applied to head and neck and other cancers.  The next project was based on the observation that the Bik protein in the BCL-2 family was pro-apoptotic.  Dr. Hung produced the genetic variant, BikDD, with an enhanced destructive effect. 

Next Dr. Hortobagyi describes the new view of cancer that emerged in the 1990s as a result of discoveries in cell biology, and how this has influenced research.  In the early 90s, he explains, physicians were working with ideas that had been known in the basic sciences at least ten years earlier.  Dr. Hortobagyi explains that through his conversations with Dr. Mien Chie Hung, it began to dawn on both of them how to transport the basic science information into a new context.  Dr. Hortobagyi notes that it’s “an epiphany” to take a laboratory observation and then visualize its possible applications in clinical settings.  He also connects his ability to think in these translational terms to his interest in setting up multi-disciplinary teams.  He then explains an “inherent contradiction of translational research”: despite the prevailing wisdom that scientific thinking is disciplined and logical, truly important discoveries require that you become undisciplined and think outside the box.  Traditional thinking leads back to existing knowledge.

 

Chapter 17 (Professional Service beyond MD Anderson)
Thinking Outside the Box to Stage the World Summit Against Cancer for a New Millennium (listen/read)

 

Topics Covered

  • The Administrator
  • Beyond the Institution
  • Career and Accomplishments
  • Institutional Mission and Values
  • Discovery, Creativity and Innovation
  • Patients, Treatment, Survivors
  • The History of Cancer Research and Care
  • The History of Health Care, Patient Care
  • Global Issues –Cancer, Health, Medicine 

To demonstrate thinking out of the box, Dr. Hortobagyi describes how he and Dr. Charles Jacquillat organized an important millennium event for the Congress of Anti-Cancer Therapy (formerly the International Congress of Neoadjuvant Therapy).  He describes the “crazy” way of free-associating that led them to envision (and successfully plan) the World Summit Against Cancer for a New Millenium held in Paris.  The event also introduced the Charter of Paris, a list of patients’ human rights.  Between fifty and sixty nations sent delegates to sign the Charter; MD Anderson president John Mendelsohn went to Paris to participate in the signing, and there is a photograph of the document in the Rose Building on MD Anderson’s main campus.  Dr. Hortobagyi also explains the purpose of the Charter –to draw attention to the fact that in most countries, cancer patients are undertreated, ill-treated, or ignored.  He notes that the UACC adopted their Charter and that in 2012 the World Health Organization adopted the Charter as a basis for its continued efforts to encourage governments to improve patient care.

 

Chapter 18 (The Researcher)
Therapy to Block Angiogenesis (listen/read)

 

Topics Covered

  • The Researcher
  • Discovery, Creativity and Innovation
  • Overview
  • Definitions, Explanations, Translations
  • Professional Practice
  • The Professional at Work
  • On Research and Researchers
  • The History of Cancer Research and Care
  • On Pharmaceutical Companies and Industry

In this chapter, Dr. Hortobagyi talks about research on anti-angiogenesis therapies funded by The Breast Cancer Research Foundation.  He begins, however, by noting that once he had embraced the understanding that breast cancer is multiple diseases, rather than a single pathological phenomenon, he realized that other colleagues and basic scientists needed to undergo the same “epiphany.”  “We all needed to learn more and go beyond our slice of the world” in order for diagnosis and therapy to progress.  Dr. Hortobagyi then describes his work on anti-angiogenesis therapy.  He defines angiogenesis and lists MD Anderson faculty who have contributed to understanding the process.  He then describes early work with Endostatin and Angiostatin, early anti-angiogenesis agents, which never provided adequate results because of their very short half-life.  Work on the subject revived when Genentech developed Avastin (bevacizumab), a drug that caused tumor regression, but that also created serious side effects.  Dr. Hortobagyi next explains that, with the revival of the field, he and Dr. Hung developed the Endo-CD project (Endostatin-cytosine deaminase fusion protein)[1] which was similar to gene therapy in that it involved molecular manipulations in vivo.  He and Dr. Hung worked with molecular processes to make the earlier drug, Endostatin, more effective.  He describes the chemical construct they createa chemical compound with no activity was linked to Endostatin and used as a vehicle to deliver Endostatin directly to tumor vasculature.  Another activating agent was then administered to activate Endostatin. With the drug so locally attached to the tumor, side effects were minimized. 

