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0:00 - Segment 00C: Interview Identifier

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Partial Transcript: "Let me just put an identifier on, and then we will be ready to roll. Okay—we are recording. And this is Tacey Ann Rosolowski, and today I am at the Proton Therapy Center for my third session with Dr. James Cox. Today is April 23, 2013, and the time is 10:31. So thanks Dr. Cox. "

Segment Synopsis:

Keywords:

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0:18 - Segment 13: The Regional Care Centers and Sister Institutions

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Partial Transcript: "And we were just talking about how today we are going to focus on your administrative roles, and you said you wanted to start at the end. So where would you like to start today?"

Segment Synopsis: 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.

Keywords:

Subjects: 1. Segment Code - B: Beyond the Institution 2. Story Codes - B: Building/Transforming the Institution B: Critical Perspectives on MD Anderson B: Devices, Drugs, Procedures B: Institutional Mission and Values B: Institutional Processes B: MD Anderson History B: Multi-disciplinary Approaches B: The MD Anderson Brand, Reputation C: Patients D: Fiscal Realities in Healthcare

25:23 - Segment 14: Head of the Department and Division of Radiation Oncology

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Partial Transcript: "And this was—this was after you were department chair (both speaking at once)—this is when you were division head?"

Segment Synopsis: 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 He also notes that the department was technologically out of date when he took over, and he explains the upgrades he introduced: a modern system for treatment planning, a CT simulator, and the transition from 2-D to 3-D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.

Keywords:

Subjects: 1. Segment Code - A: The Administrator 2. Story Codes - C: Professional Practice A: Definitions, Explanations, Translations B: Building/Transforming the Institution C: The Professional at Work D: Technology and R&D

45:22 - Segment 15: The Division of Radiation Oncology

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Partial Transcript: "I wanted to ask you—it is the second time you mentioned that the physicists—there was kind of a communication gap there or a disconnect—do you want to talk more about that in the department?"

Segment Synopsis: 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 segment with comments on his administrative approach.

Keywords:

Subjects: 1. Segment Code - B: An Institutional Unit 2. Story Codes - B: Controversy A: Obstacles, Challenges B: Building/Transforming the Institution B: Growth and/or Change B: Institutional Politics B: Multi-disciplinary Approaches C: Leadership

54:38 - Segment 16: The Division of Radiation Oncology—Strategic Planning and Growth

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Partial Transcript: "So, anyhow, we went from seventeen full-time faculty and by the time I—let’s see from ’97 let’s say to 2007 when we split the division department into a separate department and a separate division, and obviously they are not separate, but we had over fifty faculty."

Segment Synopsis: Dr. Cox summarizes the growth of the division between ’97 and 2007, when he retired: from 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 segment, Dr. Cox offers reasons for the separation of Departments within the Division of Radiation Oncology.

Keywords:

Subjects: 1. Segment Code - B: An Institutional Unit 2. Story Codes - B: Building/Transforming the Institution B: Growth and/or Change B: Institutional Processes B: MD Anderson Culture B: Multi-disciplinary Approaches C: Leadership

72:09 - Segment 17: The Story of the Proton Therapy Center

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Partial Transcript: "Right. Right. Would you like to talk about the Proton Therapy Center now?"

Segment Synopsis: 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 UT System would not fund it, Leon Leach, 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.

Keywords:

Subjects: 1. Segment Code - B: An Institutional Unit 2. Story Codes - A: Overview A: Definitions, Explanations, Translations A: The Clinician A: The Researcher B: Beyond the Institution B: Building/Transforming the Institution B: Devices, Drugs, Procedures B: Growth and/or Change B: Industry Partnerships B: MD Anderson Mission and Values B: Multi-disciplinary Approaches B: Obstacles, Challenges B: The Business of MD Anderson C: Discovery and Success D: Technology and R&D

90:07 - Segment 18: Research at the Proton Therapy Center; the Future

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Partial Transcript: "So we ramped up. We started in the—started building in May of 2003 and treated our first patients in May of 2006. We have now treated approximately 4,400 patients, and we have treated over 1,000 with the scanning beam. And still there is hardly—you know—there are only a handful of patients that have been treated with this scanning beam any other place."

Segment Synopsis: 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.

Keywords:

Subjects: 1. Segment Code - B: An Institutional Unit 2. Story Codes - A: Overview A: Definitions, Explanations, Translations A: The Clinician A: The Researcher B: Beyond the Institution B: Building/Transforming the Institution B: Controversy B: Devices, Drugs, Procedures B: Growth and/or Change B: Multi-disciplinary Approaches B: Obstacles, Challenges B: The Business of MD Anderson C: Discovery and Success C: Patients D: Technology and R&D D: The History of Health Care, Patient Care D: Understanding Cancer, the History of Science, Cancer Research

109:27 - Segment 19: The MD Anderson Presidents

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Partial Transcript: "I wanted to ask you some questions about relationships with the different presidents since you have worked with three of them now, and I know you were brought in by Charles LeMaistre [Oral History Interview] and was wondering if you could talk about him as an administrator—a leader—your working relationship with him. I know you had some questions and issues."

Segment Synopsis: 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.

Keywords:

Subjects: 1. Segment Code - B: Key MD Anderson Figures 2. Story Codes - B: Critical Perspectives on MD Anderson A: Personal Background B: MD Anderson in the Future C: Portraits

128:31 - Segment 20: Contributions to MD Anderson

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Partial Transcript: "I am aware that we are running over, so I wanted to ask you just a couple final questions. First of all, is there anything else that you would like to add about your experience at MD Anderson, your contributions?"

Segment Synopsis: 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.

Keywords:

Subjects: 1. Segment Code - A: View on Career and Accomplishments 2. Story Codes - A: Contributions A: Activities Outside Institution A: Career and Accomplishments A: The Researcher B: Institutional Mission and Values B: The MD Anderson Brand, Reputation C: Personal Reflections on MD Anderson C: Portraits

0:00

ROSOLOWSKI:

Let me just put an identifier on, and then we will be ready to roll. Okay—we are recording. And this is Tacey Ann Rosolowski, and today I am at the Proton Therapy Center for my third session with Dr. James Cox. Today is April 23, 2013, and the time is 10:31. So thanks Dr. Cox.

ROSOLOWSKI:

And we were just talking about how today we are going to focus on your administrative roles, and you said you wanted to start at the end. So where would you like to start today?

COX:

Well I want to start at the end only because of the Banner component that I don't really think that I played any significant role in that.

ROSOLOWSKI:

Okay.

James Cox MD I initially had discussions with Dr. [Thomas W.] Burke [Oral History Interview] about the role that the head of radiation oncology might assume relative to Banner, but it was clear that that role which I envisioned as something similar to what we do in the regional care centers nearby was not going to be that way. It was going to be a role where we would not appoint a faculty. We would not have—I mean—ostensibly we would have control if they got into trouble, but—I mean—we would not really have control. And that has been the case. I hear almost nothing about them. Matt Callister, who is a trainee of ours, is heading the program there. He is a very, very good person. And aside from his visiting from time to time I have almost no interaction with him. Now it is possible—I think Dr. [Thomas A.] Buchholz has had more interaction after I left the division head position, but I don't identify that.

ROSOLOWSKI:

Well what was the relationship that you had envisioned and that you would have wanted to work for?

COX:

Well it would be the same one that we have with the regional care centers where each of those people at—at least the radiation oncology part of the regional care centers—are faculty members of ours. And so we are responsible for evaluating them. We expect regular interactions with them, and we are in charge of the quality assurance program with them. We started that—did we ever touch on how we started the regional therapy (both speaking at once)?

ROSOLOWSKI:

No. Not at all.

COX:

Okay. Well, I'm sorry to be going backwards then.

ROSOLOWSKI:

No—that's quite all right.

