An Interview with Allen Lichter, MD, FASTRO - American Society for Radiation Oncology (ASTRO) (2022)

By Theodore Phillips, MD, FASTRO and Adam Currey, MD

The following interview of Allen Lichter, MD, FASTRO, was conducted on June 28, 2016, by Theodore Phillips, MD, FASTRO and Adam Currey, MD.

Theodore Phillips: Allen, can you tell us where you were born and what your parents did?

Allen Lichter: I was born in Detroit, Michigan. My father practiced family medicine for 50 years and my mother was civically minded and an organizational person in various civic organizations around Detroit.

Theodore Phillips: Was your father’s office at home so that you grew up with medicine?

Allen Lichter: No. He practiced in a small community near Dearborn, Michigan. So he wasn’t practicing at home. But he was an old time family doc. Delivered babies, did minor surgery. He was in solo practice. And at times on weekends, I would accompany him to the office or to the hospital as a very young person where I developed my interest in medicine.

Theodore Phillips: Did you grow up in Detroit or did you grow up in Dearborn?

Allen Lichter: No. We grew up in Detroit proper.

Theodore Phillips: Where did you go to high school?

Allen Lichter: I went to high school in downtown Detroit to a high school called Cass Tech. This was a high school that took students from all around the city and required an entrance exam to get in and so forth. So I got on the bus and went off to high school.

Theodore Phillips: While you were there, were you involved in any sports?

Allen Lichter: Yes. I played golf and I was on the golf team. And that was my recreational activity, but I loved sports. I was the sports editor of the high school newspaper and have been a sports fan all my life.

Theodore Phillips: So from that point on had you determined if you would like to go to college?

Allen Lichter: The University of Michigan was in my home state and was very appealing. I applied there and to some colleges on the East Coast and ended up getting accepted at and attending the University of Michigan, both for undergraduate and medical school.

Adam Currey: What was your major?

Allen Lichter: I majored in zoology and this was one of the biologic majors that premeds at the time got involved.

Theodore Phillips: Obviously you had decided that you intend to go into medicine. Did that desire persist through college?

Allen Lichter: I never remember a day in my life not wanting to be a physician. My older brother, there’s just the two of us, went into medicine as well. He’s eight years ahead of me in school. So by the time I was a freshman in college, he was graduating from medical school. He went on to train in ophthalmology and for 34 years, was chairman of the Department of Ophthalmology at the University of Michigan. So it was a medical family and I just persisted straight through.

Why medicine? My father was an inspirational physician. He made medicine and science very exciting. They just came alive and I never wavered for one moment about getting into medicine. I went to the University of Michigan Medical School. I interned at a community hospital in Denver, Colorado, Saint Joseph Hospital, where I was a medicine intern. And then I did my residency, Ted, as you know, at UCSF.

Why radiation oncology, you know, it’s an interesting story. When you’re a senior at Michigan, you can take three months away in a clinical rotation elsewhere. I decided that it would be fun to go to San Francisco. I had never spent any time there. It was a time when a lot of interesting cultural things were evolving in San Francisco in the early 1970s. So, my brother had done his internship in San Francisco and was an intern with a guy named Larry Margolis. My brother called Larry and said that I was interested in radiology, and asked if he could secure a student elective in radiology for me? And Larry called back and said, it’s set up but he’s got to do six weeks in diagnosis and six weeks in therapy. And that was fine with me.

I went out there and did my six weeks looking at films and trying to become acquainted with the field of radiology. And then I started my time in radiation oncology. I went to the department. After one day, I remember coming home and picking up the phone and calling my father and saying, I figured out what I’m going to do with my career. I’m going into radiation oncology. It was instantly captivating and exciting. There was a spirit in the department. Dr. Buschke was still active and of course, was a very good friend of Isadore Lampe who was the chair at Michigan. And Dr. Buschke took an interest in me because I had come from Michigan. There was never a doubt that I was going to go into the field.

This was at a time when, in contrast to today when you sort of have to start planning your career very early on, I actually then finished medical school and started my internship and I did not have a residency. And that was quite common. But I finally decided to do it. I called this guy, Ted Philips, and I said, Ted, I’ve decided I’d like to go into radiation oncology. What should I do? And he said, basically, can you start next July? And I said, yes. And basically, that was about it.