Dr. Hortobagyi notes that during work on EndoCD, he was also conducting clinical trials on Avastin.  He describes the disappointing results.  He notes that the pharmaceutical industry had looked to the drug as a potential “cash cow,” and he explains how the drug became a political issue in insurance reimbursement.

 

Chapter 19 (The Researcher)
A New View of Breast Cancer and Research on HER2 Positive Breast Cancer (listen/read)

 

Topics Covered

  • The Researcher
  • Discovery and Success
  • Overview
  • Definitions, Explanations, Translations
  • Discovery, Creativity and Innovation
  • Professional Practice
  • The History of Cancer Research and Care

In this chapter, Dr. Hortobagyi talks about the next stages for breast cancer research.  He first provides a snapshot of how breast cancer was viewed ten to fifteen years ago.  He then traces the many forces that came to together to revolutionize the understanding of the disease, which is now seen as many chemically and genetically unique diseases, rather than a single phenomenon.  The factors Dr. Hortobagyi lists are: a new understanding of the significance o estrogen receptors in cancer cells, the completion of the Human Genome Project, the completion of gene expression profiles of various breast cancers, investments by the government in the ‘war on cancer,’ and the pharmaceutical industry’s investment in cancer treatment drugs.  By the mid -2000s, all of this work had led to an explosion of knowledge about the significance of breast cancer subtypes.

Dr. Hortobagyi then talks about his work on HER2 positive breast cancer. He notes that through his work on Herceptin, he was involved in advancing the understanding of this breast cancer subtype.  He describes how he organized yearly by-invitation meetings of researchers: this event led to many collaborations that advanced the field.  Dr. Hortobagyi then explains that his role in research changed.  With more involvement in administration, he did more coordinating and facilitating of research for others.  He notes his involvement in national organizations.  He explains that in 2005 he joined the South West Oncology Group and became chair of the breast cancer committee, responsible for coordinating research.  Dr. Hortobagyi comments on how important such organizations are for extending MD Anderson’s reach and to generate enough participants in clinical trials.

 

Chapter 20 (The Administrator)
Breast Cancer Service at MD Anderson in the Late Seventies (listen/read)

 

Topics Covered

  • The Administrator
  • MD Anderson History
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Growth and/or Change
  • Understanding the Institution
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care

In this chapter, Dr. Hortobagyi talks about the state of breast cancer services at MD Anderson and in the country in the late seventies.  He begins explaining the position of the Breast Cancer Service within the institution, lists his colleagues, then notes that the non-surgical treatment of breast cancer was evolving in the seventies (and eighties).  Dr. Aman Buzdar shared Dr. Hortobagyi’s commitment to research, and they both learned how to treat breast cancer via an “empirical” process that was common in institutions at that time, when medical oncology was not yet a specialty and institutions lacked formal training programs of the type common today.  In general, health care institutions were less structured than they are today, and researchers had much more freedom. 

 

Chapter 21 (Building the Institution)
The Breast Cancer Service: From Section to Department (listen/read)

 

Topics Covered

  • Professional Path
  • Contributions to MD Anderson
  • Career and Accomplishments
  • Growth and/or Change
  • MD Anderson History
  • Leadership
  • The Administrator at Work
  • On Leadership

In this chapter, Dr. Hortobagyi first compares the formal processes by which Section Chiefs are recruited today with the informal process by which Dr. Hortobagyi first came to serve as Alternative Section Chief of the Breast Medical Oncology Service under Dr. George Blumenschein.  Dr. Hortobagyi became Chief in 1984 when Dr. Charles LeMaistre removed Dr. Blumenschein.  Dr. Hortobagyi then explains how, in 1992, institutional politics drove the re-classification of the Breast Medical Oncology as a Department.

Dr. Hortobagyi explains how his understanding of his administrative role evolved, beginning with his role as Alternative Section Chief, when he was “so junior that he didn’t know much.”   Dr. Hortobagyi explains that as he matured, he came to understand that he had his own ideas of how work should be organized.  He lists some of his first contributions to the Section/Department: he recruited the first three research nurses to the service; he and Dr. Benjamin worked with the Texas legislature to pass a bill in support of physicians’ assistants and nurse practitioners; he was the first to recruit nurse practitioners; he recognized the need to grow the department to grow the number of grants and research support and he visited other institutions to better understand what a breast center should look like.  He describes his “gradual awakening” to the idea that the breast center should be re-thought from a patient-centered perspective.  He then strengthened the Department to support clinical research, moved on to build up the educational mission of the Department, and finally integrated translational research into the Department and into the process of recruiting new faculty.