COX:

Anyhow—there was an occasional discussion of MD Anderson doing something in the community, but it was just discussion. In 1998 or 1999 I became aware of two things simultaneously. One was that a former trainee of ours whom we all held in high regard was finishing her military obligation. She was stationed in—I think in Biloxi, Mississippi, and so she was wanting to come back to the Houston area. Her husband is a dentist, and they were wanting to return to the Houston area. At the same time we became aware of a facility in Bellaire that had—for lack of any other laborious description—had fallen on hard times. They had had difficulty staffing it. It had had—I think—problems with some results in patients that were not good—not satisfactory. And they were—the person who was leading that—a physicist—was interested in selling it. So we didn't sell it; we leased it. But that was the beginning of the entire regional care center program, and for many years the only activities in the regional care centers were radiation therapy. So when—and I was cautioned not to do that—that it was a mistake. It was a facility that had a bad reputation. It was going to tarnish the reputation of the institution, and I think by that time I had enough credibility with the senior leaders of the institution that they were willing to give us a chance to do it.

ROSOLOWSKI:

What was the need at the time for the regional care centers, particularly in radiation?

COX:

Well there were two needs. One is that the individual who was moving back to Houston was either going to be part of it or was going to be part of our competition.

ROSOLOWSKI:

Who was this individual?

James Cox. MD Elizabeth Bloom. And she is still very active—not there anymore. And she is an outstanding person.

ROSOLOWSKI:

Is that B-L-U-H-M?

COX:

B-L-O-O-M.

ROSOLOWSKI:

Okay. Thank you.

COX:

Liz took it on with enthusiasm and worked very hard, and we worked hard to bring the facility up to a presentable state to actually get new equipment put in there. In time it evolved in a way that made her happy and made us satisfied. And we were pleased with it (both speaking at once). Itt never built up to a very large number of patients, but it was successful.

ROSOLOWSKI:

What was the need from the patient care end?

COX:

Well, because patients often do not like to come to the Texas Medical Center. They find it confusing, intimidating, expensive, and if they can get their care closer to where they live and in a more comfortable, convenient environment as far as parking and things like that, they vastly prefer that. And it turned out that many of the patients that were treated there were actually seen in our multi-disciplinary care centers at MD Anderson—a program that involved radiation therapy was mapped out for them. And then they were given the option of being treated there. And some of them chose to be treated at the main center, and some of them chose to be treated there. And Liz did an excellent job. We did—we reviewed just as we do with every other patient—we reviewed—you know, a peer review of every patient that she treated. And she welcomed that, and it went very well. I wouldn't say it was without any bumps, but from a professional side it was quite smooth.

ROSOLOWSKI:

So is that peer review process—that is something that is done only with the development of treatment plans in the regional care centers? I am just trying to get—

COX:

No. It is done with every patient treated here.

ROSOLOWSKI:

With every patient (???)(inaudible)—oh wow.

COX:

Every patient treated in our department has a peer review by other faculty members.

ROSOLOWSKI:

Wow. Wow.

COX:

And that is—I don't know if that is unique to MD Anderson—it probably isn't now, but it is something that has been true at MD Anderson for at least thirty years—maybe longer.

ROSOLOWSKI:

Wow.

COX:

And it is very valuable because suggestions are made that sometimes change the course of treatment for a patient or at least fine tune it so that subtle distinctions are picked up by various people, and recommendations are made, and they are followed through. We do it here—every patient that is treated at the Proton Center is—undergoes peer review.

ROSOLOWSKI:

And that seems like a really key piece for regional and satellite care centers for quality control.

COX:

It is.

ROSOLOWSKI:

Yeah. Is that something—was that kind of the gold standard for you?

COX:

Uh-hunh (affirmative).

ROSOLOWSKI:

I mean—that was absolutely essential?

COX:

Yes.

ROSOLOWSKI:

Okay.

COX:

Yes. And then by invitation—we did not go seeking it out in the community—by invitation we established a relationship with St. Luke's Medical Center in the Woodlands, and then eventually I think it is CHRISTUS in Clear Lake and then I think another CHRISTUS facility in Katy. Then we had a brief stint at Fort Bend that did not work out well, and we went on to Sugar Land where we have a facility now with one and now—almost all of those places two faculty members.

ROSOLOWSKI:

Now what were the various lessons you learned in each of—setting up programs in each of those places?

COX:

It varied. There was generally enthusiasm on the part of the practitioners in the facilities, and they welcomed the presence of radiation therapy from MD Anderson, but there were certain things they didn't want to do. They did not want to have our pathologists involved or our diagnostic imaging people involved, and it took a long time to get over that. For Bellaire that was no issue, but in The Woodlands it was an issue, and it was a bigger issue as we went to Fort Bend. There were competitors in the community that really, really did not like us at all—in fact—in one case one of the competitors wanted to hire the radiation oncologist that we had at the facility and offered—I seemed to recall offered her more or less $1 million. We talked about it—she said no. But—I mean, it shows the degree to which there was competition in the community and not a uniform acceptance by any means. In some cases the people in the community established a radiation therapy facility quite close by for purposes of competition. But—anyhow—the tie-in with Anderson, the peer review, the quality of what we did in general has stood the test of time, and we are proud of it. Of course, it served as the basis for going into—then having medical oncology go into the same facility that first happened at Clear Lake, and it was very successful there. Having the laboratory go in there with the—able to obtain blood products and do blood tests. And then the pathologists were able to be involved. Some of that was facilitated by the electronic medical record. As it evolved it became easier to do those things in the community with the same record keeping approach and the same standard and everything that we have here.

ROSOLOWSKI:

Was that originally part of the plan to have all of those services in the regional care centers?

COX:

No. I think it was only after we showed success in Bellaire that it sparked the interest of a couple people. The gynecologist who had moved into the community on their own in some ways, but soon after that, and then Dr. Burke wanted to see it develop that way. Sorry. So medical oncology was next; the last to come in were the surgeons. And now there are—I think there are surgeon jobs in all of those centers, mostly surgeons dealing with cancer of the breast. I would say there is a preponderance of treatment of cancer of the breast in those centers, but pretty much everything is treated.

ROSOLOWSKI:

And what is the value for—when I was talking to Leon Leach [Oral History Interview], he was talking about the regional care centers as a strategic kind of opportunity. How do you see the regional care centers serving MD Anderson—you know (both speaking at once).

COX:

Well—it's not so simple. It helps the patients. I mean, it's good for the patients in terms of their convenience. There are certain things that we do that it is difficult to do—that are difficult to do in the regional care centers, especially as it involves coordination of several specialties. I mean—concurrent chemotherapy and radiation therapy and surgery—it becomes more complicated. And that is especially true for cancer of the esophagus, lung, and head and neck. But the other thing is that it undoubtedly takes some patients away from MD Anderson that would otherwise come here to the main center. And the way the—I don't know quite how to say it—the way the attribution of financial benefit from those centers to MD Anderson is recognized—is not very satisfactory from my side. When we were overseeing the radiation therapy practices in these centers, we kept separate books on that. We knew exactly how many patients were treated. We knew what the income was, we knew what the expenses were, and we had control of it. Then it was taken over by the institution, and it all flowed into a black box. And we can keep track of what happens with radiation therapy at the regional care centers, but I don't know if any of the other disciplines do or not.

ROSOLOWSKI:

So how does it work? I mean the idea is that the regional care centers—the payment—does flow back to the institution, and then the institution decides what portion of that goes back to the regional care center. And how—?

COX:

Well—no—it's—they have their budget. They have to justify anything that they want or need. They have to justify an extra nurse. They don't have any control. The control comes from the institution, and the institution doesn't always see the same need that is seen at the regional care center, so there can be differences of opinion about what the needs are in the regional care centers. I think most of that has become ironed out, but at the beginning that was a big problem.

ROSOLOWSKI:

Were there some themes in what the administration didn't recognize as a need? You know part of their learning curve is how to do this.