I had spent three months in the department. There was no extensive need to interview me or whatever. He had a slot and that was it. And I remember at the time, this was not something that -- this was not a field that was filled with the top U.S. medical school grads. It was heavily dominated by physicians with international backgrounds, you know, Franz Buschke and Gilbert Fletcher and Juan del Regato and on and on. The field did not have a sparkling reputation. And I remember many of my colleagues and teachers in my internship saying, you know, you’re committing career suicide. This is horrible. You’re making a huge mistake. But luckily, I went ahead with it and it turned out okay, let’s put it that way.

Theodore Phillips: Who were the other residents who were there while you were at UCSF?

Allen Lichter: Well, you know, my class was me and Steve Leibel. But right behind me was Jim Schwade. You know, ahead of me was Warner Ray, Jean Quivey. My goodness, you know that crowd. And it was a great group of people and there was a wonderful camaraderie in the department. But you know, Steve was --

Theodore Phillips: You know, three of you became chairs and major leaders in the field, you in tremendous ways. Why do you think that was the case?

Allen Lichter: I think we fed off each other. I think we had a wonderful competition to be the smartest resident. Of course, Steve won it hands down. But you know, we kept pushing. And the department had a very serious academic and knowledge discovery atmosphere to it. People were writing papers, analyzing results. Ted, you were there and Glenn Sheline and Bill Wara and Stan Myler and Larry Margolis, on and on. It was just a great, great group.

When I finished residency, it was my intention to go into practice where the majority of my fellow resident mates over the years did. But I don’t know. You might have introduced me to Stan Order. Stan was just starting out at Johns Hopkins, building a department. Moody Wharam had gone there. And I just decided I’ll just do this academic thing for a year or two, you know, just to make sure my skill set was right and then I would go into practice. So I started in expectation of temporarily being involved in academic medicine. But as you know I never got around to leaving academic medicine.

Theodore Phillips: Can you tell us a little bit about you and Jim had a sail boat in the Bay area? Can you tell us a little bit about that?

Allen Lichter: Yeah. I joked that I -- you know, at times when I look back and say I never lived as well as I did when I was a house staff in San Francisco making $17,000 a year. My wife and I rented a lovely home in Sausalito and I drove a BMW. Jim and I owned a sailboat. I don’t know how we did it. But it was a lovely period of discovery, not only in the field of radiation oncology for me but also to all of terrific things that one can get involved in in San Francisco. So it was quite a sparkling time. I did not want to stay in San Francisco or in California. I felt much more tuned in long term to the Eastern Time Zone and I always felt that I would move back and that’s what I did.

Theodore Phillips: I remember Jim lived there as well. You guys lived better than any of the faculty. We couldn’t figure it out either.

Allen Lichter: I still look back and try to wish I could duplicate the alchemy that seemed to characterize the residents in radiation oncology at UCSF.

Theodore Phillips: You didn’t moonlight, many of the residents did back then.

Allen Lichter: No, no. I never moonlighted, but my wife worked. So we had two incomes and of course, we were young and not interested in saving a penny which we didn’t do. But you know, we were skiing at Aspen and going up to the Wine Country and starting wine sellers and on and on and on. And of course, Ted, you were a fabulous role model for us and have always been so and helped arrange this job for me to go to Hopkins. And so, I moved to Baltimore, which was not exactly a garden spot at the time. But we enjoyed living in Baltimore and enjoyed Johns Hopkins.

I will say that Dr. Order, a brilliant radiation oncologist and excellent chair, but Stan and I, you know, frankly just did not get along well. He ran a much tighter ship than I was used to in my residency where people were given a lot of freedom and the ability to do their own thing. I chafed under some of the structure in the department.

Jim Schwade had gone and joined Eli Glatstein who had recently taken over the radiation branch at the National Cancer Institute. Jim called me and said they were looking for people. And that was at a time when I just said, I don’t think my long-term future is at Hopkins. It’s just one of those wonderful collisions of events, just the randomness of life. Just as I was thinking that I might want to do something else, Jim calls and says, we’re looking for people. I knew Eli from Stanford and admired him a great deal. It didn’t take very long for Eli and I to get together and work out the detail to move to Bethesda and join the National Cancer Institute.