 

 

Interview Session Four: 28 January 2013 (listen/read)

 

Note: The recorder is turned on during a conversation in progress.  The notes appear below. 

Before the recorder is turned on, Dr. Hortobagyi describes a leadership course [Innovations in Breast Cancer] developed around 1995 because, as he explains, medical education does not provide physicians with necessary leadership skills.  Funds were secured from a pharmaceutical company to run the course twice per year (and then once per year) for ten years.  For each session, eight to ten faculty with administrative responsibilities were selected to go through a three-day course; each class had international representation, including professionals from Europe and North America, Asia and other regions.  The curriculum included discussions of team-building, debate, and effective and dispassionate argumentation.  Dr. Hortobagyi lists some individuals who went through the course, including Francisco Esteva from MD Anderson and professionals from many other institutions. 

Dr. Dr. Hortobagyi then explains how leadership vacuums become apparent and notes the ineffective ways in which leaders are often identified in institutions.  Dr. Dr. Hortobagyi notes that MD Anderson hires “wonderful people” then stresses that the next step is to train them to put together a plan for professional growth.  A professional needs to know how to move strategically from the goal “I’m going to cure breast cancer” to identify “all the hundreds of steps” required to achieve it. 

Dr. Dr. Hortobagyi then speaks more about the Innovations in Breast Cancer program.

Dr. Hortobagyi finds the name of the leadership program he developed, “Innovations in Breast Cancer.”  He then talks about how the program folded, noting funding and the fact that he had to leave when he became involved in ASCO.  He says that “committees stand on the back of a few people, relying on a dynamic person or persons.” 

Today, Dr. Hortobagyi says, he Chairs the Breast Cancer Committee in SWOG, and he describes how he tries to get people involved in activities.  Many of the ideas for research studies that go to trials are his brainchildren, he says, observing that groups can be passive.  For a program to succeed, there must be a passionate champion.

Dr. Hortobagyi reflects on his own leadership style and says that he is a consensus-builder.  He notes that he loves to read history and lists some leaders from his readings.  They all had a sense of history and a belief in their ability to move things forward, he explains, and he believes he has these qualities himself.

He says he has never been comfortable in the limelight and gives an alternative example of several past ASCO presidents who couldn’t give up the idea that they were president after their tenure was over.  Dr. Hortobagyi himself is delighted when the group is acknowledged.

Dr. Hortobagyi then turns to the history of the Dept and Division of Breast Medical Oncology.  Bringing the different components of breast cancer treatment together was a difficult management process that involved a paradigm shift to create a patient-centered model of care.  At the time, services were separated.  No shared clinic time with other specialists (surgery, radiation therapy).  The bi-weekly case assessment meetings underscored the need for a different approach: everyone was in the same room and perspectives were changed on how patient treatment should move forward. 

From this came the idea for a breast center, an entity that didn’t exist at the time.

At this point, Breast Medical Oncology moved to the Rose Building (the Main Building) and the Lutheran Pavilion.  They contributed to the design discussions during the planning and requested physical efficiencies, separate space for research, and to locate the breast surgical group adjacent to Breast Medical Oncology (that didn’t happen).

The next opportunity to develop Breast Medical Oncology came when they outgrew that space just at the time the Mays Clinic was constructed.  They had a group based on a SPORE and began to bring the breast cancer community together.  Dr. Dr. Hortobagyi explains how this was all laid out in the new plan.

 

Chapter 22 (MD Anderson Past)
Creating a Patient-Centered Breast Service (listen/read)

 

Topics Covered

  • Patients
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Growth and/or Change
  • The Clinician
  • Understanding the Institution
  • The Business of MD Anderson
  • The MD Anderson Brand, Reputation
  • Professional Practice
  • The Professional at Work
  • The Clinician at Work
  • On Care
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care

Dr. Hortobagyi notes that there was huge resistance, at first, to integrating all services associated with the treatment of breast cancer.  He then talks about what convinced people this was the best move, beginning with the case of Eva Singletary, a patient who was literally followed throughout her treatment, beginning with the moment she set foot in MD Anderson for a diagnosis.  This exercise revealed that the institution was organized in a bureaucracy centered, rather than a patient centered, scheme.  Dr. Hortobagyi explains that there was also a rise in patient load and a concurrent rise in MD Anderson’s reputation.  MD Anderson faculty were also publishing important research, which drives growth and the institutions’ reputation, Dr. Hortobagyi says.  He then goes on to explain how MD Anderson discoveries have indirect effects on patient referrals.

