Interviewed by Peter Tishler, MD, December 2012

Transcription

1 DAVID SUGARBAKER Interviewed by Peter Tishler, MD, December 2012 My name is David Sugarbaker and I am the Chief of the Division of Thoracic Surgery here at the Brigham. That is a division that does everything but cardiac surgery in the chest. It is the oldest division of thoracic surgery in the country. And it was formed back in 1988 by John Mannick who was chairman of the department. I am Professor of Surgery at the Harvard Medical School, the Richard E. Wilson Chair in Surgical Oncology. Dr. Wilson was a very prominent and active teacher in Brigham. And so with both the division chief and the Harvard Medical School appointment, things are very busy. Let me ask you some questions of a personal nature as a start. You graduated in 1979 from Cornell Medical College as many other Brighamites have. What motivated you to choose surgery? I grew up with a father who was a very active and prominent surgical oncologist and I was the 8 th of 10 children and I grew up around surgery. He was in practice in a small town in Missouri, Jefferson City. I was hearing about surgery all the time. I have two older brothers: Everett who was trained at the Mass General Hospital in surgery, and Paul who is down in DC and also trained at the Peter Bent Brigham when Francis Moore was the chairman. So I was, I think, destined from a very early age to be a surgeon. I always wanted to be so that s how I got here. Why did you join the Brigham for your surgical training? I had heard good things about both the MGH and the Peter Bent Brigham from my two brothers. My father thought that training in Boston was the epitome of surgical training. I looked at both places. I spent some time here as a student at the Peter Bent and basically fell in love with the Brigham family at that time. I was sold on the Brigham pretty solidly by the time I finished medical school. 1

2 What did the Toronto General Hospital offer that prompted your finishing your residency there? I was very interested at that time in esophageal surgery and also interested in the concept of lung transplantation. I had done some work at the Harvard Thorndike Laboratory in esophageal peristalsis. When I looked around, most of the esophageal surgeons who at that time were contributing to the field were thoracic surgeons who had obtained their boards in cardiothoracic surgery. When I considered what was the best program, it was at the Toronto General Hospital in Toronto, Ontario. I applied and was accepted. During my time there I was exposed to a wide variety of thoracic surgical procedures and was privileged to be at the Toronto General when lung transplantation was just being formulated and performed there. That gave me an exposure that was invaluable in terms of coming back to the Brigham to start that program. Over the course of your professional lifetime, who have been your mentors? I d say first and foremost my father, who was always available to give advice as I started my practice and started the division of thoracic surgery. It was formed in 1988; and as I finished my training, they appointed me chief of the division. So lots of questions were coming up as to how to start and which projects to focus on, and my father was very helpful. As were my two older brothers. One is 12 years older and the other was 13 years older; they had a perspective that was very helpful. When I was at the Peter Bent, John Mannick was chairman at that time. He was a tremendous mentor. He encouraged me to pursue the thoracic career and was extremely supportive by setting up, through the hospital leadership, this new division. For the first six years he was my chairman and was always there to help, give advice and support me as I hired other surgeons and at that time pulmonologists. While I was at Toronto, a gentleman called Griff Pearson a very prominent general thoracic surgeon who had started the Toronto program, was my extremely effective mentor. So I would say those have been the primary mentors for me during my career. Wonderful. Let me now ask you some questions concerning your role at the Brigham and the Dana- Farber Cancer Institute. Why did you rejoin the Brigham as you did in the late 1980s? I looked at a number of different jobs as I finished Toronto. The lure of the Brigham family, the expectation and belief in support, and the offer to be a new division chief at the Harvard Medical School and at the Brigham was quite compelling to me to rejoin. I had the concept of a mission to bring what I learned back to the Brigham with the hope that it would add to what was already a very prominent and vibrant department of surgery. John Mannick had stressed that in his interview also. What are your major clinical interests? 2

3 Overall, the thoracic surgical umbrella includes esophageal surgery, lung cancer surgery, and the relatively new field, which I had the opportunity to participate in early on, of mesothelioma, which is a tumor that is caused by asbestos exposure. Most of us have heard about it at this time from the ads on TV do you have mesothelioma? But early on surgical resection was very very new as I got back. For some reason I began to see referrals for consideration of treatment of these patients. I didn t know what to do with them. So I called my father and he said there s two steps to approaching any cancer. One is to remove it all, all of it that you can see, and then go after the disease that might be left behind, the so- called metastatic disease. So the first effort was to work on the operation to redesign it, as it had been performed with a prohibitive mortality; four out of ten patients never left the hospital. We worked on it through the years and now the mortality is down around 3-4% which is in the same range as other cancer operations. That has been my focus. We started the International mesothelioma program here at the Brigham. This has been a very fulfilling effort. We have a house that we ve raised money for across the street. It draws patients from all over the world and has been very fulfilling. We ve had a number of protocols that we think have improved survival very significantly. And again it s something that I don t think could have been done anywhere else. The commitment of nursing, anesthesia, the whole team has allowed us to really move ahead in the field. That s absolutely wonderful. Are there other clinical innovations that you ve evolved for your division? Yes. On arriving to the Brigham in 1988 I immediately began working on a lung transplant program. We put together a Brigham team and in 1990 performed the first lung transplant in Massachusetts. There had been one previously done in one of the Southern New England States. We performed, I think, the second double lung transplant in the United States and certainly in New England. So that really got us off and running, and that program has grown exponentially in the last couple of decades. Is the Brigham significantly supportive of thoracic surgery and of your patients as they experience this hospital? It s a definite yes. And the patient experience at the Brigham in thoracic surgery I think is second to none. We have started a number of new initiatives with support of the hospital. We now have a fulltime attending who looks after the patients while we re in the operating room. This sort of surgical- less program is innovative and new at the Brigham, and they ve been very supportive. We ve also brought on board chaplains as well as social workers focused on and dedicated to the thoracic surgery. That s propelled us to be the largest thoracic surgery program in the United States, in terms of the number of patients who we treat as well as our training program being the largest in the country. The Brigham has been very very supportive. 3

