David Raubach: Well, I want to thank you for joining us on today’s episode of the Cancer Project podcast. We’re really privileged today to have Dr. Jim Gray with us. He’s the medical director of the Tennessee Oncology Proton Therapy Center in Franklin, Tennessee. A longtime radiation oncologist, a fantastic person, and also has a very unique story as he actually went through treatment for prostate cancer himself a few years ago. So, we’re going to talk about all of the above here. And so, Jim, thank you so much for joining us today.

Dr. Jim Gray: No, thanks for asking me, David.

David Raubach: So you’re sitting there at the Proton Center, is that correct? In Franklin.

Dr. Jim Gray: I am. I am.

David Raubach: So, tell us before we get going on your career, tell us about that facility. I know that it opened back in October of 2018. So just tell us a little bit about where you’re practicing today.

Dr. Jim Gray: Yeah, it started as a venture through a company called Provision Healthcare and Provision started a center in Knoxville and then built this center here in Franklin, Tennessee, which is just south of Nashville. And they ran into some financial difficulties about 3 years ago and this center was actually acquired at that point in time by Tennessee Oncology which is my company. I’m a partner physician within Tennessee Oncology which is a very large multi-specialty physician group here in Tennessee. And then since then we’ve been in ownership of the facility owning and operating it. So that’s been for the last three years, but the center’s been in operation since October of 2018.

David Raubach: And Tennessee Oncology. So, tell us a little bit more about Tennessee Oncology because I do think that they’re unique in terms of the structure of their group and the size of their group and just what they’ve been able to do in central Tennessee.

Dr. Jim Gray: Yeah. Tennessee Oncology started actually really if it goes back 50 years. This is a 50th anniversary of Tennessee Oncology. And for many years it was a medical oncology only group. It was a collection of medical oncology doctors here in basically in Nashville. And then it began to expand into more of Tennessee. And then I worked with some other guys within our company to bring my group of doctors which has been here — I’ve been in Nashville since 1994 as a radiation oncologist and we were in a separate private practice group a partnership and then we basically merged our group into Tennessee Oncology making Tennessee Oncology a multi-specialty oncology group and that was in 2008 and so we’ve been part of Tennessee Oncology I guess now for 18 years coming up on it. And so now Tennessee Oncology has even a broader spectrum. It has now brought in a group of surgeons within the group. We have breast surgeons, general surgeons, vascular surgeons. So a lot of different specialties now within the umbrella of Tennessee Oncology and it is still the single most common group of doctors within the group are medical oncologists. We also have psychologists, clinical psychologists, we have a pathologist, we have even a cardio-oncologist. So now trying to be a broader group of doctors to be able to answer all the needs of cancer patients here in primarily middle Tennessee, but we have a large presence in Chattanooga. We now have a growing presence in eastern Tennessee. And then Tennessee Oncology is a partner within a larger overarching company called OneOncology and OneOncology now — I don’t know what the number is but it’s several dozen different practices across the country and this is a way of trying to use a larger set of resources to allow us to do what we want to do financially.

David Raubach: So I think you started practicing in 1994, is that correct, in Nashville?

Dr. Jim Gray: In Tennessee. In Nashville. I started practice in 1990 after I finished residency and I was a Navy doctor. I was in the Navy with the Naval Medical Corps. And this was a debt that I paid back for having the Navy and you and other good American taxpayers pay for my medical education at Vanderbilt University. And so after finishing training in New York, I came to the National Naval Medical Center and the National Cancer Institute and had four great years there. So although I was paying off a debt, it was a really great time for me and then in 1994 after my obligation was up, I chose to actually leave the Navy and found a private practice opportunity in Nashville and that’s what brought me to Nashville for the second time after having been here for medical school.

David Raubach: So you did medical school at Vanderbilt and then residency at Memorial Sloan Kettering. Where did the Navy come into the picture? When did you join the Navy?