Dr. Hortobagyi explains that, when the new Breast Center was constructed, there was a “retrenchment” as physicians were afraid that they would give up their own territory in a situation based on collaboration. A decade later, the Breast Service is based on a mentality of sharing and shifting traditional ideas of how a service should be run. 

Dr. Hortobagyi gives the example of making room utilization more efficient, then explains that in the new “pod” layout of the Breast Center, it is easy to find a specialist for a consultation, sharing weeks of works ups.

 

Chapter 23 (The Administrator)
Regulations on Clinical Trials and New Research Projects in Breast Medical Oncology (listen/read)

 

Topics Covered

  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • MD Anderson Culture
  • Growth and/or Change
  • The Clinician
  • Understanding the Institution
  • The Business of MD Anderson
  • The MD Anderson Brand, Reputation
  • Professional Practice
  • The Professional at Work
  • The Clinician at Work
  • On Care
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care

Dr. Hortobagyi begins this chapter by talking about how clinical trials helped build a multi-disciplinary mentality in Breast Medical Oncology.  He then observes that increasing costs and institutional/national regulations on clinical trials holds back research efforts.  He then explains how he developed the research infrastructure in Breast Medical Oncology, beginning with his development of clinical trials with FAC and inflammatory breast cancer.  Pharmaceutical companies provided drugs for these trials and other resources.  Dr. Hortobagyi describes the different cost components of a budget for a drug trial (nurses, data managers, etc.).  As the numbers of trials increased over time, he explains, research simultaneously became more complex, and he gives the example of his first research nurse, who could handle eight or nine clinical trials, while today many more individuals are involved.

Dr. Hortobagyi then gives an overview of regulatory practices governing trials, which also add to the complexity of research.  He notes that a few people decided to be “slippery or dishonest,” and their actions resulted in a burden of regulation for everyone that slows research.  He also describes how regulation has increased the cost of health care and absorbed the efforts of the best investigators, tapping their energy for tasks that add no value to their research.

Dr. Hortobagyi describes how difficult it was to set in place all the pieces required for an optimal research structure, underscoring how important it was to strategize for resources, efficiency, and to work within budget constraints.  He returns to subject of physicians who lack leadership training, and who need these skills to manage complex initiatives.  Dr. Hortobagyi gives an overview of the tasks he manageproviding the highest quality of care; insuring that all faculty and staff work at their highest level; influence the development of the Breast Center; increase research productivity, coordinate research activities, ensure that research breaks even; foster careers; educate the next generation.

 

Chapter 24 (The Administrator)
Mentoring, Career Support, and Education in Breast Medical Oncology (listen/read)

 

Topics Covered

  • The Administrator
  • Professional Practice
  • The Professional at Work
  • Leadership
  • Mentoring
  • On Research and Researchers
  • On Leadership
  • On Mentoring
  • Building/Transforming the Institution
  • Institutional Processes
  • Understanding the Institution
  • On the Nature of Institutions

In this chapter, Dr. Hortobagyi discusses his efforts to support faculty careers via mentoring and administrative decisions.  He begins by noting that the grant application process can be used strategically to encourage faculty to work together.

Dr. Hortobagyi notes that it is very challenging to lead bright people, and a leader must empower then and build on their strengths.  He compares the “one size fits all” approach he took many years ago to his newer, nuanced approach of recognizing people’s different strengths.  He notes how he developed listening skills.  He gives an example of how he continuously challenges people in positive ways so they can stretch, and underscores how important it is for a leader to be transparent about the purpose and goals of decisions to reduce conflict and increase faculty/staff buy in.

Dr. Hortobagyi gives the example setting expectations for faculty on clinical contracts versus those on 75% research contracts.  Every month a report shows how much income a faculty member generates.  Transparency is important to motivate faculty and to guide them through tenure and promotion hurdles. 

Leadership principles are the same in all organizations, Dr. Hortobagyi says.  However it is especially difficult to lead in academic institutions.  Dr. Hortobagyi explains why medical academics are “fiercely independent.”