COX:

They did not know what was important that was missing, and some of it may be obvious, but some of it was a hard sell to them. We could say we needed an extra clerk to have—to be there for the patients when they checked in at a certain time of day. They would say, "Well—why do you need that?" And you'd say, "Well, we need it because we need it." And they would say, "Well, why?" And to try to document in some laborious way why you need what those people working there felt was obvious. You know—there was a disconnect, and there may still be, I just do not see it any more. I think that has become smoothed out as there has sort of been a head administrative framework developed for the regional care centers with Peter Pisters as a surgeon being the person responsible ultimately for it and a very reasonable guy, and I think one that tries very hard to do the right thing. So I think as an intermediary who has spent a lot of time—as we say—in the trenches, it is not so hard to make a case to him for the needs at one center or another as it is to somebody who has never taken care of a patient.

ROSOLOWSKI:

Do you think that the regional care centers had a positive effect on MD Anderson's public profile?

COX:

Yeah, I think they have. I think they have—certainly in the greater Houston area they have and in Albuquerque where we reached out the first time outside the state. It has had a very positive effect in Albuquerque. Now there are two other what might be called regional care centers, but they were there before any of the stuff that we started in 1999. One was in Orlando; one was in Madrid. Those were governed entirely locally, in some cases with a good business sense and in some cases like Madrid with a weak approach to business. Or—you know—I mean—it seemed weak to us. Plus, we had no quality control over what they did at all. We do now a little bit more in Orlando—we have some people who go there and review patients already treated, but it is not a prospective review. We don't have any of that in Madrid. And I don't know to what extent we have that at Banner. I mean—maybe I should know, but I just don't. So I dare say in my view Banner has developed more in the direction of the Orlando/Madrid model than it has the similar approach to what we have done with these regional centers around Houston, and quality control and control of the faculty—and that also means control of physics support. We think it is critical, and that is done in a consistent way in the regional care centers around Houston. That is not done in any consistent way in Madrid. Again—it is better now in Orlando as it's evolved over the last few years. So it has all started out with the discussion of Banner because I wanted to disavow any knowledge of Banner, but then one of the administrative things that I was heavily involved with was the early years of the development of the regional care centers.

ROSOLOWSKI:

And this was—this was after you were department chair (both speaking at once)—this is when you were division head?

COX:

Yeah. Now a department chair and division head were one and the same when I took over in—

ROSOLOWSKI:

'95?

COX:

'95. And they stayed linked until, I believe, 2007.

ROSOLOWSKI:

That is what I have down here, and then the title changed.

COX:

And then there was a separate department chair and a separate division head.

ROSOLOWSKI:

So there was a restructuring of the department at that time? Was there?

COX:

No. There was a dividing up of work.

ROSOLOWSKI:

Oh—okay. So how did that all work? What was the change?

COX:

I mean a lot of—the heavy load that falls upon the department chair and the person who shared both titles was evaluation of faculty, and that—you know—there is a requirement that the faculty are evaluated annually, and that forms are filled out, and questions are answered about have they done this and what—what contributions have they made and so on. And then that evaluation is supposed to match up with any recommendations for merit increases. In a more complicated way it is supposed to match up with how people use their time. In other words, are they spending only twenty percent of their time doing academic activities or are they more heavily involved in research that they are doing maybe in a laboratory in which case it may be a fifty/fifty designation. There are a very small number of individuals who spend twenty percent of their time clinical and eighty percent of their time in the lab, but those are specifically designated within the institution as physician-scientists. So there are only a few of those in radiation oncology, I think maybe four or five.

ROSOLOWSKI:

So what was the scope of your—well—tell me how you came to become department chair in '95.

COX:

They were linked together. They were just—it was one job—department chair and division head (both speaking at once).

ROSOLOWSKI:

Okay. So it was simply just a more limited title at that point. So what was the scope of your responsibilities?

COX:

Well—you know—in that position you did everything.

ROSOLOWSKI:

Yeah. How big was the department in '95?

COX:

In 1995 there were seventeen faculty. I think there were probably fifteen full-time physicists. There was only a pretty small symmetry group. The symmetrists are sort of a bridge between the physicists and the physicians. So—well, there were things that we did and not necessarily in chronological order, but in an order of some importance we expanded the faculty as we expanded the number of patients that we were treating. And we expanded the number of patients we were treating in part to keep up with the expansion and other disciplines in surgery and medical oncology throughout the institution. In doing that and recruiting the right people and having them in the right place and governing all that because we are so highly specialized that people who take care of patients with cancer of the prostate never treat a patient with cancer of the breast. And people who take care of patients with cancer in the head and neck do not treat patients with cancer of the lung even though it is a few centimeters away. So we are super specialized, and getting the right people into those right specialization areas is a challenge both for recruitment and retention.

ROSOLOWSKI:

When you say the right people—what were you looking for?

COX:

Well you are looking for people who are interested in that area who will make a contribution who have expressed some strategies or goals that would make them contribute in a favorable way to the group. And rarely—I don't know if I should say rarely—infrequently has the role of one entirely of taking care of patients. The goal is to have academic interests, academic accomplishments and to evaluate faculty on the basis of those accomplishments as well as the patient care.

ROSOLOWSKI:

What did you envision for the department and division when you took over in '95?

COX:

Well, the other thing that was lacking was that it was technologically pretty much out of date. And so approaches to equipment—new equipment, new—

ROSOLOWSKI:

Why was there—why was it out of date? Why hadn't there been a commitment to keeping up?

COX:

Well, I'm not sure I can answer that for certain. I believe it was the interest of my predecessor as department chair and division head that his interest was primarily in the laboratory, and I think he took pretty good care of what went on in the laboratory, but I think he was less interested in the breadth of activities in a clinical domain. And so—and at the same time the same was true—I guess—in physics. So it was a—there needed to be some changes in those areas. I mean—Dr. [Lester] Peters left and went back to Australia. Dr. [Ken] Hogstrum and I were together for a while. He was not as open to that movement of technology as I was hoping to see.

ROSOLOWSKI:

What was going on in technology that you wanted to grab hold of?

COX:

Well—for example—we didn't have modern computer systems for treatment planning. They had a home-grown system that they were sort of married to, but there were commercial systems now becoming available that were much more sophisticated, and that other people in the community and private practice in the community had these systems and were able to do things that we were not able to do.

ROSOLOWSKI:

What does a system like that do?

COX:

It stores the characteristics of the beams that you have. You know—if you have an accelerator and it has got two photon beams and 6 electron beams—those beam characteristics are measured and stored in the computer. And then you capture—and that was the other thing that was missing—we did not have a CT simulator, so we were using old fashioned simulation. And so we needed to get CT simulators to use which then that information could be put into the computer, and it could be planned in three dimensions. So we went from doing two-dimensional treatment to three-dimensional treatment at virtually every site—some earlier than others. And then as time went on and the field moved forward, we went from the three-dimensional planning which was based on CT and MR—those two major approaches, and then that combined with the computer-assisted treatment planning systems or the computerized treatment planning systems, and with that was the development of a much more sophisticated dosimetry program. We developed a dosimetry school, and for the first couple of years we could train the dosimetrists, but they did not want to stay and work here.

ROSOLOWSKI:

Why didn't they?

COX:

Well—I don't know. I guess the work environment was not as comfortable as they would like, but—so that changed over time.

ROSOLOWSKI:

Now is the dosimetry school still in existence?

COX:

Oh yeah.

ROSOLOWSKI:

I had no idea.

COX:

It is very vigorous.

ROSOLOWSKI:

Wow.

COX:

I've forgotten how many students there are—probably fifteen maybe. We have a therapy school and a dosimetry school, and they are both excellent, and the people who are trained are in very high demand.

Tacey Ann Rosolowski, PhD And these are all things that were started when you were division head?

COX:

The therapy school was already there, but the dosimetry school was not. And so it was started—I recruited—actually Robin Famiglietti, who is now the division administrator who came and started the therapy school, started the therapy program, expanded it greatly, did a wonderful job in developing it, and now it is a gem of the department or division.

ROSOLOWSKI:

Were there other technological initiatives—technologies available that you brought to MD Anderson?

COX:

Well—I mean—those—I think those were the major ones. There were similar kinds of technological developments in the area of brachytherapy—that is where you put sources in the body—but probably the major ones were computerized dosimetries so that we could go from 2-D to 3-D, and then the imaging that fit into that kind of dosimetry. And then as time went on we went on to intensity-modulated radiation therapy, which was another more sophisticated way of planning and delivery, and it was dependent upon getting new accelerators that had the capability of delivering IMRT.