I finished my residency in ‘76. I was at Hopkins for two years. And in ‘78, I went to the NCI. And there, of course, is an organization that is a hundred percent research focused. Every patient you treat is on a study. And that was, in many respects, the heyday of the National Cancer Institute. Vince DeVita was the director; Bruce Chabner and Bob Young and Marc Lippman and Steven Rosenberg in surgery; and Phil Pizzo and a great group of people in pediatrics. I was there with Eli and Joel Tepper and Tim Kinsella and Jim Schwade. And we just had a terrific group. It was enormously exciting.

I got interested in what type of clinical studies that I thought would make an impact on the field. We did some of the fundamental work on combined modality therapy in small cell lung cancer with Paul Bunn and John Minna and that group. This was a time when lumpectomy and radiation was just getting started.

I had visited Sam Hellman and the team up in Boston. And there was a big study going on in the NSABP. Bernie Fisher and team were running it. And they were treating with lumpectomy and whole breast radiation. There was no boost being given. That was more the standard of care that Sam and the Joint Center people had established. I felt that it would be wise if we ran a study that was quite similar to the one that the NSABP was running, but to add the added dose that comes at that time an interstitial implant boost.

And my feeling was if the Fisher study was positive, that’s great. You know, no harm, no foul. If the Fisher study was negative and our study was positive, one could speculate that, in fact, the boost made a difference. This would be a useful study and to a large extent, an insurance policy. We were giving lumpectomy and radiation the best chance of displaying its merits by having it done in two technically different ways.

We started our study and it accrued about 250 patients. The Fisher study came out and obviously, was positive. And our study then was closed and showed, of course, the same things that the Fisher study showed. It was confirmatory in that respect. Because we were using adjuvant chemotherapy, we learned a lot about how to administer chemotherapy and radiation to breast cancer patients. We did a little bit to help put this technique on the map. And also, inside the branch, we developed some technology to make the field setup just much, much easier and much more accurate at a variety of small technical details that we wrote about to help make breast radiation better.

Theodore Phillips: We just recently interviewed Norm Coleman. Now they have a terrible time recruiting any patients to come to the NIH. Before, I think they got free health care, free care. Do you think that’s why you were able to recruit 250 patients to the breast study?

Allen Lichter: It’s actually, Ted, quite remarkable that we could accrue, yes. The patients - all their travel, all their accommodation, all their health care was taken care off. But this was a time when women were having trouble getting lumpectomy and radiation. I remember one of the early patients that I saw. When I saw a patient in consultation with the diagnosis of cancer I always ask them, tell me what your doctors have told you about your condition and so forth. And I’ll never forget one of my early patients said to me, Dr. Lichter, I went and saw the surgeon after the biopsy and he said, your biopsy is positive. You have breast cancer. You have two choices, you can have a mastectomy or you can die.

That was the prevailing wisdom, so many of our patients came to us because there was no alternative except to have mastectomy. With our study, there was at least a 50:50 chance that they could get this new treatment, which you will remember well, it was at the time being regarded as experimental at best and highly dangerous at worst. So we were able to accrue reasonably nicely for a single institution, 250 cases over a few years’ time. It was pretty good.

There was also one other thing that happened to me at the National Cancer Institute. It turned out to be quite interesting. I opened the door of a room and I saw this machine which turned out to be a CT scanner, an EMI 5005, one of the very earliest CT scanners. It was purchased by Ralph Johnson, the former head. But nobody really knew how to use it or what they would use it for. It had a small bore. It was a body scanner but it didn’t have a very large aperture. But we started to put patients in and scanned them.

It just hit me like a ton of bricks that this was a machine that was -- it was as though it was designed for radiation oncology treatment planning. We put a flat tabletop in the place of the standard round tabletop. And all of a sudden, we had a contour of the patient’s surface and you could see everything on the inside. You could see all of the anatomy and the tumor and anything else you needed to see.