 

Chapter 25 (The Administrator)
Education in Breast Medical Oncology (listen/read)

 

Topics Covered

  • The Administrator
  • Personal Background
  • The Educator
  • The Leader
  • The Mentor
  • Education
  • Education at MD Anderson
  • On Education
  • On Mentoring
  • Education at MD Anderson
  • Professional Practice
  • The Professional at Work
  • Collaborations
  • Leadership
  • Mentoring

Dr. Hortobagyi explains that medical education includes two parts: the technical information a physician needs to practice and learning that comes via mentoring.  Dr. Hortobagyi describes good mentoring and the kinds of career questions a good mentor can help a fellow or young faculty member confront. 

He then discusses principles of research mentoring and how it is connected to funding of medical education after the M.D.  He notes that a fellow has six or more years of training after the M.D., but is “still green behind the ears,” a situation in which mentoring is key for preserving quality of care and research. 

Dr. Hortobagyi ends this session with the observation that he himself did not have strong mentors, but he observed how strong mentorship influenced the careers of many of his colleagues.

Interview Session Five: 15 March 2013 (listen/read)

 

Chapter 00E
Interview Identifier (listen/read)

 

Chapter 26 (An Institutional Unit)
A Brief History of Breast Medical Oncology (listen/read)

 

Topics Covered

  • MD Anderson History
  • MD Anderson Culture
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Growth and/or Change
  • The MD Anderson Brand, Reputation
  • Institutional Mission and Values
  • Giving Recognition

In this chapter, Dr. Hortobagyi begins an overview of the evolution of Breast Medical Oncology and the Breast Center.  He recalls that in the early days, the Department needed to communicate better to develop patient care.  As an example, he points out that scheduling sequential consults with specialists could take weeks, greatly slowing progress on a patient’s treatment plan.  Bi-weekly meetings were established with all related specialties to aid communication and come up with a majority view of what needed to be come.  Dr. Hortobagyi explains the specialties represented and how some individuals resisted collaboration on treatment plans.  He notes that it took years for difficulties to smooth out, but that patients were happy and grateful.  Dr. Hortobagyi says that the patients had figured out that it was good to get their doctors talking to one another. The multidisciplinary meetings were an educational tool and an instrument for cultural change in the department, he observes.  Surgeons had been in charge of managing breast cancer, but slowly imagers and breast medical oncologists made inroads and with good results.  He also says that conflict over treatment plans could give rise to clinical trials to prove a point (e.g. demonstrating the benefits of different types of surgery and of integrating chemotherapy at different stages of treatment and in combination with radiotherapy and immunotherapy). 

Dr. Hortobagyi describes the successes that came from multidisciplinary discussions of treatment.  “We were leaders in breast cancer management,” he says.  “Everything we proposed and developed has survived the test of time.”

 

Chapter 27 (The Researcher)
An Overview of Research Issues (listen/read)

 

Topics Covered

  • Controversy
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Growth and/or Change
  • Research, Care, and Education in Transition
  • The Clinician
  • The Researcher
  • Professional Practice
  • The Professional at Work
  • On Research and Researchers
  • The History of Cancer Research and Care
  • Ethics

Dr. Hortobagyi explains that recruitment of research nurses and research managers was a key to strengthening the research mission of Breast Medical Oncology.  He then moves to a related discussion of conflict of interest, noting monetary dimensions of conflict of interest are only “the tip of the iceberg.”  He explains that a Principle Investigator has a vested interest in the success of a clinical trial.  The research nurse thus serves as unbiased party to collect and manage data.  He explains the decision not to permit principle investigators to look at data before all the results of a trial are in.

Dr. Hortobagyi recalls the controversies at MD Anderson regarding the running of clinical trials, which some researchers believed were unethical.  The discussions revealed, however, how difficult it is for a researcher to be unbiased and that the process of generating data needed management to insure that results were unimpeachable.

Dr. Hortobagyi notes the reasons why scientific misconduct was not discussed in the 70s and 80s.