ROSOLOWSKI:

What does that mean—intensity-modulated?

COX:

It means that you can target a tumor and deliver unequal doses with the beams that come in from various different directions, often five to nine different directions, and they sum in a way so that it gives a high-dose to the tumor, but it avoids the nearby normal tissues. And it is now our preferred way of treating—I would say the majority of patients that we treat with curative intent in any site—maybe not every site. But like in head and neck it is the only way we do it now.

ROSOLOWSKI:

It sounds like it has a similar function to the proton therapy in that it can target and not (both speaking at once)—

COX:

Yeah. It does. It does.

ROSOLOWSKI:

Yeah—go into healthy tissues.

COX:

Yes. It does. And, in fact, it was a challenge on the part of some of the people who were doing so well with IMRT—especially our head and neck team—were doing so well with IMRT that they didn't have any interest in protons. Now that has changed or at least is in the process of changing so that now some of the areas that are treated under the title or rubric of head and neck are now being treated only—well not only but preferentially with protons.

ROSOLOWSKI:

Tell me about some of the kind of key moments of change or growth in the division when you were head.

COX:

I'm not sure there were moments so much as it was a continuum. I probably—I think that probably the first thing that changed was an approach to buying equipment. There were those who felt that it was good to have different kinds of equipment from different vendors because there were research opportunities. This was among the physicists. I didn't agree with that, and I had some problems with the physicists on that because if we had equipment that replicated each other—if one piece of equipment went down and we could change over and patients would never lose a treatment, and we evolved in that direction. So there was a change there. And then the equipment itself evolved, and we sort of kept up with what were the latest capabilities that the equipment itself provided like these multi-leaf collimators where you could shape the beam with devices inside the head of the linear accelerator, and that is especially important for IMRT. And so you got accelerators that had that. And then there were others that had imaging devices attached to the accelerators. We used to call it OBI—on-board imaging, but now pretty much every accelerator has on-board imaging, so we don't talk about it anymore. It's just part of what an accelerator does because we set up the patients with imaging before we treat them. So all of this was in evolution, but I think changing the approach to buying accelerators was a big change early on, changing the approach to dosimetry systems was a pretty big change, and some of the physicists bought into that, and some didn't at the beginning because they were interested in their own research area that involved that. A lesson there that the institution is learning now is that you can develop something within your department or within your institution, and it is not only state of the art it is ahead of state of the art. But then companies come along, and they can devote absolutely everything that they do to developing the same thing, and it can quickly go beyond what our department can do or what the institution can do. And so now that's coming up with the electronic medical record. They are going to change the electronic medical record from what we have now to a commercial system sooner or later. I am not sure exactly when that is going to take place. So that was very much true for the treatment planning systems also.

ROSOLOWSKI:

I wanted to ask you—it is the second time you mentioned that the physicists—there was kind of a communication gap there or a disconnect—do you want to talk more about that in the department?

COX:

Well it is a delicate area. I mean—the fact of the matter is that the head of physics at that time and I did not see eye to eye with where we needed to go, and I eventually realized that I couldn't get to where we wanted to go with him.

ROSOLOWSKI:

What were the differences in opinion—viewpoint?

COX:

It was more—it was more an almost full-time concentration on education as the main part of what a physicist should do rather than patient care and research. That was the main difference. And certainly there's nothing that I have against education. I think it's terribly important, but it could not be at the expense of everything else. So I think that was the most fundamental thing. And then there was the business of equipment and wanting to move into new equipment, and there was—just a hesitancy to do that, and we just weren't moving.

ROSOLOWSKI:

Who was the person who was head of radiation and physics at the time?

COX:

Ken Hogstrom.

ROSOLOWSKI:

And so how did you resolve that? Get around it?

COX:

I got rid of him. That is why I am a little hesitant—because when I got rid of him there were other people who were personally very tied to him that left. So we had a real changeover of the physics group. Some stayed and continued to make a really important contribution, some very talented people left. And we brought in Radhe Mohan who was the—had been the head of clinical physics at Memorial Sloan Kettering and then the head of the department of physics what is now called Virginia Commonwealth Institution—Virginia Commonwealth University—then it was called the Medical College of Virginia. When Radhe came he was very much on the same wavelength that I was as far as developing both the clinical or the technological aspects about the department and the research portfolio of the department. So we went from having no externally funded research to several million dollars' worth of externally funded grants, and that's not counting contributions from companies that wanted us to do certain kinds of research with them.

ROSOLOWSKI:

Now when you said the research portfolio, what was in that portfolio? What did you envision as sort of an idea balance?

COX:

Well I envisioned—I didn't necessarily have a goal of a certain kind of research, and it has taken several forms. The idea of having people spend a significant portion of their time working in new areas where they could apply for grants to the National Cancer Institute or the Department of Defense or the Department of Energy where it would be peer-reviewed and externally funded—I think that was an important goal that we achieved, and Dr. Mohan deserves a lot of credit for that. In the process, he brushed up against some people in the division. And—you know—it was entirely smooth, but in general things went in a very positive direction. Administratively—my approach—whether it is with residents or faculty or even department heads—and there are of course two other departments in the division besides radiation oncology. There is experimental radiation oncology and radiation physics. So my approach has been to hire good people, not tell them what to do, but support the ideas and directions that they want to go, and I think that leads to happier, more productive individuals, although sometimes it can lead off into tangents. And if we have reviews of the activities, eventually that gets sort of corrected with time. And it gets corrected by peer-review. I mean external reviewers.

ROSOLOWSKI:

How did you develop that kind of leadership or administrative approach?

COX:

Pretty much that has been my approach all along from the beginning. When I was at the Medical College of Wisconsin I was recruiting people, and there were several things that I liked to do myself in terms of clinical activities—take care of patients with head and neck cancer, with cancer of the prostate, with lymphomas. Well, in order to recruit people that I wanted I had to give that up to them, and I often sort of kept a hand in and was sort of involved with it, but I had to give that up. And ultimately about the only thing that was left that nobody wanted was cancer of the lung. So I ended up working in that area. And one of my colleagues twenty-five years ago said, "You are wasting your time doing research on cancer of the lung because it's just hopeless, and you're not going to get anywhere, and it's just going to bury you." So—anyhow—it did not, but I—that has been my approach. Sometimes selecting the people has not been correct, although I think my sense of evaluation of people is pretty good. And I have few regrets—a few—but I have relatively few regrets about the people that I have recruited, and the people who are here now I think are fabulous (both speaking at once).

COX:

So, anyhow, we went from seventeen full-time faculty and by the time I—let's see from '97 let's say to 2007 when we split the division department into a separate department and a separate division, and obviously they are not separate, but we had over fifty faculty.

ROSOLOWSKI:

That's amazing.

COX:

We had gone from treating 240 patients a day in '97 to treating about 600 patients a day now with absolutely advanced technology and still with peer-review.

ROSOLOWSKI:

What has that represented for the institution?

COX:

By and large they have been happy. We have made a lot of money for them. They have been supportive, and I think probably I have made—and the people that I've hired that have worked with me closely have made reasonable estimates of what we were going to do, let's say, in planning a budget, and we have been pretty accurate in doing that. So we have maintained a high level of credibility in terms of our planning.

ROSOLOWSKI:

What kind of revenue stream are we talking about here? What kind of money does the division of radiation (both speaking at once)?

COX:

Right now I am not entirely sure. I think from the technical side—that is to say that which flows to the institution as opposed to PRS—gosh I don't know—it's been so long since I've looked at the figures with a high level of interest that I want to say in general the whole portfolio is of the order of—maybe $250 million or more.

ROSOLOWSKI:

I was asking because in one of the articles that I read for background research the author was saying that you were interested in looking at strategic planning issues with the division. And so I was—

COX:

We did that regularly.

ROSOLOWSKI:

So how did that work? And with what result?