4 This has allowed us to grow in a number of different areas to become, we hope, the best and biggest program with both a large number of patients being treated and to train young surgeons to go out and do thoracic surgery. We have over a dozen chiefs at this point that we ve trained here at the Brigham who have obtained leadership positions, and many others who are on their way to that. So it s been fun to have an impact. Is there something in your training program that has evolved during this time? Yes. We have involved a number of specific programs that the residents and fellows are exposed to. The first is a minimally invasive thoracic surgical approach to lung cancer, esophageal cancer and other types of thoracic disease. This minimally invasive program was one of the first in the country. We now perform the majority of lung cancer cases minimally invasively, with very small incisions and avoiding cracking of the chest, which used to be so common back when I trained. We are involved in new instruments. We have had a number of patents on new instruments developed here at the Brigham. This is an area that is extremely gratifying, because it does what we re here to do, which is to relieve the pain and suffering of our patients. I mentioned the mesothelioma program, and I have the lung transplant program. We began a program with the Dana- Farber, which was the first multidisciplinary program at the Brigham and Dana- Farber and one of the first in the country to bring oncologists, surgeons and radiation oncologists all together to meet the patient together and come up with a plan a one- stop plan that allowed patients to see all three specialties in one office visit. And that s been very successful and has spread to other programs - the breast cancer program, other types of malignancy, GI program and so forth. Can you give me an overview of your research? My personal research has been very involved in mesothelioma. In , we began a tissue bank in which a piece of each patient s tumor was banked- frozen along with normal tissue from the patient, usually from the accompanying lung. We built a tissue bank that is the largest in the country in lung cancer, mesothelioma and esophageal cancer. And early on we were talking about and working with different proteins that predicted survival. In the last 7 or 8 years we ve been very active in the genetics and genomics field for mesothelioma do genome sequencing with human cancer. It s a very very exciting area of research. We think it s going to yield big dividends in terms of treatment for patients and prolonging survival. In another area, we ve had a number of clinical protocols or innovative new therapy studies, conducted with IRB approval. And these have focused on lung cancer, minimally invasive work, and mesothelioma, with the heated intraoperative chemotherapy program, started about ten years ago, to give a heated chemotherapy bath after removing the tumor. It s been successful in prolonging life. There are a number of different research areas, both bench or basic research in genetics as well as in the operating room with new applications of chemotherapy. 4

5 Who does your genomics? Is it done here in your surgical division or is it done somewhere else? We direct the research. We have the human tissue and the questions to be asked, given the rapidly advancing technology. We have farmed out some of the science to some new companies who are constantly changing their techniques to advance and more completely report on the mutated genes that have gone wrong. Of course, the data come back to us. We also have a collaborator in Kuala Lumpur who does all of the statistics, the computer evaluation of what is gigabytes or billions of pieces of data This has allowed us again to move with the field so we don t get so invested in a particular technique, which can happen when you are confined to one institution. lung cancer and other cancers. We have worked diligently to sequence these tumors, and have a number of the first publications on what is called high throughput or whole genome sequencing. You ve heard about the human genome; and we were one of the first to Let me ask you a final question and this concerns the future of medicine. What will your division do to meet the mandate of reducing the cost of medical care which will be compulsory? I would say we are well under way. When you look at one of the big drivers of length of stay, which is the major driver of cost in surgery, how many days you spend in the hospital, the consistent team and systems approach to patient care has already allowed us to have the lowest length of stay in New England, when you look at the statistics generated by third parties about our program. And as we consolidate and standardize the approach to certain tumors, we are able to reduce costs along the way, as some of the needless variation and surgical approach can be eliminated. Those are the two major areas in which we are pushing forward. One of the other areas is rapid evaluation and application, where appropriate, of new technology. We have an active robotics program, which is in its infancy but expanding rapidly, which dramatically reduces the size of the excisions or operative holes. Reducing the stress and injury to the patient that the surgical procedure inflicts allows the patient to leave the hospital sooner. So in a variety of different ways, our systems approach, our rapid evaluation, and application of new technology have allowed us to make significant strides; and we anticipate more significant strides in the future. 5