Larry Leichman, MD
I gave my first national presentation of my original clinical research on a topic that was to become a professional obsession: finding a cure for esophageal cancer. (Spoiler, I failed.) It was late May 1982. Writing about this now is undoubtedly predicated on my recent retirement, my desire to look back, and my hope that I am not truly irrelevant at a time when the sense of my irrelevance seems to come in waves. In retrospect, the presentation was a seminal event that proved to a self-doubter that, “I can do this.” By ‘this,’ I meant I could be a successful academic medical oncologist in a field that was thrust on me by the sudden decision of one of my mentors to leave Wayne State University. It left a leadership gap in the Gastrointestinal Cancer Program that I was asked to fill.
In 1982, the ASCO Annual Meeting was in a large hotel ballroom in Washington, DC. I don’t remember the hotel, but I’m certain it didn’t have a presidential signature. In those days, academic oncologists and members of ASCO could meet in a single hotel. Now, with the globalization of medicine and the growth of oncology as a specialty, we require enormous convention centers that can hold 35,000 attendees attending multiple meetings on different oncologic disciplines.
DC was a good venue for me. Washington was close enough to Wayne State University School of Medicine in Detroit, so my wife (about to complete her medical oncology training) and our three young sons could drive with me to the meeting. My parents drove down from New York to attend the 15-minute presentation. I was very grateful. Also, my sisters lived in the DC area and threatened to attend as well. Of course, none of this truly put my anxiety to rest.
Unique Protocol at the Time
Because the sessions in gastrointestinal cancer generally work from the top to the bottom, the esophagus was the lead topic. And, at this meeting, I was to be the first speaker in the session. I was to expand on our abstract that described a novel approach to curing esophageal cancer.
Coming from an unknown in this field, the hubris embedded in the abstract’s title was there for all to see. Although I wrote the treatment protocol, I had enormous help from colleagues and mentors in medical oncology, radiation oncology, and surgery at Wayne State. Our protocol, unique at the time, treated patients with esophageal cancer with chemotherapy at the same time as radiation therapy prior to an operation. At that time, the standard of care was an operation, which managed to cure less than 10% of those afflicted with esophageal cancer. So, there was plenty of room for improvement. A young investigator with a good plan could make a mark.
Although preliminary, the results for our first 14 patients were encouraging. The treatment prior to surgery, now known as “neoadjuvant therapy,” was tolerated better than we expected. Unfortunately, our patients were older and had long histories of alcohol and tobacco abuse. Three of our patients died after surgery. Certainly, these protocol deaths were a major failure. That said, the excitement generated by the treatment was based on the fact that five of our patients had no cancer in the surgical specimen after chemotherapy and radiation. These five had complete pathologic responses.
The results implied that if we could predict which patient would have a complete pathologic response or “no cancer left before the surgery,” we could eliminate a difficult, potentially life-threatening surgery. Making that prediction became another of my unfulfilled, life-long professional obsessions. So, despite the deaths after surgery and the fact that we had only a handful of patients with limited follow-up, the organizers of the conference thought these early results should be discussed and scrutinized by ASCO members.
Preparing to Take Center Stage
The presentation was a big deal for me and for my colleagues. My mentors recognized this. I was young, and this was my first national presentation. The senior members of my division forced me into what seemed to be interminable practice sessions. I frequently wilted under their unstinting criticism. But, by the time we had our sixth or seventh rehearsal, fewer arrows pierced my ego, and they felt that I was ready to go.
Late May can be very warm, even for DC. At the hotel, in the air conditioning, I was shivering with cold. My mother and wife checked my tie several times as I arrived at the hotel. My mother analyzed the knot; my wife, knowing her husband, checked for food stains. I was pronounced set to go by these judges before my mind and body felt set to go.
I entered the backstage area (in those days we didn’t sit in the front of the auditorium). This was an area that might now be called a Green Room. There I parted with my slides, which were placed with extraordinary care in a particular order within a circular carousel. They were now in the hands of a projectionist, whose mission, I was certain, was to ensure one or two slides would become stuck in the projector.