And then we had some pretty sharp people in physics, a young guy named, Dick Fraass, Dick just won the ASTRO gold medal. Dick and I started to play around with this and then started to look at some techniques where we could begin to put the slices together. You remember back then, you saw a CT scan because X-ray films were 14 x 17 chest X-ray films. And all of these slices were printed out 12 to a page. My analogy was this was like taking a loaf of bread and putting the pieces out on a countertop. If you could only pick the pieces up and stick them back together, you could rebuild the loaf of bread as a three-dimensional object.

So we started to play around with doing that. And this looked pretty exciting. We began to start calculating doses, taking into account a lot more off-axis scatter and started to write papers about this. And then along came the University of Michigan that said they were establishing the Department of Radiation Oncology, would I be interested in interviewing. And I did and negotiated a package. Part of the package, Ted, was to bring several physicists with me and to buy lots of computer equipment and pretty sophisticated radiation oncology equipment.

Back then, our first computer - which was a VAX computer made by DEC, the Digital Equipment Corporation - it filled a good-sized room. It cost about $500,000 and had the power that’s less than one of our iPhones right now. But nonetheless, they said yes. Dick came and we recruited Dan McShan from Rhode Island and Randy Ten Haken from the Fermi Lab. And so, this was an indication of what we were going to start to do at Michigan because the first three faculty members I recruited were physicists. And I think it’s fair to say we made some important contributions to turning radio therapy from a 2D field into a 3D field and then conform the dose distribution using IMRT with moving collimators. It was quite an exciting run. I was chair from 1984 until 1996 when I stepped down and Ted Lawrence took over as chair.

And I was happily minding my own business as professor of radiation oncology. My golf handicapped dropped like a stone. I was enjoying life, and then the dean resigned. And to make a long story short, I was approached to be the interim dean. All the chairs knew me, the institution knew me. I was a fairly safe bet and they made it very clear that they were actively engaged in a search and they should have the search wrapped up in a few months and then I could go back to being professor so I said okay.

I always say be careful about accepting an interim job. Because the search fell apart, they approached me and said, you’re not half bad at this; how would you like to be the dean? And I agreed. So, in late 1998, I became the dean of the medical school and I did that until 2006.

Also in 1998, I became president of ASCO, the American Society of Clinical Oncology. I was always involved in both ASTRO and ASCO. I loved working in ASTRO and had been a member of the board. And I loved working in ASCO because it brought all the oncologic specialties together and cancer care is a team sport and we need to be together, exchanging information and being part of the ecosystem that defines oncology care today.

So, I was on the board of ASCO and they asked me to run for president. I actually ran twice, I lost the first time but won the second time. So, I was president ‘98 to ‘99 and became dean right during my ASCO presidency so it was a busy, busy year. I stayed dean until 2006. I had to start looking ahead because in Michigan, you can only be dean for ten years. They just have kind of an unwritten policy that deanships should rotate. So, I started to look ahead and said, you know, I’ve got two more years. I had stopped practicing. The deanship is really a full-time job. And although Ted Lawrence and the department was very kind to me and happy to take me back, I was concerned that I had not practiced for a while and was not as expert a clinician as I once was.

And again, as luck would have it, while I’m thinking about what am I going to do, the phone rings and it’s ASCO saying their CEO has resigned, would I interview for the job and I did.

Theodore Phillips: The thread that runs through all this is your tremendous organizational ability. I mean together the team that has revolutionized treatment planning. And then being a dean - didn’t that teach you a lot of skills that then would go on to benefit you at ASCO?

Allen Lichter: First of all, I always felt that radiation oncologists are, you know, we are used to bringing together and working with teams. We interact with every single specialty in medicine. We’re almost the only specialty that can say that we touch every other specialty in medicine. We work collaboratively on every single patient we treat, we understand things about internal medicine, about surgery, about pediatrics, about gynecology, about neurosurgery, and orthopedic surgery, and neurologic surgery, and on and on and on, all those. If you can’t get along, and you can’t understand, and you can’t collaborate, you can’t do this job.

And so, when I became dean, this was not an unnatural experience for me to be at the helm of this complex institution with 2000 faculty and a set of interconnectedness that was just very familiar and very comfortable to me. We helped the school progress and I loved my deanship. And ASCO became, to some extent, a natural offshoot of that. Here were all the specialties working together to try to make cancer care better. I had the experience of doing this as a department chair and as a dean of the medical school. So, it was a very comfortable experience to go to ASCO.

