Quest for excellence: The ultimate goal of the radiation oncologist: ASTRO gold medal address, 1992

Abstract

I am deeply indebted to the American Society for Therapeutic Radiology and Oncology for the opportunity it has given me to contribute in some small ways to the advancement of the specialty and for enhancing my own professional growth. Receiving this highly regarded Gold Medal Award would not have been possible without the encouragement and tolerance of my family, beginning with my parents, my sons, Carlos Santiago, Bernardo, and Edward, and my wife Susie, and her family, or without the strong support of a very competent and dedicated staff, who through the years have developed an outstanding radiation oncology program at the Mallinckrodt Institute of Radiology, or without the inspiration of my mentors, Dr. Gilbert H. Fletcher and Dr. William E. Powers, or without the collaboration of many of you, who have given me valuable advice and your friendship. In these days of turmoil in the political and, specifically, in the health care environment in the United States, I have chosen for this address a topic critical to our survival as an innovative and caring clinical specialty: The search for foundations and avenues to strengthen our scientific development, professional standing, and care rendered to our patients. Our specialty, since the discovery of x-rays by Roentgen (102) and radioactivity by Curie and Becquerel (16), has advanced at an extraordinary pace. Since Rubin’s Gold Medal Address (104) the active and total membership of ASTRO has grown steadily (Fig. 1 A), with substantial increase in academic positions, particularly at the instructor/ assistant professor level (Fig. lB), a reflection of the young character of our specialty and, more gratifying, the fact that we are attracting a new generation of bright, enthusiastic minds. Despite this growth, our ranks continue to fall short of those of medical oncologists, who number approximately 9000 (3 1) and have established a prominent role in the primary care of the patient with cancer (74). Over the past 90 years, radiation therapy alone, combined with surgery or chemotherapy or both has been shown to be an effective curative modality in many malignant neoplasias, with high survival rates in Stages I and II, but with a need for improvement in more advanced stages. Many clinical trials document improved local/regional tumor control with higher disease-free and, in some instances, overall survival with multimodality therapy than with one or two modalities (when two modalities are more effective) (87). Looking to the future, we should vigorously promote organ preservation in the management of patients with cancer, an approach that significantly augments the role of irradiation and profoundly affects the quality of life and psychoemotional state of our patients, as has been demonstrated in some head and neck tumors, carcinoma of the breast, esophagus, soft tissue sarcomas, carcinoma of the vulva, rectum, anus, and in pediatric tumors (15, 20, 32, 33, 47, 52, 65, 77, 88, 109) (Table 1). Whether in academic or community practice, every radiation oncologist must enthusiastically support and actively participate in properly designed and conducted clinical trials (institutional or cooperative groups) to develop and appropriately evaluate more effective therapeutic strategies. Noteworthy, despite substantial gain with administration of systemic cytotoxic drugs in some tumors, such as in malignant lymphomas and trophoblastic and testicular tumors in which chemotherapy alone is effective, or in other neoplasms such as in carcinoma of the breast, esophagus, colon, rectum, and anus, in which it is combined with irradiation or surgery, it should be emphasized