 

Chapter 28 (Overview)
Physician Extenders and a View of the Coming Physician Shortage (listen/read)

 

Topics Covered

  • The Researcher
  • The Administrator
  • Beyond the Institution
  • MD Anderson and Government
  • Cultural/Social Influences
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care
  • Contributions
  • Activities Outside Institution
  • Career and Accomplishments

Dr. Hortobagyi explains that he worked with Dr. Robert Benjamin to encourage the Texas Legislature to pass laws enabling the use of physician extenders, then notes that this profession will play an increasingly important role as oncology moves forward.  He then moves to a related subject: the shortage of physicians in chronic illnesses.  Dr. Hortobagyi explains that he became a ‘pseudo-expert’ in the area when he was president of the American Society of Clinical Oncology and conducted a study which projected that, by 2020, there available physicians would only be able to cover 2/3 of the hours required by patients for treatment.  He then lists the causes of this projected shortage and what is going to be result.  He observes that Medicare patients are already seeing the effects, as they are having difficulty locating doctors.  He also notes that, in the aftermath of the study, little has been done to ease the shortage.  “How we deal with that will define us as a society,” he says, and notes the other diseases that will experience the same shortfall as cancer.

 

Chapter 29 (An Institutional Unit)
The Evolution of Breast Medical Oncology and the Breast Center (listen/read)

 

Topics Covered

  • Understanding the Institution
  • Building/Transforming the Institution
  • Multi-disciplinary Approaches
  • Growth and/or Change
  • Critical Perspectives on MD Anderson  
  • Institutional Processes
  • The Clinician
  • Professional Practice
  • The Professional at Work
  • Collaborations
  • Institutional Mission and Values
  • On Care
  • Leadership
  • Mentoring

In this chapter, Dr. Hortobagyi continues to sketch the evolution of the Breast Service.  He describes first, tiny Breast Clinic on the ground floor of the Bates Freeman Building, where about 800 patients per year were seen.  From there, the Clinic moved (to where the Anderson Network offices are now located), then to the Rose building, then to the Faculty Tower.  The faculty made a real effort to influence the design of the clinic when it moved to the 6th floor of the Rose Building.  Dr. Blumenschein developed a list of what was needed, but he was unfortunately ignored, though they “got more real estate” and faculty offices were next to the Breast Clinic.  Many more advances were made when the Clinic moved the new Cancer Prevention Building.  Dr. John Mendelsohn requested input from administrators on design requirements, and Dr. Hortobagyi notes that his was a fairly public and transparent process.  Dr. Hortobagyi wanted all functions located in the same areoffices, clinics, surgical suites, radiation therapy, and laboratory research related to breast cancer.  (Not all of this was accomplished.) 

Dr. Hortobagyi describes the “shift in your mind” that takes place when one adopts a logic of multi-disciplinary care for a service.  He describes the importance of collegiality and “geography” for overcoming the “separate republics” that prevent physicians from working together.  He reviews what is needed to get people working together, including the development of translational research projects and recognition of the importance of imagers and pathologists to what breast medical oncologists do.  Dr. Hortobagyi notes that the Clinic was able to implement multidisciplinary care effectively for the first time when it moved to the Cancer Prevention Building.

Dr. Hortobagyi next notes that the practice of multi-disciplinary care would evolve if medical schools laid the foundation for inter-specialty interaction.  He explains how MD Anderson’s compensation system fostered interdisciplinary.  He comments on the current administration (of Dr. Ronald DePinho), stating that decisions have been made that will change MD Anderson culture to the detriment of research and education.

 

Chapter 30 (The Administrator)
Stepping Down as Chair of Breast Medical Oncology (listen/read)

 

Topics Covered

  • Evolution of Career
  • Professional Values, Ethics, Purpose
  • Critical Perspectives on MD Anderson 
  • The History of Health Care, Patient Care
  • Character, Values, Beliefs, Talents
  • Personal Background
  • Professional Path
  • Inspirations to Practice Science/Medicine

In this chapter, Dr. Hortobagyi explains the issues surrounding his decision to step down as Chair of Breast Medical Oncology (effective on 31 August 2012).  In part, he realized he no longer wanted the leadership position, he explains.  In addition, cultural changes at MD Anderson have created a shift so that business people, instead of physicians and scientists, now lead the institution.  He talks about how medicine in general is “in a profound state of disarray,” and these factors dulled his enthusiasm, as MD Anderson is currently asking “how can we function optimally within this (dysfunctional) system,” not “how can we change the system.”  He also notes that leaders should not remain overlong in their positions.  He lists some of the personal interests he would like more time to pursue (music, literature, poetry, history) and also notes his interest in medical policy issues.  Finally, he observes that his professional life took precedence in the early part of his career, and now his private life is perhaps more important to him.