I think it’s also a tribute to ASCO that they had no hesitation about making a radiation oncologist the CEO of the organization. It truly is a meritocracy and the person ahead of me who preceded me was a surgeon, Charles Balch. So, it’s an organization that finds its talents from many, many different places.

Theodore Phillips: But Allen, has ASCO always had an oncologist as its head; you know ASTRO never has. That’s the difference, I think, between the two societies.

Allen Lichter: ASCO became a professionally run organization in 1995. Prior to that, we were run by an association management firm out of Chicago. I was on the board at that time and decided to take over our own management. We made a very conscious decision that we would be physician-led.

I think that there is something valuable that physician administrators bring to a medical professional society. Interestingly, about two-thirds of the major medical professional societies are not led by physicians. But a lot of the major ones - the American College of Surgeons, the American College of Physicians, the American Academy of Pediatrics, the American Academy of Family Physicians, the American Academy of Ophthalmology - a lot of these big and influential societies are led by physicians.

I’ve always felt that ASCO made a good choice in being physician-led. And I’ve talked to my colleagues in ASTRO about this and they had the chance over the years to evaluate this decision and have not done it and stayed with the majority of the other -- their sister societies in being led by a lay administrator. And of course, Laura’s been there a long time and does a terrific job. But ASCO is quite comfortable being physician-led and we just hired my replacement who has now started - Cliff Hudis from Memorial Sloan Kettering. Cliff is going to be another terrific person in this lineage.

Theodore Phillips: What’s his specialty?

Allen Lichter: Cliff was the head of breast cancer medicine at Memorial for many years. So, he’s a world renowned breast cancer expert and a past president of the society and a longtime volunteer.

Theodore Phillips: Do you have anything to say about anything you’ve done with the RTOG or American College or American Board?

Allen Lichter: Well, you know, RTOG, of course, I got involved with RTOG as a resident because we’d have to review the charts and fill out the forms. It was a little bit of drudgery but you start to learn on a hands-on basis what clinical research is like. I didn’t spend a lot of time actively involved with RTOG but I did get involved with SWOG. I was the head of the radiotherapy committee in SWOG for a number of years so I was very much part of the cooperative group system during my active career.

I didn’t have a lot of involvement with the board except to take my boards and pass them. And the college I had, not that much involvement with and even less as time went on as ASTRO kind of took over a lot of the roles for radiation oncologists that the college had for many, many years. But I’m proud to be a fellow of the college, a diplomate of the board, and a loyal member of the cooperative group structure for many, many years.

Theodore Phillips: Can you tell us about the various honors you received over the years?

Allen Lichter: Oh, I don’t know. I was elected to the Institute of Medicine, now the National Academy of Medicine in – I’m trying to remember the year – 2001. I was privileged to win the gold medal from ASTRO in 2005, and won the gold medal from RSNA in 2014 and the distinguished alumni award from my medical school. And so, those are the ones that I’m most proud of.

Theodore Phillips: Can you talk a little bit about your hobbies? As I understand it mainly golf and skiing, is that correct?

Allen Lichter: You know, I love golf. In fact, when I get done talking to you today, I will go out and practice. I used to love to ski. I finally reached a point where I have skied for many years and not had a major injury so I decided to quit while I was ahead and that was the end of that. But I do love to garden and I do love to cook and those are the things that -- the hobbies that occupy my time.

As I said, I’m an avid sports fan when we left Ann Arbor and moved to Washington in 2006. It didn’t take very long for me to realize that I was going to be coming back to most of the Michigan football games and the family events. So, in 2008, we bought back into Ann Arbor in a condo we live in now. But I go to all the Michigan football games, and if I was here in the winter, I would go to all of the basketball games. But the warm weather is --

Theodore Phillips: Do you remember when we had the U.S.-Japan meeting in Michigan, we went to the game?