Dr. Jim Gray: The Navy came into the picture right as I finished college. So I had an engineering degree out of the University of Tennessee, Knoxville. And I still really cherish that experience being trained as an engineer, biomedical engineering essentially. And I still just this past week I was in Knoxville twice for some advisory boards that I serve on within departments of the Tickle School of Engineering. And so that’s really a fun way to give back on that. And then when I finished I applied to medical school and really didn’t want my family to try to go into debt to pay for that and the option of having it through the Navy, which is sort of like a medical school version of ROTC, if you will. It’s called the Health Science Education Training Command, the Health Professions Scholarship Program. They paid for medical school in agreement for me to serve for four years as a medical officer. The time in training, which was four years in training, was a neutral period of time. I didn’t pay off the debt, but I didn’t incur any additional debt. The Navy wasn’t supporting me during that time, although I was actually a drilling reservist when I was in New York City. So 12 years actually in the Navy altogether. Lots of people do a lot more — about five years in essence on active duty and again very privileged to get to work at the National Naval Medical Center and the National Cancer Institute. Incredible people I got to work with and get more experience. It was like a four-year fellowship for me in reality. So I was very very fortunate.

David Raubach: And talk about the decision to become a radiation oncologist. How did that come about?

Dr. Jim Gray: Like for most people it happens during medical school. I went to medical school absolutely convinced I was going to be a surgeon. Or thought I wanted to be orthopedic or ophthalmology. You probably wanted to do a specialty surgery type career and got into it and although that was interesting it just happened to stumble across some of the technical innovations that were going on within radiation oncology at that time. This is in the early to mid 1980s. I graduated from medical school in 1986 and we were just beginning to get into three-dimensional — I studied computer-aided design, computer-aided manufacturing as an engineering student when it was in its absolute infancy and then as computer power began to take off we saw what that could bring to the world of delivering radiation treatment and wow that just — I caught the bug off of that and talked to a few different people and got the chance to see what it was like at Vanderbilt University and then said, “Okay, this is for me.” Decided to go into radiation oncology and trained and went straight out of medical school. So I didn’t do anything else first. I went straight into radiation oncology.

David Raubach: So that’s about 35-36 years ago. What is something or maybe a couple things that as you think back at what radiation oncology looked like at that point in time that you’re like, man, we have come a long ways since the early 90s.

Dr. Jim Gray: Oh, yeah. It’s quite different. And I got a chance to see some of the really basic levels of it at different places. I spent a summer at the San Diego Naval Hospital and they had not yet upgraded their equipment that much and just saw how good clinical efforts are applied to it. But without the tools that we have now, three-dimensional treatment planning was just still science fiction at that time and how you had to use clinical knowledge about how a cancer was operating, use physical exam skills, use much less detailed x-ray information to set up your fields. So I am that old. I saw that. But then I did my training starting at Memorial Sloan Kettering in 1987 in New York City and it threw me instantly. And of course, Memorial was one of the early developers of the entire concept of three-dimensional reconstruction and then how do you orient the beam based upon that and throw that reconstruction into a computer imaging system and you know by today’s standards it would look laughingly crude. We did like you know just contours that were stacked in a three-dimensional basis but you could tell what you were treating. I actually still have a copy of a National Geographic magazine that tried to show this to the scientific community and it had a picture of a head-neck reconstruction just with contour lines on the front cover of the National Geographic. It was like 1986 or something. It’s just like hey this is where and it came from Memorial. It came out of the physics division there and it’s like man is this so cool and then you look back at it now and you go wow it was like mortar and pestle compared to what we’re doing now with full-blown three-dimensional reconstructions and everybody does it now but I was at one of the sites that was helping to develop that at that time and that was just a real rush.

David Raubach: So you had the opportunity in 2018 to open up a proton center, but that was kind of the latest iteration of new technology, new equipment, fancy engineering. Think back to the 90s or the early 2000s. What was the first revolutionary machine that you had the opportunity to be a part of purchasing where it was like, man, this is really exciting. I can’t believe that we’re about to buy X.