 

Chapter 31 (Professional Service beyond MD Anderson)
Contributions to International Policy Issues (listen/read)

 

Topics Covered

  • Contributions
  • Activities Outside Institution
  • Global Issues –Cancer, Health, Medicine 
  • Professional Practice
  • The Professional at Work
  • Understanding Cancer, the History of Science, Cancer Research
  • The History of Health Care, Patient Care
  • Patients, Treatment, Survivors

Dr. Hortobagyi begins this chapter on his work with international organizations by explaining why he has such firm professional connections in Hungary and Europe as well as in North and South America, and Latin America.  He then talks about the Breast Health Global Initiative (which he co-founded) and a major project: developing guidelines for the treatment of breast cancer, taking into account the realistic availability of resources.  Dr. Hortobagyi explains, for example, that in some areas of Africa, a physician may perform a mastectomy as a diagnostic procedure, and the samples must be sent to far-off labs for study, with results coming back after six months.  Dr. Hortobagyi explains how the BHGI set about creating guidelines for minimal levels of care for breast cancer where possibility for care is extremely limited.  Methods include using physician extenders as well as training women from the local community to give care. The Initiative has also developed research projects to study how to implement the guidelines. Guidelines were developed, discussed, published, and then republished in three different versions after more public discussion.  Dr. Hortobagyi describes how fascinating it has been to participate in this project and he hopes it will force governments to rethink their obligations to their populations.

 

Chapter 32 (Key MD Anderson Figures)
The MD Anderson Presidents (listen/read)

 

Topics Covered

  • Portraits
  • Funny Stories
  • Personal Reflections on MD Anderson
  • Human Stories
  • Offering Care, Compassion, Help
  • This is MD Anderson
  • MD Anderson History
  • Building/Transforming the Institution
  • Growth and/or Change
  • Obstacles, Challenges
  • Controversy

Dr. Hortobagyi first gives an overview of R. Lee Clark and sketches a portrait of MD Anderson in 1974, when Dr. Clark recruited him.  Dr. Hortobagyi tells a story to show how solicitous the Texas Legislature was of R. Lee Clark’s requests for money.  He goes on to talk about the many good recruitments Dr. Clark secured as well as his incredible vision.  Dr. Hortobagyi then describes the situation in Texas in 1941, when Dr. Clark conceived of the new cancer center, then describes his administrative style.  Dr. Hortobagyi recalls his fellowship period and notes that Dr. Clark always knew who he was and remembered the project he was working on.  Dr. Hortobagyi also remembers that fellows would sleep on a couch in Dr. Clark’s office, and he’d nudge them out in the morning when he came in.

Dr. Hortobagyi praises Dr. Clark’s practice of developing international connections.  As a result, he says, MD Anderson trained many international students who became leaders in the global cancer community.  Dr. Hortobagyi then shifts to Charles LeMaistre, offering background on his research, then noting that he was a more reserved administrator, with primary skills in political interactions with the Legislature and with higher education.  He talks about the difficult years of Dr. LeMaistre’s tenure, when about two thousand employees were laid off, “dampening the spirit of the institution. 

He then shifts to John Mendelsohn, who was able to “lift the institutions spirits in an hour” by going on record and saying that MD Anderson was doing fine. Dr. Hortobagyi give some background on Dr. Mendelohn’s administration, noting his fundraising skills, his innocence, candor and ability to talk to anyone.  He describes him as “a communicator.”

Dr. Hortobagyi then talks about the growth of the Development Office under Dr. Mendelsohn and his ability to recruit good people.  He also notes that Dr. Mendelsohn “didn’t have a mean bone in his body,” which was a disadvantage when it came to making painful decisions.  Dr. Hortobagyi offers an example of decision making about laboratory space that was held back because of this limitation.  He also observes that Dr. Mendelsohn’s administration was tarnished in the last years of his tenure and that he became more enclosed with his inner circle and lost touch with the faculty.  Dr. Hortobagyi then shifts to Dr. DePinho, saying that he was a surprise choice, never having led a patient-care institution.  Dr. Hortobagyi hopes that he picks up those skills and that the four missions stay in balance.

 

Chapter 33 (View on Career and Accomplishments)
Fostering Collaboration and Collegiality (listen/read)

 

Topics Covered

  • Career and Accomplishments
  • The Leader
  • Character, Values, Beliefs, Talents
  • Professional Values, Ethics, Purpose

In this chapter, Dr. Hortobagyi explains that he is most gratified that he was able together a diverse individuals interested in breast cancer into a collaborative and collegial group.  He reflects on his own leadership style: a reluctant leader, but one that is good at organization and gets pleasure from seeing others grow.  Dr. Hortobagyi lists some of his leadership principles.  In closing, he says that it is wise to remember that one looks good because of others.  He makes some comments on awards and notes that he is currently enjoying his “senior statesman” status.