Allen Lichter: Oh, yes. Well, you know, that was fun. We used to have that meeting. I can’t remember every other year or whatever. It bounced back and forth. Typically, when it was in the United States, it was in San Francisco. One year, I was able to host it in Ann Arbor. We had a great meeting and a great time and it was the weekend of the Michigan-Ohio state football game. Somehow, I was able to gather enough tickets. We all sat in the end zone and that was the game that Desmond Howard ran a punt back, I don’t know, 90 yards or something for a touchdown. He struck the Heisman pose in the end zone right in front of me. And that’s an iconic image not only in Michigan football, but I think in college football. He did go on to win the Heisman and so, I remember that well.

You were there, Ted, and Steve Leibel and Zvi Fuks was there and I can’t remember who else but it was just a great, great event.

Theodore Phillips: Well all the leaders of general radiation oncology were there at that time.

Allen Lichter: Yeah. You know, if you start looking back, the inspiration for three-dimensional radiotherapy came from the Japanese in the late 1940s who began to take planar tomography and using little wooden dowels, stacked them to build the three-dimensional image of the patient. The Japanese had the concepts and created a rudimentary multileaf collimator that could move while it delivered treatment. So, they had the elements, they just didn’t have the technology. And so, there’s a strong tradition, as you know, of Japanese radiation oncology.

Theodore Phillips: You never had children. Is that correct?

Allen Lichter: Right. We never had children. When I was in San Francisco, I was married to Karen Lichter, we stayed married for 14 years and divorced in the mid-‘80s. I married my current wife, Evie, Evie Lichter in 1988 and we’ve been happily married ever since but children just never came along. And so, we missed doing that but we’ve enjoyed having our freedom. It’s been an opportunity that I missed but we have not looked back and just this is how it turned out.

Theodore Phillips: Can you say a little bit about the, you know, visiting professorships and did you do any sabbaticals during your career?

Allan Lichter: You know, I did one sabbatical in 1993, Zvi Fuks set it up for me to go to Hadassah Hospital in Jerusalem, Israel. I took a six-month of sabbatical, spent three months in Jerusalem and three months back here. I should have taken all six months away but I wasn’t smart enough. At that time, we were working on a new edition of a textbook that the bears the late Marty Abeloff’s name. And so, this was a chance, really, for me to do the writing and the research that I needed to do that and so, that was a nice event.

And then, we all did visiting professorships all around the country from time to time. It was nice to have a chance to give a named lectureship at the UCSF course a few years ago and at most of the major centers around the country. I love that and we’re a small community, closely knit, and it was great to not only be the visiting professor, but to host all the top people in the field in Ann Arbor.

Theodore Phillips: Your book with Marty Abeloff, is that still going on?

Allen Lichter: It is still going but without me. I don’t have a copy sitting in front of me; it’s in our home in Florida. So, I just don’t recall who took it over but, yeah, it’s still one of the vibrant textbooks.

Theodore Phillips: It is competing with DeVita’s.

Allen Lichter: Yeah, I mean, DeVita always was and probably still is the biggest seller but this was quite a nice effort done originally with Marty Abeloff and Jim Armitage and Bill Wood, a surgeon from Emory, and me. We had a great time doing it.

Theodore Phillips: Can you give us any reflections on your career? Anything you would have done differently if you went back to repeat it?

Allen Lichter: No, I would not have done anything differently. I did a lot more than I ever thought I would but opportunities kept coming along. It really is better to be lucky than to be good. I was just fortunate to stumble into the field of radiation oncology, fortunate to stumble into one of the great iconic departments in UCSF under your leadership to train, the chance to go East and work at Hopkins and at the NCI. Then out of the blue a chance to come back to my alma matter and lead a department, and then to become a dean of the medical school truly by accident. And then have the ASCO position come along just as I was going to have to start transitioning away from the deanship.

Somebody was looking out for me and guided me on an extremely interesting career. I’m proud of what I was able to accomplish. Of course, it’s all a team effort and I had outstanding colleagues over the years. But it’s been a very special career and I’ve enjoyed it.

When I left ASCO last week, they named a lectureship after me. It will be delivered at the annual meeting each year starting next year and the staff named our conference center the Allen S. Lichter, MD, Conference Center. So, I’m just thrilled with what has happened. There’s an Allen Lichter professorship in radiation oncology. It was held first by Dick Fraass and now, Marc Kessler.

Theodore Phillips: Marc Kessler, he came from LBL, right?