Dr. Jim Gray: Yeah, several things like that. I mean, for one thing, when I came, we didn’t have a very active brachytherapy program and prostate permanent seed brachytherapy was taking off. And I came out of Memorial Sloan and although I didn’t do it at all when I was in the Navy, so I had like a four-year gap, my partner said you’re the best person to develop that program. And so I did. I used different experts in the field and we had really brilliant people working around me at Centennial Medical Center which is where I was first working within my group in downtown Nashville and had a hospital willing to support that from the OR point of view and I trained with the guys that were up in Seattle at the time and we developed a prostate brachytherapy program. The next thing that happened is we had the opportunity to put in one of the earliest versions of an IMRT device and that was actually in 1999. This was really early. Not many people were doing any form of IMRT. It was a form of inverse-modulated therapy with a device called the Peacock which we could strap on to one of the older accelerators we had. And all of a sudden we were truly doing inverse planning IMRT when hardly anybody even in the field of radiation oncology knew what that was and we had the ability to really sculpt our doses in a way that hadn’t happened before. So that was exciting. We actually even had the capability of doing hyperthermia where I was working at Centennial Medical Center, including three-dimensional guided hyperthermia. It was some really good advanced stuff to be outside of an academic medical center. We had access to a lot of toys. We brought in a CyberKnife in 2009-2010 time frame. So we had been doing stereotactic work though with standard linear accelerators. Even up until that point we had some of the different software programs that allowed us to do that for SRS. This is before SBRT really took off. We were just doing pure SRS in the central nervous system with bolted-on head frames that our neurosurgeons would do with us. And so a lot of things — I’ve spent most of my life outside of the academic sphere. I feel very fortunate to have seen a lot of this technology before a lot of my colleagues in the world of radiation oncology were able to get their hands on it. And then I’d always trained and seen what the idea of charged particle therapy would be like and said, “Well, I’ll never get to do that unless I decide to uproot my family and move to MD Anderson and beg for a faculty position so I could work with the proton system in Houston.” Just didn’t really want to do that. Kids were in school and all this kind of stuff. And then lo and behold, Provision develops this system in Knoxville and gets that going in 2014. And then I get a call and somebody said, “Hey, I’ve heard you’re kind of interested in charged particle therapy. How would you like to help us with one that we’re planning on putting in the Nashville area?” And I said, “Well, yeah, very quickly.” It didn’t take me long to decide on that. So that opportunity came up and I was offered the ability to help develop the center here in Franklin with Provision and then unfortunately finances didn’t work out for them that well, although I was still on loan from Tennessee Oncology essentially as the medical director providing my professional services. And then you know as large as Tennessee Oncology is we had the wherewithal and the capital resources to actually be part of the bidding process to acquire that essentially out of bankruptcy. As you know, proton centers have had and are still having financial woes. It’s a very tough economic battle to run a proton center. So I’ve been here ever since.

David Raubach: So what — why were you interested — I guess this is your opportunity to say why you personally, Dr. Jim Gray, were interested in charged particle therapy because you talked about some of these other amazing technologies that you had access to. Why were you as a physician interested in proton therapy?

Dr. Jim Gray: Well the ability to control where the radiation goes. As I laughingly tell people if you want me to write down on a napkin what my job is: my job is to figure out where to put radiation, put it there, and don’t put it anywhere else because anywhere else is just leading to potential toxicities or bad side effects and things. And the bottom line is if you have a charged particle system, you can control where the radiation goes — or as I like to tell people, standard radiation is very excellent at putting radiation where you want to put it, but you have to put some radiation into other tissues in the process. And so proton therapy is actually better at where we don’t let the radiation go. And so that’s the way to understand proton therapy — our ability to exclude uninvolved tissues from higher doses or perhaps any dose of radiation in a way that you can’t achieve in the same way with a standard radiation beam. But you take an entire jump into a different realm of having to generate a proton beam. And I tell people laughingly — it’s like if you want to haul things around, you go from having a Ford F-150 pickup truck to now you’ve got an 18-wheeler and it’s all the good and the bad that goes along with that. I mean, where are you going to park the thing and how much do you pay the insurance on it? It’s still energy distribution. You’re aiming an energy beam to create the same damage at the DNA to kill the cancer cells very much in the same way. There’s subtle differences we can get into, but it’s about put the radiation where you want it, don’t put the radiation where you don’t want it, and you can almost always do it better with a proton system. The question remains, how big a difference is that going to make in the outcome of the patient? And that’s where our ongoing controversy about justifying the cost of proton therapy revolves around.

David Raubach: And so maybe talk about that as it relates to prostate cancer because there’s different viewpoints on the use of proton therapy for prostate cancer and you guys treat a lot of prostate cancer at your facility. We treat prostate cancer at the Oklahoma Proton Center. So just talk about the utilization of proton therapy for prostate cancer and why it might be justified or what some of the questions are about why maybe it wouldn’t be justified. Just kind of walk us through that.

