Proton Therapy: Advancing Precision in Cancer Treatment with Dr. Steven J. Frank
Proton Therapy: Advancing Precision in Cancer Treatment with Dr. Steven J. Frank
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In this landmark episode, David Raubach sits down with Dr. Steven J. Frank, a radiation oncologist at MD Anderson Cancer Center and one of the world’s foremost experts in intensity-modulated proton therapy (IMPT). The conversation unfolds at the ASTRO annual meeting, where the release of the UK’s TORPEDO trial data has set the oncology world buzzing. Dr. Frank, who serves as an adviser on that very trial, offers an authoritative, nuanced breakdown of what the data shows, what it does not show, and why the distinctions matter enormously for patients with oropharyngeal cancer.
Dr. Frank’s own 440-patient, 17-center, phase III randomized controlled trial, soon to be published in The Lancet, is the centerpiece of this discussion. The trial, the first of its kind to achieve level-one evidence for IMPT versus IMRT in head and neck cancer, confirmed non-inferiority in progression-free survival while simultaneously demonstrating dramatic reductions in toxicity. Gastrectomy tube dependence fell from 40% (IMRT) to 27% (IMPT) during treatment, an absolute 13-point reduction. Dysphagia, xerostomia, and lymphopenia all showed statistically significant improvements in the proton arm. Most strikingly, at the five-year mark, overall survival diverged: 91% of IMPT patients were alive versus 81% in the IMRT arm; a 10-percentage-point absolute benefit that Dr. Frank describes as an “unexpected finding” that will reshape how the field thinks about proton therapy.
The episode digs deeply into the biological mechanisms that may explain this survival benefit. Dr. Frank introduces the concept of T-cell exhaustion, the progressive erosion of immune-system capacity caused by chronic radiation-induced inflammation and lymphocyte depletion in the IMRT arm. He hypothesizes that when IMRT patients progress, their immune systems may be too compromised to mount an effective response to salvage therapies, whereas IMPT patients retain more immunologic reserve. The team is now pursuing follow-on grants, drawing blood at years three, five, and ten post-treatment, and has extended trial evaluation out to a decade to test this hypothesis alongside two other candidate mechanisms: radiation-induced changes to the oral microbiome, and swallowing dysfunction leading to aspiration pneumonia and downstream mortality.
David and Dr. Frank also examine the real-world economics of proton therapy. Drawing on a collaboration with the University of Texas self-funded employee health plan, Dr. Frank describes how the analysis unexpectedly found that IMPT patients had fewer hospitalizations and emergency room visits than IMRT patients, enough to produce a net-negative impact on insurance premiums despite the higher upfront cost of proton treatment. The UT System subsequently issued a generalized approval of proton therapy across multiple disease sites for all covered employees and family members. Dr. Frank is also modeling indirect costs, caregiver FMLA leave, lost employer productivity, delayed return to work, showing that IMRT patients were more likely to remain unemployed even three years after treatment, a finding with profound societal cost implications.
The final third of the conversation pivots to Dr. Frank’s remarkable personal story. A history major at the University of Pennsylvania, he joined the Navy on an ROTC scholarship, was accepted into the submarine nuclear program despite never having been an engineering major, and served aboard the USS Batfish, a fast-attack submarine, for seven months at sea in the Mediterranean. He took his MCATs while deployed at sea, earned the equivalent of a master’s degree in nuclear engineering, and went on to Emory Medical School before completing his residency at MD Anderson in 2001. He treated MD Anderson’s first head and neck IMPT patients in 2010 to 2011 and has spent the intervening fifteen years turning a single dramatic clinical observation, a 33-year-old woman with an unresectable nasopharyngeal adenoid cystic carcinoma who achieved a complete response, into a multi-institution, multi-continent body of randomized evidence.
What You’ll Learn in This Episode
- TORPEDO Trial (UK): A phase III randomized trial comparing IMPT and IMRT in oropharyngeal cancer; showed comparable 1.7% feeding-tube rates at 12 months and confirmed IMPT is no longer investigational, though it lacked long-term survival follow-up and did not capture end-of-treatment toxicity burden.