COX:

Well—we got people together once a year, and we set aside a certain amount of time to look at various components that included our educational program that included research, and the research of course included ERO physics as well as the clinical department. In the clinical department there were people doing research that was actually in the laboratory, but they were clinicians doing research in the lab.

ROSOLOWSKI:

What were the strategic planning goals?

COX:

They differed each year. I mean we developed—we had a meeting one time in the midst of this where somebody from outside of the institutions challenged—what is your goal? And I said, "It's to be the best, it's to have the best division or department of radiation oncology in the world—bar none." And I think we have done it. So in each area it was how can we enhance what we are doing? Accepting the fact that we are doing really well here, how can we make it better? Don't rest on your laurels—think about how you can move forward in a more positive direction. Now it is true in every part of the division. There is another piece of it—and I may have mentioned this before in other context—and this is not part of strategic planning, although it underlies strategic planning. We wanted to have a department that is absolutely as supportive as it possibly could be for the people who work within it, so something that I have said frequently is absolutely our top priority in everything we do is the patient. Nothing gets in the way of that. And if you do strategic planning with some goals, the goals have to point in that direction, but second only to the patients is taking care of each other. I have emphasized that over and over again, and I think that has become part of the culture I believe.

ROSOLOWSKI:

What are some things that you did or fostered to create a supportive environment?

COX:

I have very little patience for people who are trying to intimidate each other. And that is true among the residents, it is true with the faculty, it is true throughout the entire department, so occasionally there would be people who would sort of—in one way or another—put unnecessary or inappropriate pressures on other people. You might say brow beat them. And I just—I would talk with them and say, "Just don't do it." Now I would not do it in public, and so a lot of times they wouldn't know I had even done it, and the other people wouldn't know. They might complain to me and say, "Why haven't you done something about this?" And I would say, "But I have." And sometimes it was not obvious for a while. So that was one major thing, and it included faculty.

ROSOLOWSKI:

Well, in general I think the people who are hired at MD Anderson are pretty high intensity independent people.

COX:

Yeah. They are.

Tacey Ann Rosolowsk,i PhD And that must create some unusual challenges of getting people to work together, leaderships—you know—is that something you have found?

COX:

Well, I think if people enjoy doing what they're doing, if they are working in a supportive environment, then to be able to transmit that to the components that they are responsible for—you know—the other parts of the department and even within the institution because—I mean—we know many circumstances where people in other divisions were really, really unhappy with the leadership and really unhappy with the way things were done within their section. And sometimes the solutions were really obvious to me, but of course it wasn't my division so what could I do? On rare, rare occasions I went to John Mendelsohn about it, but not on any kind of routine basis.

ROSOLOWSKI:

Is there anything else you would like to say about your time as division head?

COX:

You know there is a publication, and I have forgotten was the occasion is, but Robin Famiglietti—do you know Robin?

ROSOLOWSKI:

Uh-hunh (negative). I'll just pause here.

COX:

Yeah. I think so. So Robin would have the publication. They did—and I cannot remember what the occasion was. I guess maybe it was we started doing an annual report, and I think maybe the first one that was done was more than an annual report. And I suspected this was in—I think it was after we separated the departments, so I think it was probably somewhere between 2007 and 2009. But there was an annual report, and I think it documents what happened over time so that there are numbers put to the things that I have told you about how the division changed.

ROSOLOWSKI:

I didn't ask you why the departments were separated in the way that they were.

COX:

That is a funny story. Well one—the amount of work to be done just got to be too great. At the same time you were trying—needing to do everything in regard to the faculty and to make sure people were doing what they needed to as far as taking care of patients. And then there was the issue of recruiting a new head of experimental radiation oncology and a new head of physics when Dr. [Radhe] Mohan stepped down as chair. So there were a lot of things to be done on the division head side as well as the department chair side. Plus the reality is that there was—in my mind—a natural successor, and that was Tom Buchholz, and he was being recruited away to another institution. And so I decided to separate it at that time, and then they would launch a national search, which they had to do. This was with the blessing of the president of course. They would have a national search with the hope that Dr. Buchholz would be selected, although there was another fine candidate from the outside—or actually who had been here before and who is in another state—they were finalists. And anyhow Buchholz was chosen through the usual search process—not a quick process—it took a year. But he knew he was a candidate, hopes that he could have that job, and he and I have a very close working relationship, and I have tried to be a mentor to him in many ways. And so it was in no small part a way of trying to keep him, and that was sort of decided at the time when he was getting stronger overtures from other institutions. At that same time it was happening in other divisions. They were separating the head of the division from the head of the department whether it was in pathology, diagnostic imaging, medical oncology, so there was ample precedent for it.

ROSOLOWSKI:

Was there an impact on how resources were allocated? Space? All of that? I'm just curious what effect it had.

COX:

Not a whole lot. There was not a whole lot of impact there. The impact had to do with sharing decision making, having some resources that previously had come to me as department chair that were already designated in that way by PRS—how PRS funds float. But it was more decision making, but it was also recruitment. He took a major role in recruiting the faculty. So it worked out well, and once he was well-established it made good sense for me to step down from that position, although now he's got this situation of being department chair and division head, which is not a comfortable situation, but with the sort of economic situation at the moment I don't think that is going to change right now.

ROSOLOWSKI:

Right. Right. Would you like to talk about the Proton Therapy Center now?

COX:

Sure.

ROSOLOWSKI:

How it all got started and—.

COX:

As we evolved—as I described to you earlier. Technologically going from 2-D treatment planning and delivery to 3-D treatment planning and delivery to IMRT—it became abundantly clear just as you suggested that we could do a better and better job avoiding normal tissues and concentrating the beam on the tumor, and in principle the best way to do that is with protons because they can be made to stop, you can shape the proton beam so that it conforms to the tumor, and so it seemed obvious that was the logical next step. And there were a couple other facilities in the U.S. that were hospital-based, so—

ROSOLOWSKI:

When was this idea born really?

COX:

It was born around 1998 or less, and we went and talked to Dr. Mendelsohn who in turn talked to people at the University of Texas system, and we looked at what it would cost in a sort of global sense. And they said that sounds like a great idea—we are not going to spend the money to do that. It would—taking on that additional debt would mess up our bond rating, which is hallowed to them. So with the help of Mr. Leach, Dan Fontaine, and at that time the person who was very important—Mitch Latinkic, who was our division administrator—but primarily led by Leon and Dan. We looked for another way of getting funding, and the idea of developing a public/private partnership was born in those discussions, and we put out a request for proposal and had more than one proposal.

ROSOLOWSKI:

Can I stop you just for a second? I want to ask you what was it that convinced you and enabled you to convince John Mendelsohn and Leon Leach and (both speaking at once).

COX:

It was the results—it was the results that we were seeing as we went from 2-D to 3-D—even 2-D to 3-D.

ROSOLOWSKI:

So could you describe those results?

COX:

Well we were able to give higher doses and still not have higher side effects with the normal tissues, and we did a randomized study here in cancer of the prostate, and it showed that we could give higher doses and have a better result from that—a higher rate of freedom from progression.

ROSOLOWSKI:

So was the decision—I mean—I'm just wanting to make sure I get this correct—was the decision to embrace the proton therapy based on studies done with IMT or there were studies available from proton therapy that—

COX:

No—no. Studies were not available for proton therapy (both speaking at once). There were some studies available that showed the safety of using proton therapy, and those studies were done in physics research laboratories, but enough patients were treated—probably 40,000 or 50,000 patients were treated in those physics laboratories that showed that it was safe and that it worked and that you could spare the normal tissues, and it really had a big effect in some areas, especially children.

ROSOLOWSKI:

But the technology was pretty new so—there wasn't—

COX:

Oh the technology was very new. In these other places it had been developed in their facility—Mass General—it was developed at Mass General. They had treated patients at the heart and cyclotron laboratory—the physics laboratory for years, but they were going to take on placing proton capability at Massachusetts General Hospital, and Loma Linda University had started treating patients in 1991 with proton therapy. It hadn't published; they were not a very academic crew. But what we knew of what they had done was very favorable.