I was reviewing my notes with others on the program for gastrointestinal cancers when it dawned on me that I was amid the icons of my field. These were professors (about 95% male) who wrote the major research manuscripts and textbooks on gastrointestinal cancers. Although the Cancer Program at Wayne State was well regarded, those backstage with me came from the finest cancer programs in the United States: Mayo Clinic, MD Anderson, Memorial Sloan Kettering, and Harvard’s Dana-Farber, to name a few. In their presence, my slight height at five feet six inches melted down to about two feet.
I then made an almost fatal mistake: I recognized the nametag hanging from the neck of The World’s Greatest Authority on Esophageal Cancer (my phrase, not his). I had hoped to model my career after his. Also, he was to give the talk after mine. To paraphrase the Bard, “I screwed my courage to the sticking place” and introduced myself. I never stutter, but, I stuttered, ‘Hi, Dr. (World’s Greatest Authority). I’m…I’m Larry Leichman from…uh Wayne State; I’m a GI oncologist. Your work…your work has…has been an inspiration for me.” That was all it took for the conversation to go south. Not much taller than me, The World’s Greatest Authority on Esophageal Cancer looked down his nose to remark that he wasn’t clear where Wayne State was on the map. More to the point, he had read my abstract and didn’t think much of our results.
Enthusiastic Applause Followed by Relief
No sooner had this confidence-draining tête-à-tête taken place, I was told they were ready for me. I listened as the moderators for the session read the title of my abstract along with the six coauthors who participated in the research. I was introduced to the audience as the Principal Investigator. I walked to the podium, wishing I had a stool to make me taller and wishing that the few notes I was carrying were in bigger print. Just before the lights went out to focus the audience on the slides, I looked out and spied my family in the back of the auditorium. Unfortunately, the sighting did little for my nerves.
I had 10 minutes for the presentation and 5 minutes to answer questions. The very first sound that came from the podium was the knocking of my knees. They knocked together and then found the side of the podium. A double whammy of sound. The knocking sounds continued throughout the presentation, but I made it through.
My voice came through. My slides were fine. None got stuck in the projector. I remembered most of the points that were made during the rehearsals. I remembered to thank the conference organizers for choosing our research to be presented. Most important, I remembered to thank my patients and colleagues.
Our protocol, unique at the time, treated patients with esophageal cancer with chemotherapy at the same time as radiation therapy prior to an operation.— Larry Leichman, MD
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To my surprise, the applause from the audience was enthusiastic. My knees came under control for the 5 minutes of tough questions. As a medical student, thinking on my feet was not my forte. As a student on clinical rounds, I frequently made a fool of myself in front of five or six students, residents, and an attending doctor. But at this meeting, I was called upon to think on my feet to answer questions designed to poke holes in our hypothesis, methods, results, and conclusions. I was in front of 1,200 medical oncologists, most of whom were far more experienced than me.
Why did we choose those particular drugs? Why did we give those doses? How did we decide on the radiation dose? Why give the radiation with the chemotherapy? Why did so many die after surgery? Was surgery necessary at all? Did we really think cure was within our grasp? What was the meaning of the complete pathologic response? I tried to answer these questions with the humility of a junior investigator and the anxiety of one inspired by true stage fright. I remember being blinded by the lights as I tried see my questioner. I humbly began each answer with, “Thank you for that thoughtful question.” It gave me the needed time to think. The relief when the moderators stated, “Time’s up, we have to move on” was immeasurable. The next talk was from The World’s Greatest Authority on Esophageal Cancer.
It was my first encounter with a national audience. It was my first encounter with The World’s Greatest Authority on Esophageal Cancer. Neither would be my last. My knees didn’t shake at my next major talk. And about the The World’s Greatest Authority, after many years in the trenches with back-and-forth critiques, I believe a mutual respect developed. The old cliché “what goes around, comes around” fit our future academic relationship. But, that’s for another time. ■
DISCLOSURE: Dr. Leichman reported no conflicts of interest.
Dr. Leichman recently retired as Professor of Medicine at the University of California San Diego and Co-Director of Gastrointestinal GI Translational Research at the Moores Cancer Center.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.