- Non-Inferiority Phase III RCT (MD Anderson / NRG): Dr. Frank’s 440-patient, 17-proton-center, 21-institution trial, the first confirmatory level-one evidence study, demonstrated IMPT is non-inferior to IMRT in progression-free survival while achieving significant toxicity reductions across multiple endpoints.
- Gastrectomy / Feeding Tube Dependence: During active treatment, 40% of IMRT patients required a feeding tube compared to 27% of IMPT patients, a 13-percentage-point absolute reduction representing a clinically meaningful de-intensification of the treatment experience.
- 10% Overall Survival Benefit at Five Years: An unexpected finding in the trial showed 91% five-year survival in the IMPT arm versus 81% in the IMRT arm, a statistically significant absolute difference that emerged after the three-year mark when survival curves began to diverge.
- T-Cell Exhaustion Hypothesis: Dr. Frank proposes that chronic radiation-induced lymphopenia in the IMRT arm impairs T-cell function over time, leaving patients immunologically unable to respond to salvage therapy after disease progression, potentially explaining why IMRT patients died faster following recurrence.
- IMPT vs. IMRT, Mechanism of Precision: Intensity-modulated proton therapy delivers dose with no exit radiation and minimal entry dose to surrounding normal tissues, in contrast to IMRT (photon-based), which deposits dose along the entire beam path; a physics advantage that reduces cumulative toxicity to the immune system, salivary glands, and mucosa.
- Lymphopenia and Immune Reserve: IMRT’s broader radiation field depletes circulating lymphocytes more aggressively than IMPT; reduced lymphocyte counts correlate with worse long-term outcomes and are one of the primary measurable differences between the two treatment arms in the trial.
- Cost-Effectiveness and the UT System Study: A collaboration with the University of Texas self-funded employee health plan found IMPT patients had fewer hospitalizations and ER visits, resulting in a net-negative impact on premiums, prompting the UT System to issue a generalized approval of proton therapy across multiple cancer diagnoses.
- Indirect and Societal Costs of Toxicity: Dr. Frank’s economic modeling captures costs that never appear in direct care expenses: caregiver FMLA leave, lost productivity for self-employed patients, delayed return to work (IMRT patients remained unemployed at higher rates even three years post-treatment), and Medicare expenditures for patients who cannot re-enter the workforce.
- Single-Field vs. Multi-Field Optimization: Early proton therapy (circa 2008) used single-field optimization, where each beam treats the entire target volume. Modern IMPT uses multi-field optimization, analogous to IMRT’s inverse planning, where each field treats only a portion of the target, enabling far tighter dose sculpting.
- Proton Therapy for Orbital and Perorbital Tumors: In cases where tumors abut the eye, IMPT’s precision has allowed MD Anderson to achieve cure while preserving the patient’s vision and cosmesis, outcomes previously impossible with conventional photon therapy, which often necessitated orbital exenteration (surgical removal of the eye).
- Rising Indication Share, Head & Neck: Head and neck cancer represented approximately 3% of proton therapy cases nationally in 2008; by the time of this conversation it had risen to roughly 35%, making it the leading indication for proton therapy both at MD Anderson and increasingly at centers worldwide.
Dr. Steven J. Frank’s journey, from nuclear submarine officer to radiation oncology pioneer, is a testament to how intellectual curiosity, rigorous scientific discipline, and genuine compassion for patients can drive a field forward over decades. From his first IMPT head and neck cases in 2010 to the imminent Lancet publication of a 440-patient phase III trial showing a 10% overall survival benefit, Dr. Frank has demonstrated what it looks like to build level-one evidence from the ground up. The Cancer Project is grateful to him for his time, his transparency about the data, including its uncertainties, and his commitment to ensuring that no data is left behind in the pursuit of better outcomes for cancer patients everywhere.
Full Transcript
Read Full Transcript
Transcript generated from the episode’s audio. Speaker names are identified from the context of the conversation rather than from recorded speaker data, and automatic transcription may misspell names and terminology. Please refer to the video for the authoritative version.