ROSOLOWSKI:

So what else did—I mean—just as sort of the background piece because I know—I mean—Leon Leach and John Mendelsohn certainly would not have gotten on board with this if it hadn't—there had not been something very compelling in terms of what it offered for patient care, but then on the other side something compelling of what it would offer the institution financially.

James Cox MD I don't think they were looking at it from the point of view of what it would offer the institution finally. I mean—they were looking at it as a resource to—they didn't want to lose money, but they were looking at it as a resource for the care of patients, and I think—if you asked others I am pretty sure they would say that it was the credibility that I had both with John [Mendelsohn] and with Leon [Leach] and Dan [Fontaine] that if I said that this would do this and that this was a right thing to do they would believe me. And they studied enough on it to—you know—to understand what I was talking about. But basically I think they believed what I said, and that was enough to move forward.

ROSOLOWSKI:

So you were talking about that process of creating that public/private partnership.

COX:

Right. So that was led by (both speaking at once)—that was led by Leon, who did a wonderful job. Leon and Dan especially, but the final thing on this was that it was Leon's. And developing the public/private partnership, and the private part of it was a joint enterprise between Sanders, Morris, Harris, the investment banking company, and The Styles Company, which had been—had a history of building and running healthcare facilities over many years. So they put together a proposal, they said that they would raise the money, that they had the knowledge to build the facility, and so we developed that partnership with them. Then it was a matter of finding who the—you know—who the vendor was going to be or what the company was going to be that would provide the proton source if you will. And that turned out to be Hitachi. And we looked at many others. We looked at the one that was involved with Loma Linda. We looked at the one in Belgium, which is Ion Beam Associates—IBA—and we visited them. And we visited Tsukuba University in Japan where Hitachi had built from scratch a proton facility, and it was seeing that and knowing the depth of Hitachi's capability. I don't know how many hundreds of billion dollar company with engineering capability, which is just enormous, and we worked out a proposal from them. It was not easy because of the difference in business cultures, but actually that is where my wife's role came in because she played a very important role in bridging with the Japanese.

ROSOLOWSKI:

And your wife's name?

COX:

Ritsuko Komaki—Dr. Komaki—K-O-M-A-K-I. She was absolutely instrumental in getting this. It turned out that one of the key people in Hitachi—actually the president of the company within Hitachi that was responsible for proton therapy, had been a high school classmate of hers.

ROSOLOWSKI:

Oh—how funny.

COX:

In Hiroshima.

ROSOLOWSKI:

It is a small world.

COX:

And—you know—again—it was the credibility that she had and through her that I had with him that made it possible. Otherwise, I think it would have fallen through.

ROSOLOWSKI:

What were some of the issues that were coming up to make the negotiations difficult?

COX:

The people who were negotiating from Hitachi and the United States couldn't say yes to anything; they could only say no, and they needed somebody to tell them that it was okay to say yes. The people from our side were exceedingly legalistic. They wanted penalties if you didn't reach this milestone or that milestone or so on, and that wasn't the way they were used to doing business in Japan. You know—it was not the matter of talking about penalties; it was saying if you said you were going to do something you would do it, and not doing it was a matter of losing face, and that was driving them more than anything else here. The people here didn't understand anything about the idea of losing face. They wanted it all spelled out on paper that if you did not do this you would have to pay them that, though we finally got over all of that, signed the contracts in December of 2002 in Houston, and—

ROSOLOWSKI:

I have got this lawn mower coming back and forth.

COX:

That does not help you at all—does it?

ROSOLOWSKI:

Well he is looking like he is almost done. They could probably filter some of it out.

COX:

Then from that point on it was an intense thing with our physics team working together with Hitachi's engineers and physicists to describe exactly what we wanted in it—what capability we wanted in the unit here.

ROSOLOWSKI:

Because this was a complete custom build? I mean—(both speaking at once).

COX:

Oh yes.

ROSOLOWSKI:

Yeah.

COX:

Totally.

ROSOLOWSKI:

Yeah.

COX:

Well—it was not complete—I mean there was a very credible example at Tsukuba University, but we were asking capabilities of them that were not part of that.

ROSOLOWSKI:

And what did you—what were you asking?

COX:

We were asking for one thing—we were asking for what is called a pencil beam or scanning beam where you can sort of aim the proton beam into the tumor, and you did not have to have any devices to shape the beam or anything like that.

ROSOLOWSKI:

Interesting. Was that done manually or—?

COX:

No—by magnets.

ROSOLOWSKI:

By magnets. I see.

COX:

It avoided your having to do—put in these devices manually, which you did with the other—with passage scattering, which is what we call the other way of giving proton therapy where we have a proton beam that is broadened, and then you have to shape it with brass pieces and then with acrylic pieces that sort of partially absorb the protons so that it ends up with a distribution in depth that looks like the tumor.

ROSOLOWSKI:

Interesting.

COX:

But with the scanning beam you do not need those devices, but it is a very sophisticated thing, and there was no commercial vendor that had that.

ROSOLOWSKI:

Was that the main feature you were asking for, or were there others?

COX:

Well it was one of them.

ROSOLOWSKI:

What were the others?

COX:

Oh—dose rates and sort of automation of various components.

ROSOLOWSKI:

Now how does it work? I mean—can you only—how many patients can you have receiving these beams at once?

COX:

You can only have one patient at a time.

ROSOLOWSKI:

Oh really?

COX:

We have four rooms. One patient being treated, and during that time the other patients are being set up, but then you have to switch from room to room because there is only one synchrotron, and it is producing beam all the time, but it is being extracted and sent into one room and then into another room with various energies. So the switching of energies had to be electronic, and the changing from one room to another had to be—it all had to be based on a computer that Hitachi had. But then we had two other computer systems, and therein lies part of the bumps in the road that we ran into. One was the treatment planning system where—you know—you had the beam characteristics stored as we talked about earlier—beam characteristics stored in the computer, and then we captured the CT images of the patient, and then the dosimetrists and physicists and physicians put together a plan to avoid normal tissues and to have a high dose at the tumor. So I mean—and the third computer was the record and verify system—the electronic record, and they were all produced by different manufacturers, and they all had to talk nicely to each other. And it took a lot of give and take before that happened.

ROSOLOWSKI:

It is always in the details.

COX:

Right.

ROSOLOWSKI:

Yeah. So—

COX:

So we ramped up. We started in the—started building in May of 2003 and treated our first patients in May of 2006. We have now treated approximately 4,400 patients, and we have treated over 1,000 with the scanning beam. And still there is hardly—you know—there are only a handful of patients that have been treated with this scanning beam any other place.

ROSOLOWSKI:

So I assume—I mean are all of the patients—or the majority of patients who are receiving treatment involved in some sort of study?

COX:

Uh-hunh (affirmative). Yes.

ROSOLOWSKI:

And what kind of studies are you doing?

COX:

There are several. One is in—basically they are studies of trying to increase the dose or deliver the same dose to the tumor while sparing normal tissues and documenting the degree to which you are sparing normal tissues. So we have a master protocol that takes all of those patients into account, and then we have discrete specific protocols for various components. We are doing the only studies comparing proton therapy and IMRT. We have a protocol that we started in 2008 that is nearing its completion that is for non-small cell lung cancer, and then we have a relatively recent protocol within the last year or so comparing IMRT and protons for cancer of the esophagus, and then we have a new protocol—a new protocol that is being developed for the RTOG, which is also asking that same question—protons versus IMRT.

ROSOLOWSKI:

So this is still—since the number of patients is still pretty small, these must be fairly small studies.

COX:

Right. They are. I mean—

ROSOLOWSKI:

Are these all MD Anderson-based or are you collaborating?

COX:

The one with—the only randomized study the IMRT versus protons that is in conjunction with Massachusetts General Hospital. And then there are some other small studies with Mass General that involve radiating the liver, children—various tumors in children, and the base of the skull.

ROSOLOWSKI:

How long do you think—well—what is—is there a controversy right now about the value of proton therapy?

COX:

Oh yeah. Big.

ROSOLOWSKI:

And what is that based on? What is the conversation about?