Dr. Jim Gray: Sure. I mean the reality is prostate cancer is not the best argument to develop proton therapy because we have multiple different ways including surgery, including brachytherapy, including IMRT, IGRT — we have a lot of good ways of treating prostate cancer so it wasn’t like a problem that needed solving, that oh if we don’t have proton therapy we’re not going to be able to treat prostate cancer very well. The reality is you have so many different good ways of treating prostate cancer — it’s one of the cancers we’ve done a good job with, particularly now that we have a biomarker PSA that allows you to find it at an earlier stage than we used to. So we’re treating earlier stage and prostate cancer is a pretty good success story across the board. Now can proton therapy do it better? Yeah, it can do it better. I can give less dose to say the posterior rectum. I can give less dose volumetrically to other structures. And if we’re treating higher risk prostate cancer where there’s a debate about whether we should treat lymph nodes for example if you don’t obviously see lymph nodes involved but when you’re treating larger volumes like that the superiority of proton therapy dose distribution becomes more noticeable. But the controversy rages because we are so good at doing radiation therapy or for that matter other things such as brachytherapy or surgical removal. We’re so good at treating prostate cancer in a variety of ways — do we have to have proton therapy to do that? Well, no. We’re not going to all of a sudden just say oh wow, now we can cure prostate cancer because we have a proton machine. That’s not true. But can we still improve our outcomes, the differentiation between a cure and doing it without creating issues? A paper was published out of Harvard University which randomized patients to using protons versus IMRT and thus far at least there’s not obvious advantages showing up. We don’t see a whole lot of differences in the cure rate or the toxicity rates between protons and IMRT and I don’t debate that. And Dr. Hass’s data shows that at this point, now with longer follow-up we may see some long-term toxicity show up on one arm or the other that doesn’t show up as early and it could be other things like secondary malignancies which has been shown in other issues that there still could be an advantage, but it may be subtle enough that it’s not a huge deal. I still believe that this is probably one of the superior technologies we can use to treat prostate cancer. But the true argument for proton therapy in the world of do we need to spend the money to build more of these centers and more of these machines probably is going to be in the area of other things such as head and neck cancer, certainly pediatric cancer, CNS tumors, tumors in the thorax, particularly the anterior thorax — we’re going to have a more distinct difference in what we can do with protons versus what we can do with other modalities. And I think the differences are going to be more stark in those situations, but we’re still gathering the data to try to figure this out. And we have many years yet to go to see all these differences. But the way I talk about it with colleagues is like — you know if at any given time you have the ability for no extra money or no extra hassle or any difficulty you can use a proton distribution rather than a standard radiation distribution, which one would you pick? You know if you just blindly say I get to do it this way or I get to do it this way — yeah but it’s so expensive. No, just ignore that. If you have a great situation where you can pick and choose, why would you want this distribution that sprays all this extra radiation in other tissues that you don’t need to have if you can do it with a proton system? And then they keep coming back to but it’s just not very available and it’s so expensive. And I said I understand, so we as a medical society and then society as a whole have to decide — is the amount of advantage we get from proton therapy worth the amount of money we’re spending on it? And that’s a huge debate obviously. And it goes to who’s making money off of what and it goes into the principles of a disruptive technology — this is a classic disruptive technology, we are disrupting the status quo about how you do radiation treatment. And there’s almost 50 centers operating now, 120 rooms I think now nationwide, and there’s over 120-130 centers worldwide. It’s something that we’re now going to be exploring more and more and hopefully we will find out okay we’re doing this with protons, we really need to, or we aren’t using protons for this and say you know stage three lung cancers and goodness gracious there actually is much better outcome because of decreased dose to the heart and lungs and the immune system. There’s so many different things that are going to come out I think over the years that we’ll figure out. And I think that’s where the debate should be — not do we need more proton centers, but if you ask a lot of people they’re like “Wait a second, we’ve already overbuilt this.” And I don’t think that’s true by any stretch of the imagination.

David Raubach: So you were quoted recently in an article that was published in Medscape. And I would say that it was a little bit of an analysis of proton therapy and utilization of proton therapy and specifically it talked about prostate cancer. And it’s always tough doing those interviews because you talk for 30 or 45 minutes with a reporter and then they pick out one quote and it’s not always presented in context. So I’m curious your thoughts on how your quotes were presented in the article and how the article framed proton therapy for prostate cancer generally, but especially as it framed your position on proton therapy for prostate cancer.