David Raubach: Thank you, Dr. Frank, for joining us on this episode of the Cancer Project podcast. We really appreciate the opportunity to talk to you.
Dr. Steven J. Frank: It’s great to be here, David. Thanks so much for having me.
David Raubach: Before we came on, I had asked you, of course, we’re here at ASTRO right now and there’s been different papers released and there’s lots of things going on in the industry. And one of the hot topics has been this paper, or I guess it’s called the TORPEDO study that or trial that came out of the UK recently. And I was just curious your thoughts on that paper and the data that got released.
Dr. Steven J. Frank: Well, you know, thank you, David. And I was about to I was thinking that, you know, the TORPEDO trial, I’m actually an adviser on that study. They asked me to be one after they had developed the trial and they asked me to come on and just give them some insights. So, the TORPEDO trial is near and dear to my heart because I’m a former submariner and so having the name torpedo really was I thought pretty insightful and fun to hear the you know I think there’s a couple of things when we look at the data around proton therapy and also the paper that’s coming out in Lancet shortly which is extremely exciting from our data in our phase three trial. I think the one thing that I initially took home from this is that for the first time we’ve got confirmatory evidence that IMPT is comparable and it’s no longer investigational or experimental.
David Raubach: Okay.
Dr. Steven J. Frank: And for patients with oropharyngeal cancer and what I mean by that is in the phase three trial that we completed which is a 440 patient trial multi-institution 17 proton centers 21 institutions we were able to demonstrate comparable outcomes and that was important to demonstrate because when proton therapy with IMPT first was developed and that was really in 2010 2011 when we first started treating our first patients with IMPT there were a lot of concerns amongst all of the industry that that precision could also be a detriment.
David Raubach: Okay.
Dr. Steven J. Frank: And especially in head and neck patients when patients are losing weight and the tumors are shrinking during the course of the treatment that precision could make inaccuracies right in terms of where the protons go could cause patients to recur or could cause more toxicities. And so we needed to be able to prove first of all that we could achieve at least comparable outcomes with the standard of care which is IMRT.
David Raubach: Okay.
Dr. Steven J. Frank: And so our trial was once the it was the first confirmatory trial was a non-inferiority trial design and we were able to confirm with progression free survival that IMPT it was a positive trial. IMPT is non inferior to IMRT.
David Raubach: Okay.
Dr. Steven J. Frank: So that was a is a is was a big point. Now what that what the trial also showed which was which were two exciting things from a de-intensification because these patients are suffering through their treatment right they’re having significant amounts of mucositis they’re having loss of taste they’re having difficulty swallowing they’re needing feeding tubes and what the historic data had been shown is that 60% of patients are feeding tube dependent at the end of their treatment.
David Raubach: Okay. Wow.
Dr. Steven J. Frank: So, this was a this is an important de-intensification and many de-intensification efforts have been ongoing to try to reduce the toxicity of treatment. One deintensification approach has been surgery where we use TORS but those trials were shut down because there were patients had too many fatalities.
David Raubach: Okay.
Dr. Steven J. Frank: With the surgery. Other attempts was with systemic therapy where cetuximab was attempted to be used as a means of removing cisplatin.
David Raubach: Okay.
Dr. Steven J. Frank: And that trial was that trial did not it actually showed it was more toxic.
David Raubach: Okay.
Dr. Steven J. Frank: For patients and so that didn’t work.
David Raubach: Yeah.
Dr. Steven J. Frank: But proton therapy in our trial really demonstrated significant reduction of gastrostomy tube and feeding tube dependence. It showed a and that was an absolute difference of 13% from 40 down to 27 which was significant.
David Raubach: Okay.
Dr. Steven J. Frank: It showed a significant reduction of dysphagia or difficulty swallowing.
David Raubach: Okay.
Dr. Steven J. Frank: Significant reduction of xerostomia or saliva maintenance of saliva which is very important to patients.
David Raubach: Okay.