COX:

Well—turn your recorder off and let me—

[The recorder is paused.]

ROSOLOWSKI:

All right. So we are recording again.

COX:

I think there are several reasons why people object to proton therapy. There is one group of people who are anti-technology. My wife, Ritsuko, ran into one in India when she was there at a meeting. A guy from England who simply said it is unnecessary, but then he said—you know—and IMRT is unnecessary, and he went on and on. Apparently none of the current technology seemed to be worth anything to him. So—okay—I mean if you are starting from that point I do not have much to say. There is another group that says, "Well—it looks good on paper in the computer, but how do we know it is real?" Well—we make actual measurements—our physicists make actual measurements for every patient before any treatment is given, so we know it is real. Plus we have examples of human dosimetry that have shown that it is also real. And so that does not hold water, although—again—there are people who believed that, and in this whole thing there is a lot of belief. Now the one thing that they can say which is accurate and is not believed is that proton therapy has never been shown in a prospective randomized trial to be better than x-ray therapy. And they are right. I mean—we are doing those studies now, and people have not done them before, and eventually those studies will be done and completed. But—and those are kind of purists, but they are right; there has not been any demonstration with prospective randomized comparisons.

ROSOLOWSKI:

What are the preliminary findings from the studies that are being run now?

COX:

Well—we are having fewer side effects.

ROSOLOWSKI:

Is that the main area of benefit? Or are there—?

COX:

Well, in some cases we are giving higher doses and still having fewer side effects, and we think that that will translate into better tumor control, and the side effects are—you know—especially important for children. I mean—my gosh—if you radiate any structure in a child—any growing structure—and all tissues in children are growing by and large—you run the risk of damage that is permanent and progressive. So anyhow those are the main—oh—and there is a third argument or fourth argument—whatever it is—that says okay we understand in principle the value, but there are too many uncertainties in the physics and the dose distribution and the accuracy and all of this—too many uncertainties to be able to adopt this at this time. Now hiding behind that in many cases is a viewpoint that we are either not ever going to have proton therapy, or it is going to be so many years that we are going to have to be using x-rays for a very long time. And so there is the naysayer from the point of view of we won't be able to have that. And—again—it has made it difficult in several areas. It has made it difficult to have papers accepted in journals because one or another reviewer may come at it from any one of those directions that says—you know—this is just not true or not valuable, and it has been a surprise because people who say, "Well—we need data," and then you go to publish data and they do not want to accept the data, and the data is never perfect. I mean—it is always more fragmentary and incomplete than you would like it to be. But in the meantime the body of data will build if there are publications that can be looked at. So—anyhow.

ROSOLOWSKI:

That is surprising. Yeah. So what do you foresee in the future for the research and for the Proton Therapy Center?

COX:

Well, I think—the Proton Therapy Center here is being very successful. One of our main goals was to expand the indications for proton therapy beyond those that had been already investigated in the physics research facilities years ago—expand into other areas where protons would be valuable. And this could be in the head and neck, in the brain, of course children, in the abdomen where it is not used very much, possibly in the pancreas, certainly for the liver, and maybe for the rectum. So I think proton therapy is going to establish a place for the treatment of many diseases or many stages of disease so that it will possibly occupy as much as maybe twenty percent of all the patients that are treated with radiation therapy. It is not going to ever be close to one hundred percent. So—and I think there is enough recognition of that value throughout the world now that it is just—you know—the development of proton centers is going very rapidly.

ROSOLOWSKI:

So how do you determine which patients will receive proton therapy?

COX:

Well, one are these sort of protocols that we have developed where we have thought ahead which patients would—for which patients it would be valuable. And that is brain, children, lung, head and neck, esophagus, and with this we know what specific normal tissues we are trying to avoid, what side effects we are trying to avoid, and that is the goal. And we also know that there are some types of patients that we are not ever going to treat with protons. We are not going to do total-body radiation. We are not going to do whole-breast radiation in place of mastectomy. We're just not—and we are not going to use it by and large for just palliative care. It's not that we will never use it for symptom relief, but by and large it is to be used to treat patients with curative intent. If it's to be used for palliative care, it's to give a very high dose in an area where they are surrounding normal tissues that are really worrisome.

ROSOLOWSKI:

So do you see the center expanding, or how do you—where do you see it going?

COX:

Oh I think it will—I think it will stay pretty much the way it is probably for another year or two because there needs to be upgrades of certain things. Hitachi has made further developments as they have developed facilities for other institutions, so they have made progress in areas that we are interested in. We can do a better job of combining imaging with the proton therapy, which we do not have the best imaging in the room that we would like to have, and so we need to get that developed. But there are plans and a way to do that. So I think it will continue to develop and—

ROSOLOWSKI:

Now, in terms of the relationship of this center with other departments and services at MD Anderson, do you find that you work well with people—identifying patients of theirs that might be—

COX:

Yeah.

ROSOLOWSKI:

And so that communication process has been pretty smooth?

COX:

In general that has been quite favorable. We have not had—yeah—that has been quite favorable.

ROSOLOWSKI:

And I'm sure that will help a lot in feeding patients into your study—

COX:

Oh—it does.

ROSOLOWSKI:

Right.

COX:

It does help a lot.

ROSOLOWSKI:

Yeah. Is there anything else that you would like to say about—

COX:

Where we have not had great success is recognition in the regional care centers of the value of proton therapy, so we get very few referrals from the regional care centers.

ROSOLOWSKI:

What do you think that's about?

COX:

I don't know.

ROSOLOWSKI:

That's interesting.

COX:

I don't have a good explanation for that. We have one person in Clear Lake who sends us patients—not high volume—but sends us patients on a regular basis, but she is the only one.

ROSOLOWSKI:

Who knows—that is interesting. Is there anything else you would like to say about the Proton Therapy Center? Or the process of developing it (both speaking at once)?

COX:

You know—I think it's been—well what has happened over the past few years is that the original investors have pulled out there—the financial commitments to them have been completed. I don't know what the financial breakdown of the various components of support for the Proton Center, but it is my understanding that there are Chinese investors that are involved in the last year, and there are—and MD Anderson now owns actually the majority. I mean—it has—I think it has fifty-one percent interest, and I believe that was bought out from Hitachi. So I think it is going okay. I think it is maybe not—we are not treating as many patients as they would like to see, but I think that will fluctuate over time.

ROSOLOWSKI:

I wanted to ask you some questions about relationships with the different presidents since you have worked with three of them now, and I know you were brought in by Charles LeMaistre [Oral History Interview] and was wondering if you could talk about him as an administrator—a leader—your working relationship with him. I know you had some questions and issues.

COX:

You know—in something like this I don't know what I should say because—

ROSOLOWSKI:

Well—the way I look at it is not so much telling tales out of school, but really an evaluation. You know—like what could have been done better, what was done okay—that kind of thing.

COX:

I think—as I have summarized it—and I think even to you—I came in with what seemed to be a great title that turned out to be a bad job. And the reason it was a bad job is that the division heads—the division heads felt I had a responsibility to them. I thought coming in that I had more of a responsibility to—that I was not limited by my responsibility to them.

ROSOLOWSKI:

And just for the recorder (both speaking at once)—

COX:

That it was more of a—that it was more of a leadership position than a management position, and it turned out to be purely a management position. And if the division heads did not like a decision that I would make, they would turn around and go to Dr. LeMaistre, and he did not dissuade them.

ROSOLOWSKI:

And just for the recorder I will say you are speaking about your period as vice president of patient care.

COX:

Yes.

ROSOLOWSKI:

Yeah.

COX:

Entirely. And then as time went on—you know—it became clear that we had a different orientation. He—actually LeMaistre was interested in issues that were related to the University of Texas system. I think he was proud to be president of MD Anderson. I think it served him from the point of view of posture within the community. I don't think that he really fully understood what was going on within the institution. Now, in fairness I will say that having come from the outside and having spent four years in that position of vice president for patient care, I did not fully understand what was happening throughout the institution until I went back to taking care of patients within MD Anderson and essentially was side-by-side with the people who were caring for patients in every division—pathology and diagnostic imaging—and only then did I understand what MD Anderson was all about.