Dr. Jim Gray: Right. Well, I talked to him the same way I’m talking to you — that I believe proton therapy is a superior way to deliver radiation just about in any circumstance. Is it economically justified to do it if you can — is it okay to spend twice as much money, say to treat a cancer when you’re only given a 5% benefit? I don’t know. That’s not for a physician to decide. That’s for society to decide what expense we’re going to bear. I mean we come out all the time with new drugs that cost an order of magnitude more than the old drug yet it only offers a 5% reduction in toxicity or something and but it catches on and there you’ve got pharma driving it because they get better profits and revenue and they advertise it and you don’t have those kinds of drivers in the area of proton therapy. You just don’t have — there’s not that much money to be made essentially by building these centers and doing that. I mean some people think oh centers are getting rich off of this. Well, you know as well as I do that you don’t get rich really by doing proton therapy. Quite the opposite — you struggle to stay afloat and but you’re offering a technologically superior way of putting radiation energy at the tumor. So in this interview I told him — and I think one of the quotes was something about patients with a certain level of prostate cancer should get treated with standard radiation. I don’t know how he took that out of context. I don’t believe a patient should be treated with standard radiation rather than proton therapy. I certainly don’t believe that. But what I do believe is that as we move forward, there will be certain patients that we decide there’s not going to be enough of a difference and we need to be careful. You can’t broad-stroke prostate cancer into just prostate. You have to say, well, is it high risk? Is it node positive? Is it a situation where — you know, I tell patients all the time that think they ought to get proton therapy — I said, “I actually think you should get no therapy. You just need to be monitored with active surveillance.” And they think, “Well, geez, are you running this proton center?” I said, “No, I just want you to have the best outcome you can have and we’re using the science, independent of whether I’m aiming a proton beam or whether you’re having surgery or anything else.” So I think the author kind of wanted to make a point that we’re spending too much money on proton therapy and kind of took out selected quotes from me to do that. And I get that and I’m not an expert at dealing with a reporter who wants to make a point and kind of has an agenda. And I think he does, but that’s my opinion perhaps. But it is expensive and the interesting thing is — and I just talked to some groups of engineers over at the UT campus in Knoxville about this — how engineering is allowing us to come up with ideas to do proton therapy for far less money. We can now build a center that — a lot of it comes around the idea of for example treating a patient in the upright position or how you’re going to manipulate the beam line or how you’re going to generate the beam line with — is it a synchrotron or is it a more efficient cyclotron system? And that engineering will continue to improve. You’re not going to be able to easily get around the fact that we have to accelerate a particle that is 1,836 times more massive. So when I was doing that discussion I brought a ping-pong ball and a bowling ball up on stage. And I said, “Which one is easier to accelerate?” You know, engineers — force equals mass times acceleration, that’s one of basic Newton’s laws. Well, if the mass goes up by almost 2,000, the force has to go up by a lot. And all of that requires a lot more effort and control. And you have different scatter radiation and it’s just no easy way to do it. But you can also get a better outcome at the tumor if you’re able to do this. And it doesn’t even stop there — you know, Mayo Clinic putting in a carbon ion center — you can actually take it a step further. Whether that’s going to be justified is going to be a whole different argument, but it falls into the same argument of is particle therapy, charged particle therapy worth it. There’s never going to be a simple answer to that because it’s a matter of how much is it worth to save an extra 500 men a year from having some complication that maybe we could avoid, but you’re spending so much money treating all these other guys that don’t need it. It’s a classic dilemma we have in medicine about spending money.

David Raubach: Well, you mentioned drugs. So we do Pluvicto for metastatic prostate cancer and this is a drug that costs $300,000 over the course of six injections. And you’re talking about extension of life in a magnitude of months. And we’ve all collectively agreed as a society and insurance companies have agreed to pay for this drug and the FDA has approved this drug and we’ve decided that this is worth it — extension of life for three, four, six, eight, whatever the amount of time is, months, is worth at least $300,000. And just to provide some context for proton therapy, a full course of proton therapy might cost a third of that, or even if it’s Medicare, one sixth of that. So it’s significantly less cost than something like a drug that extends life for metastatic prostate cancer a few months. And then the cost difference between proton therapy and traditional radiation might be 10 or 15 or $20,000. It’s not necessarily a small difference, but again, when you’re talking about this kind of big scheme of oncology and treating cancer and how we’ve approached treating cancer, it’s actually a pretty small difference in the cost.