Allen Lichter: Yeah, he sure did. And so, it’s a nice legacy. I try to be as humble as I can and I had a lot of help but I’m very proud of what I was able to accomplish.

Theodore Phillips: Adam, do you have some more questions?

Adam Currey: Yeah, I have a quick question. You know, breast cancer is something that’s near and dear to my heart. You were obviously somebody that was in the forefront of developing breast conservation as an alternative to mastectomy. I wonder what your thoughts are about -- I mean, we seemed to have seen a peak in the utilization of breast conservation and now, mastectomy is on the rise. There’s more and more prophylactic mastectomies going on. I’m just wondering what your thoughts are, why you think that is, what we can do to maybe reverse the trend.

Allen Lichter: You know, it’s troubling to me only in certain ways. First of all, what we were able to show women is that they had an alternative, that you could survive breast cancer and remain intact. You did not have to lose an important piece of anatomy in order to have the chance of living a long life. That didn’t mean everybody should do it but it did mean that people have the choice. And I thought that was extremely important and remains important today and women, of course, can choose back to mastectomy.

I think one of the things that’s happened over time is as the radiographic imaging has gotten better and MRIs are more widely used, and so on and so forth, we see things inside the breast that are more widespread. Of course, if you go back to the original way this treatment was put together, we radiated the whole breast because we knew that there were likely other things in the breast. This is not a revelation. The fact that you see them now is the change. It’s not that they just occurred; they’ve been there all along.

When you look at the local control rates from the era before we had this type of imaging and see how good it is, then the desire or the tendency to disqualify patients or to steer them away from mastectomy because of the appearance of this imaging I don’t think is a great service because that multifocal disease was being well controlled.

I think the pendulum will swing back more to the middle though there always will be patients who elect the mastectomy, and there always will be patients who need mastectomy because of the size of the tumor, or the distribution of the disease, or the inability to get decent margins, and so on and so forth. So, I think some of this will begin to renormalize.

It’s also the sense that has to be top of mind that not only do the statistics show us that survival is sustained, but statistics show us there’s actually a small advantage in women who receive lumpectomy and radiation over women who receive mastectomy. This is not about your life; this is about how you want to handle this condition, what the importance is of body image, and so on and so forth.

So, I think we need to take a deep breath and recalibrate. This is a superb technique for a huge number of patients with breast cancer many of whom today, as you point out, are electing mastectomy. But having said that, it is a time of choice and we can’t say we want to give women the choice for lumpectomy and then say they shouldn’t elect the choice for mastectomy. It is their choice.

Theodore Phillips: Do you think it’s been reasonably successful that they have to be given the choice, a lot of states enacted legislation for that?

Allen Lichter: You know, I was actually against the legislative push to mandate that women had to be told about a choice. Not that I didn’t think that women should know about the choice, but I’m against state legislatures telling physicians what they can and can’t do. It’s a slippery slope and we’ve seen the result of it now in laws in many, many states. For example, prohibiting physicians from asking about firearm usage in the home and so forth.

And so, you start to politicize the practice of medicine, you’ll end up regretting it. So, I don’t think it’s a good idea that state legislatures start to tell doctors what they have to say to a woman who has increased mammographic density and what they have to say to a woman who’s thinking about terminating a pregnancy and what you have to say to a woman who has breast cancer -- where does that stop?

But I think most women today know there’s a choice. Most surgeons today are comfortable with either option. It’s certainly not like the days of when I trained. You know, when I trained, people did frozen sections. I mean, there was no chance to have anything but a mastectomy because you didn’t even know you had breast cancer until you woke up from the anesthesia. So, boy, has that world changed.

Theodore Phillips: Okay. Allen, any favorite sayings?

Allen Lichter: Ted, you know, if you don’t treat for cure, you won’t cure those you treat.

Theodore Phillips: I think that sounds familiar. Anything we forgot? Adam, Allen, anything else we should cover?

Allen Lichter: I think this was great. Sorry to drone on and on. I probably broke the tape recorder.

Theodore Phillips: No, not really. We set it for an hour and this was just about right.

Adam Currey: Yeah, I enjoyed it. It’s great to listen to you.

Allen Lichter: Thanks so much for letting me do this and I look forward to seeing the transcript.

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