ROSOLOWSKI:

Why do you think it's that way, that you can't get that view from an administrative position?

COX:

Dr. LeMaistre was not a cancer person. He did not come from a background where his primary specialization was with cancer. He was a pulmonary medicine physician. He had political clout in the arena of dangers of smoking. And the other people—you know—the other—the chief financial officer—the other people around Dr. LeMaistre were not physicians. And so—and the physicians that related to Dr. LeMaistre wanted something from him. The division heads wanted him to bless what they were doing. So it's hard to know within any institution if, in fact, you don't know what you don't know. Now, I mean, I can go anywhere and explain what is happening at MD Anderson, where its strengths and weaknesses are and what—and why I think it is a great place to work, and after I left that position of vice president for patient care I had many opportunities to go other places—sorry—it is partly—it's maybe talking and partly it is I have got allergies.

ROSOLOWSKI:

It has been a rough season for them.

COX:

But—so I think it is hard. So after I left the position of vice president for patient care and was taking care of patients and working with the residents and working with the faculty within our own division—you know—I just came to appreciate the institution very well. I think at that time the institution was on the verge of greatness but was not there, and one of the reasons why they were on the verge of greatness but had not arrived at it is they spent too much time talking to themselves. So if you are in a big place, especially with some specialization, and if people are talking to themselves all the time and convincing themselves that the conclusions that they have come to about how to care for patients, about what the research shows so on and so forth, convincing themselves that they are right but are ignoring the rest of the world of cancer treatment—cancer research and cancer treatment outside it is easy to become limited. It is easy to be living in a silo.

ROSOLOWSKI:

Interesting.

COX:

And what I said to others during the time I was in that VP position was—well, and of course I was involved in the RTOG at the same time. I said you have got—you really have got people in other places, and I got some of them to come to the RTOG meetings and they became involved. I got some of them to come to the RTOG meetings, and they had a terrible time, and I think we talked about that, but I think the interplay between what was going on here and what was going on nationally became expanded quite a lot, and as it became expanded the institution became appreciated more and more and more. And then of course there were some high-profile people who came here or were benefactors, and that was good, and there were a lot of people who came here having gone either to Johns Hopkins or Mayo Clinic or Memorial in New York and then came here and said—you know—this is just a different place. The whole atmosphere is different. The whole approach to taking care of patients is different.

ROSOLOWSKI:

What were they identifying as being so unique?

COX:

The feelings of support of everybody within the institution for them and what they needed. So if they were wandering down the hall looking a little bit lost, somebody would come up to them and say, "Can I help you?" and in some cases would take them to where they needed to be, and that just did not happen in those other places. And that—to some degree that is a bit of Texas or Houston or southern hospitality, but it is a mindset that is very favorable in terms of caring for patients, and people are very impressed with that, and they should be.

ROSOLOWSKI:

What about John Mendelsohn [Oral History Interview] and your relationship with him?

COX:

I have always had an excellent relationship with John. I mean—he is a good, outstanding scientist, a real student of what is going on within the institution, or at least he was in the first many years. And I think because of that he had a great deal of credibility with most people within the institution. As I said in a meeting the other day, there are always within the faculty or the alumni or let's say the retirees—there are always a certain number of bomb throwers, and there always will be. So I think, notwithstanding the problems that he had with the bomb throwers, I think most people viewed him and continue to view him with great respect and an appreciation for him as a scientist. Maybe—maybe listening a little too closely to certain elements of people within the institution, and thereby not getting a broad enough view. And I think he was open to the broader view, but I think just on a personal basis he would get input from some people who gave him the view that served them well, which is not surprising—I mean—it happens to the President of the United States I am sure.

ROSOLOWSKI:

Right. Sure. What about Dr. [Ronald] DePinho?

COX:

Well I have not had nearly as much interaction with him. I mean he is an—I think he is an outstanding scientist. I think he is a visionary. I think he looks to change things in a major way, and I admire that. I appreciate a little bit the problems of working in the same institution with your spouse who is strong-willed, but I think she is a terrific scientist too. And I think—you know—they are a very good—wonderful addition to the institution.

ROSOLOWSKI:

What are some of the issues that have come up for you with a spouse being employed at the same institution?

COX:

Oh—there have not been very many because actually I remember one time we were in clinic several years ago and somebody said to me, "I just learned that you are married to Dr. Komaki." I said, "Yes." They said, "Is that—we have been working together for five years, and I never knew that." So I think the majority of people have had that experience. There were—there was at least one person who really was anxious to do harm to us, but eventually that element disappeared, and so generally we have not had any difficulties. We have not been in the same kind of limelight that Dr. DePinho has and Lynda Chin.

ROSOLOWSKI:

What is your prognosis for the Moon Shots Program?

COX:

Well—on a positive note they are bringing together people and galvanizing them to try to arrive at creative solutions that have not previously been fully considered. Do I have any expectation that it's going to eliminate any of the forms of cancer at which it is aimed? No. It's not. So it will do—it will have a lot of benefit for interdisciplinary science, and that is good—team science—that is good. It will not achieve a grand goal. I remember it was Andy von Eschenbach—he first went into the position as head of the National Cancer Institute many years ago and had said we are going to cure cancer by 2015, and obviously we are not, and so I think the prognosis for the Moon Shots Program in that regard is pretty much the same. Cancer is too complicated, and it's too many diseases, and it's too fundamental, and I don't think we are going to do away with it. It is like doing away with inflammation. I don't think we will ever do away with inflammation or doing away with the degenerative diseases. You just cannot, but will we be able to help and do positive things? Yes.

[T1]ROSOLOWSKI:

I am aware that we are running over, so I wanted to ask you just a couple final questions. First of all, is there anything else that you would like to add about your experience at MD Anderson, your contributions?

COX:

I am a realist. I have done a lot at Anderson, and I have done a lot of which I am very proud of. On the other hand, when I have gone as one of the annual meet the professors at our national meeting and they are all residents sitting around a table—residents who are not from MD Anderson, and so I ask them, "So who was Gilbert Fletcher?" They don't know. "Who was Juan del Regado?" They don't know. "Who was Henry Kaplan?" Maybe one out of the whole group will have heard his name but will not know anything about him. So like those before me for whom I have great admiration that which I have done will disappear into the institution and hopefully become a part of its fabric, but it will not be identified with me.

ROSOLOWSKI:

What are some of those things that you are really glad you have accomplished?

COX:

Well, I think I have spurred a lot of clinical research in the right direction through cooperative groups and also through the individual research approaches that we have taken. And there are those—my colleagues—we are involved in translational research, and I have not done any of the laboratory part of that, but I have been key to what has happened in the clinical part of it whether it's with the RTOG, whether it's with cancer of the lung or lymphomas or any of the disease-side areas in which I have been involved, but the main things I have accomplished in the research arena have been in clinical research, and the things in clinical research are what contributes to the care of patients. I mean—those are more immediate. They are perhaps not as revered scientifically as discrete pieces of research that will appear in the Journal of Science next month, but they have a beneficial effect on patients, and when you come right down to it that is where my heart is. And administratively I think I have—I think I have helped foster the collaboration with other divisions, other departments with very few exceptions so that I and my colleagues have a very comfortable working relationship in the multi-disciplinary realm. And going back historically, when Fletcher was the head of the division, through the force of his personality and what he accomplished clinically, he set a high standard for the role of and view of radiation oncology within MD Anderson. I believe I have contributed to maintaining that stature of radiation oncology within MD Anderson, and by and large I think that differs from any other cancer center in the world. So those are the things of which I am proud.

ROSOLOWSKI:

Is there anything else that you would like to add?

COX:

I think that is enough (laughter). That is probably a good place to stop.

ROSOLOWSKI:

All right, Dr. Cox. Well, thank you very much for taking the time to do these sessions. I really do appreciate it.

COX:

My pleasure.

ROSOLOWSKI:

I am turning off the recorder at 12:51.

COX:

Oh my.

(end of audio) [T1]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.