Dr. Jim Gray: Yeah. And you look at the money even in immunotherapies that are being used in the medical oncology community. I mean, the amount of money being spent on that is shockingly large. And for some reason we say that’s okay, but you got a proton center and it costs $50 million to build a proton center — no, no, no, no, no. That’s way too much. You can build that same thing for $25 or $30 million and put a regular radiation machine in and do that. And it’s like, okay, wait a second — at what point do you really have to sit down and start putting it into a spreadsheet and saying what’s it worth doing this? I think the centers like this one which use a classic model — and like the center that you guys have in Oklahoma and some where you have a single cyclotron powering multiple rooms — has an economy of scale. But some of the newer ideas are probably going to allow us to break this down and put it into smaller communities where we can have access to protons in communities right now that may be several hundred miles from the nearest proton center and this will allow more exposure to the opportunity to have proton therapy. So I really am excited about how that’s being developed even if it’s not the exact same model that I’m working in. But the principle of being able to deliver proton therapy to more people who can benefit from it — because right now the classic numbers show we’re not even at 2% of all radiation therapy being done with proton therapy. And if you sit and look at the different types of diseases and the positions within the anatomy and how they behave, that number could easily be 10 or 20% where we get enough of a benefit to make it worth spending more money. How much more money depends upon who you ask. But you’re talking to potentially an order of magnitude more patients percentage-wise than we’re treating right now. And that takes a lot more capacity. I actually fear that we may get enough data that it’s better in lung and esophagus and head and neck and certain things in the CNS and clearly pediatrics — and we’re going to get that data and we’re going to be saying well we need to be treating 8% of our radiation therapy with proton therapy. Well wait a second, we’ve only got the capacity to treat at this point maybe 3 or 4% because we’ve slowly grown. And then society’s going to look at us and say, “Why didn’t you predict this? Why didn’t you see this? Why didn’t you build out the capacity? Now we’ve got all these patients that want to and need to have proton therapy and you didn’t build the equipment to be able to treat them.” And I don’t want to be on the end of a finger being pointed at me. Why didn’t you figure this out and tell somebody? And I said, “Well, we kind of tried.” That’s one scenario. We’ll have to see how the clinical data really does come in. And we’re doing that research although it’s going glacially slow it seems like because it takes so long. You don’t have that many centers to put the patients on trials and but we have good investigators, good scientists working diligently to try to gather that data and get where the truth is. Where do we actually get enough gain in basically decreasing toxicities of radiation treatment to make it worth having more centers? And that’s a grand challenge for us — you want to match it up right, you don’t want to build more centers than we need but you also don’t want to have too few centers for the patients to benefit from when we find out that the benefit is really there.

David Raubach: And there’s big metropolitan areas like San Francisco, Portland, Denver — just to name a few — Louisville, just to name a few that do not have a proton center today.

Dr. Jim Gray: [laughter] Right, yeah — hopefully soon.

David Raubach: Yeah. So we’ve talked a lot about prostate cancer and you have a unique experience in that you went through prostate cancer treatment as a doctor. So talk about how that came about and maybe how that overlays with cancer screening and thinking about cancer screening and then talk about just what was going through your mind as you went from being the doctor to being the patient.