[1] See http://www.ncbi.nlm.nih.gov/pubmed/21610170, date of access, 24 January 2013.

Original Profile

This interview of Gabriel Hortobagyi, M.D. (b. summer 1946, Sarvoc, Hungary), a leader in breast medical oncology, is conducted in five sessions (approximately 8 hours 45 minutes total duration) in 2012-2013. Dr. Hortobagyi came to MD Anderson in 1974 as a Fellow in the Department of Developmental Therapeutics: he joined the faculty in 1976.  He served as chair of the Department of Breast Medical Oncology until 2012.  He is currently a professor in that department and holds the Nellie B. Connelly Chair in Breast Cancer.  He also heads the Breast Cancer Research Program.  The interview sessions take place in Dr. Hortobagyi’s office in the Department of Breast Medical Oncology in the Cancer Prevention Building on the Main Campus of MD Anderson.  Tacey A. Rosolowski, Ph.D. is the interviewer.

Born in Hungary, Dr. Hortobagyi’s family escaped as refugees to Bogota, where Dr. Hortobagyi was educated.  He received the equivalent of the B.S. in 1963 from the Colegio Helvetia in Bogota, and his M.D. in 1970 from the Universidad Nacional de Colombia, Bogota.  He served as a Rotating Intern at the Hospital San Juan de Dios, Bogota (69-70).  He decided to continue his education in the United States, and secured a position as a Clinical Resident in Internal Med at St. Luke’s Hospital in Cleveland, Ohio (‘71 – ’74).  In 1974, he came to MD Anderson for his Fellowship in Developmental Therapeutics, continuing with a Clinical Fellowship in Medical Oncology from ‘75-’76.  He joined the faculty as a Faculty Associate in the Breast Medical Servie in 1977, advancing to Assistant Professor in ’79.  He became full professor in 1985.  Dr. Hortobagyi has been instrumental in building the Breast Medical Oncology service at MD Anderson since his arrival.  He became Chief of the Section in 1984 and assumed the role of Department Chair in 1992, when the section was restructured as a Department under Dr. Charles LeMaistre.  He actively built the Breast Cancer Research Group at MD Anderson and has been active in Breast Cancer and Breast Medical Oncology groups worldwide.  His research has influenced Standards of Care in breast cancer treatments:  he initiated regimen that used anthracycline as backbone of adjuvant chemotherapy (20 yrs later became standard of care for primary breast cancer) and he was the first to prove the value of paclitaxel for front line and adjuvant therapy.  He developed combination drug strategy for preoperative chemotherapy followed by surgery and radiation, now considered standard for most primary breast cancers.  He developed a neoadjuvant modality allowed surgery for many inoperable tumors and advanced multidisciplinary research efforts to design personalized therapies and clinical trials to test gene therapy.  In 2013 Dr. Hortobagyi received the Jill Rose Award for outstanding research excellence from the Breast Cancer Research Foundation and the Bob Pinedo Cancer Care Prize from the Society for Translational Oncology in 2011.  In 2004 he was the first recipient of the Umberto Veronese Award for the Future Fight Against Breast Cancer.  He is a Chevalier of the Order of the Legion of Honor, France (received 2001).  In 2009 he received the John Mendelsohn Lifetime Achievement Award from MD Anderson.

In this interview, Dr. Hortobagyi gives an overview of his career and commitments. He sketches his childhood experiences as a refugee and his formative medical training in Bogota.  He details the many dimensions of his research. (His discussion covers the ongoing debates about clinical trials that were taking place at MD Anderson into the eighties.)  He also speaks at length about what was required to establish multi-disciplinary and patient centered breast cancer service at the institution, as well as tracing the evolution of Breast Medical Oncology.  Dr. Hortobagyi comments on leadership both within the institution and in the field of Breast Medical Oncology as an international endeavor.  Dr. Hortobagyi sets events in an historical perspective, and this interview consequently includes many snapshots of the development of oncology, of research, of the design of clinical trials, as well as vignettes of leadership, mentoring, and MD Anderson at many phases of its evolution.