Dr. Jim Gray: Yeah, it’s enlightening obviously to have to see — we classically say that’s medicine from the other side of the bed rail. I would say for me it’s on the receiving end of the beam. And the truth is that although my father — my own personal history is that my father had prostate cancer and it recurred and it actually took his life younger than he should have been. He was only 80 and this was over 25 years ago. But that had a lasting impact on me. I knew there was a genetic predisposition. And I didn’t watch my PSA probably as closely as I should, but I did get one PSA, and it was actually not for the purpose of just going and getting a screening, but it was with some other laboratory tests and a colleague of mine was checking on this and he said, “Did you know your PSA is up?” And I said, “Oh, no, really.” So I started down the pathway with that. And working in this arena obviously I have close contact with a lot of guys in the urology side and a good friend that I did a lot of treatments with — I said to him, “Now you’ve got to work me up,” and so we went down that pathway and I have intermediate risk prostate cancer and obviously I had a little bit different circumstance than the average patient. I’m extremely well versed in how to manage this and what can you do, so that does not make me at all the typical patient. And I did indeed — although I had surgical options, I had a pretty wide slate of options open to me. But at that point we had opened the proton center. I’m coming up on the 7-year anniversary of diagnosis. I’m 6 and a half years out from finishing treatment. And I mean I’m working at a proton center which has the modern amenities — we have cone-beam CT, we have pencil beam scanning — and I could have gone to people like MD Anderson or back at Sloan Kettering or the University of Florida, University of Pennsylvania, people I had already gotten to know within the industry and said, “Hey, can you take me on as a patient?” But I had it available right here. And so I jokingly tell patients — of all the patients I’ve ever treated, I had the shortest commute to my treatment every day [laughter] of anybody because I was already here. I just had to go to the treatment room, get my treatment. And I had a very smooth course. I had a lot of the expected side effects. I was actually on ADT for a while, so I can speak to patients about that from firsthand experience. And or at least my version of it. But I quickly tell patients I’m just one patient — as a scientist, I’m going to tell you that’s an end of one. That does not represent what the community is going to experience. I still have to pull from the broader data to say, how do I expect you to respond and to live through this? I can say that a lot of patients have really put more faith in me as a physician because they know I’ve gone through it. And I quickly tell them I said you don’t have to — most oncologists have never had cancer. A lot have, but you don’t have to go through the disease. You don’t have to go through a laparotomy as a surgeon to understand what it’s like to have to heal up from an abdominal surgical procedure — but it does add some empathy. One of the biggest areas of empathy probably is now I really understand what I’ve heard people jokingly call PSA-denia — which is you know now you got to wait for your next PSA test and even though my PSAs have looked good, I see patients all the time where — you know this is a classic example of what we used to call medical student disease — I see patients all the time that go through this, you know a late recurrence, and even though my PSA looks good at six years I know I could still show recurrence and so every PSA’s got that little trepidation built into it and I can really identify with patients on that because I live it too.

David Raubach: So did you get involved in actually making your treatment plan?

Dr. Jim Gray: You didn’t think I would let somebody else just blindly do my — [laughter]. So I did not actually design my plan. I did not actually do the contouring. I looked at all the contours of course which is a big part of the planning process. And that was in the early days of using the rectal spacer gel — I knew I wanted to have that but I didn’t have easy access because I was like the only person in the Nashville area at that point that had a really significant experience doing it and I wasn’t going to do it on myself. Where people jokingly say you could do that — actually I have a urology colleague who did his own vasectomy but that’s a whole different story. But obviously you’re not going to do this, so I said okay well I knew people around that were capable of doing it and I had to go to a different city and had it done for that purpose. But I was involved with my own planning of course and I had a good colleague who was here. He’s not here anymore, but a very very good physician and he served as the attending for my plan. And I tell patients I had a comfort level of knowing the people that run this center, the people the therapists that deliver the treatment, the nursing staff, the administration of the center. Furthermore, I know the equipment. I mean, coming from an engineering background, I always like to crawl around this stuff. I know the people who designed the equipment that’s installed here. I know the people who actually installed it and the people who maintain it. And you know that gave me a level of comfort that I wish I could give to my patients, which I can’t really because I couldn’t get them to that point of comfort that I had — because I knew these people and I trusted them and I trusted them with my own well-being. And that’s like a constant wish that I could bestow that upon a patient and make them feel more comfortable with the choice of treatment. But I don’t want to use that as a coercion technique and say oh you’re seeing a doctor who obviously has had prostate cancer sort of like what I had and I chose radiation, so obviously you should choose radiation. No — if that patient’s more comfortable with surgery and that’s a good option for him then — I just went through this an hour and a half ago with a patient. He said, “You clearly need to consider having surgery.” And the outcomes are really fairly equivalent. So I’m not an anti-surgery kind of guy, but it wasn’t the right thing for me.

David Raubach: So what — are there things that you’ve changed about your practice or the way that you interact with patients or the process at the Proton Center after having gone through treatment?

Dr. Jim Gray: I don’t think so. I mean certainly nothing comes to mind but it makes you more empathetic about like modesty factors — which we have a great fortune our center here was designed and built with individual changing rooms going back to the treatment rooms, that’s really nice. But I mean just a lot of the little factors about what happens during treatment but I’m already familiar with so much of that right — I see patients under treatment constantly, I see them on the machine on the table and setup difficulty, I do these procedures like SpaceOAR gel procedures and the simulations. And it is enlightening to know what it’s like, but for virtually all of us at our age — you’re not quite as old as I am but at this age you’re going to have had procedures. I’ve had three shoulder procedures for example in my life which weren’t exactly minor in the big scheme of things but the rehab is a really big pain in the you know what — and so you learn things as you have to experience them yourself. But I don’t think — again, I try to always come back to the fact that if a guy’s prescribing prostate cancer treatment or doing surgery and if he’s never had it himself, he can’t really appreciate what his patient’s going through. I don’t believe that, but it gives you a deeper level of empathy and understanding, I think, but I don’t think I’ve changed anything — which is a hopeful testimony to the fact that we were pretty considerate about what the patient’s going through already. And I certainly didn’t institute any changes about how we do things and I don’t really think about it any differently than I did then.

David Raubach: So here’s my last question for you. You’re a technology nerd. I don’t mind saying that. You’re a biomed engineer. And you’ve seen a lot in your career. What is the thing — if you can make a prediction about what radiation oncology is going to look like 10 or 15 years from now — what are you either most looking forward to or something that you would say this is going to be a transformational change and you can’t wait to see it come about? And you’re still young and healthy so I know you’ll still be practicing 10 or 15 years from now. So what do you — put your looking-into-the-future lens on and what do you see for radiation oncology looking forward?

Dr. Jim Gray: [laughter] I’m 66. I don’t think I’m going to be practicing in 10 or 15.

David Raubach: Okay. So put your looking-into-the-future lens on and what do you see for radiation oncology looking forward?

Dr. Jim Gray: I think we will have more access to particle therapy and the cost of getting into particle therapy and offering it to certain communities will be lower. So you’ll have the opportunity to offer particle therapy in more settings to more patients and we need that. But it’ll never be the dominant form — X-ray therapy is just too good and too well done to have it supplanted by something that’s a little bit better but a lot more difficult to manage and take care of. So I mean even though there’s the remote possibility you could see proton therapy become the most dominant form of delivery, I don’t see that within my lifespan. I think the area of like you mentioned Pluvicto — and we do Pluvicto here at our center as well — I think that is an area that’s getting ready probably to explode as pharma begins to put its incredible resources behind it because they know they can make money off of it right. They’re going to put incredible resources behind continuing to try to — there’s as I understand hundreds of radioligands in development. You know, theranostics, if you want to call it that — I like to call it radiopharmaceuticals. Pluvicto and Pylarify are just going to be the beginning — there have been other drugs like Bexxar and some other ones out there that have done the same principle, but delivering radiation in a molecular fashion if you will. And we’ll have hits and bombs as we try to do that — more of what actually pans out in clinical practice. But I think that’s going to become a more significant way of how we deliver radiation — the liquid radiation thing that people want to call it. And then how do you combine that with what we’re doing already? And how do you combine that with standard chemotherapy, cytotoxic chemotherapy or hormonal therapies? And you have all these different combinations of things that can go different directions. But that’s probably one of the biggest changes that’s going to hit us over the next say five to 10 years — what pharma can provide us with the ability to do that. And I think we’ll continue to get better quality assurance procedures to make sure that we’re actually doing what we think we’re doing. That’s a function of technology and how to intelligently use that technology to make sure we’re doing what we think we’re doing with radiation therapy. Because when I look back in my earlier career, man, we just had to treat such a broad area to make sure you’re hitting the cancer, but that encompassed so much other tissue. And then the field of radiology is continuing to expand. And how is that going to change? We may find out ways to genetically alter tumors in a way that we can’t even imagine right now, and that scares the bejeezus out of people, but if done carefully and thoughtfully, I think it has the opportunity to really turn things around. You may find a way to trigger certain cells to become more radiosensitive — you’re still using radiation, but it’s more effective. Your mind can run wild with all the different possibilities. I think the radiopharmaceutical influence will be big. I think particle therapy will become something that more people are more acutely aware of as an opportunity, but it’s not going to become the driver obviously.

David Raubach: Well that’s great. It sounds like the future is very exciting.

Dr. Jim Gray: I think it is. I mean technology will continue to drive forward and we can do this better. We’re doing it pretty darn well right now but we can continue to do it better. I think we all know that. And I’ve just had an interesting career over almost 40 years of being involved with radiation therapy and watching it advance in so many different ways. You think about what we were doing back when I first came out of medical school. And it’s not like that was stone age stuff — it just was not nearly as precise as what we’re doing now.

David Raubach: Well thank you so much for your time, Dr. Gray. This has been fantastic. I really appreciate your perspective on being a patient, your perspective on the history of radiation oncology and just everything that you’re doing for patients today there in Franklin, Tennessee. So, thank you so much for coming on.

Dr. Jim Gray: It’s a pleasure to talk to you, David. Good to see you.