Dr. Steven J. Frank: And also a significant reduction of lymphopenia which affects the immune system and we’ll talk a little bit about how that imparts and that’s a very important one because over a course of 5 years what we are starting to see is a 10% absolute benefit in survival okay wow by patients that have proton therapy over IMRT okay and we are seeing for the first time at five years that 90% of patients 91% of patients are five whereas in the IMRT arm it’s about 81% of patients. So that absolute benefit of 10% is statistically significant and a and an unexpected finding quite frankly.
David Raubach: Yeah.
Dr. Steven J. Frank: In our trial. So these are this is an excitement that will be shared when the with the Lancet paper that’s soon to be published.
David Raubach: What do you think are some of the reasons or explanations for the overall survival benefit? I know you talked about side effects. Do you think that played a role then in this survival benefit?
Dr. Steven J. Frank: It’s impossible. So we have looked at the causes of death of each of these of the patients. We looked at acute causes and then we looked at chronic causes. Acute causes are those patients that died within 90 days of treatment and chronic causes are those that are after 90 days. And what we have found and then we separated the patients into those that have died with head and neck cancer.
David Raubach: Okay.
Dr. Steven J. Frank: Versus those that died without having recurred or with head and neck cancer. And what we found was about half of patients or about five patients that died with head and neck cancer acutely meaning within the first 90 days of treatment.
Dr. Steven J. Frank: Okay, it could have been from various reasons. Maybe they met a heart attack, maybe a patient one patient had committed suicide and that was in the IMRT arm or patients died during induction in chemotherapy.
David Raubach: Okay.
Dr. Steven J. Frank: Where they just didn’t tolerate the treatment well and passed away. So we saw that we saw about three patients that passed away or two patients that were had disease that passed away during the acute phase in the IMPT arm. Interestingly in the chronic arm is where it gets interesting because it the curves did not separate in terms of survival until about 3 years.
David Raubach: Okay.
Dr. Steven J. Frank: And at 3 years then those curves started survival. So we really are looking at that chronic phase and what we see is about 18 patients in the IMRT arm died following progression of their disease.
David Raubach: Okay.
Dr. Steven J. Frank: And that’s important to note because there wasn’t a difference in local, regional or distant control, right? And all in both arms they were roughly equivalent. And it was about 97% local control, 96% regional control, and 91% distant control in both arms. But what happened after that is really what’s the fascinating piece that we’re trying to tease and understand a little bit more. And what we see is the IM patients with IMRT are dying faster, okay, following progression. And there’s more patients with proton therapy who are salvaged after they progress.
David Raubach: Okay.
Dr. Steven J. Frank: And so there’s what are the mechanisms that we can justify that that’s happening. There’s a concept called T-cell exhaustion and that’s a an element of the of the of the immune system which is what I was referring to with the lymphopenia and that immune system what can happen is due to the chronic inflammation that happens with additional radiation IMRT and the dose path to normal tissues that over time with the decrease in the in the lymphocytes that when these patients progress their immune system cannot activate and respond as quickly and as robustly as the IMPT patients.
David Raubach: Okay.
Dr. Steven J. Frank: And perhaps that may be a reason that we’re seeing that those IMRT patients are dying faster and not able to recover with salvage in the same manner that the IMPT patients. Again, this is a hypothesis that we’re going to be looking at. And now we’re in the next phase. We’re getting grants to draw blood in with the patients in their 3 to 5 to 10 year phase and we’ve extended the trial evaluation out to a total of 10 years. We have initial grant with a P01 that’s also looking at chronic toxicities that are not associated with recurrences like dysphagia and to see if the swallowing function in patients may result in more pneumonias. Okay, that then result in deaths. And then the third thing that we’re looking at is you know with all of the changes that happen with IMRT in the anterior cavity that can change the microbiome.
David Raubach: Okay.
Dr. Steven J. Frank: And that microbiome can have impact on how patients eat and what happens in the GI tract and it could happen what can happen to with patients with respect to diabetes or cardiovascular disease you know that may affect the entire you know biome itself of the body. So these are some things that we’re looking at to try to better understand what is generating this 10% benefit and overall survival.
David Raubach: Okay.
David Raubach: So let’s go back to the TORPEDO study for a moment and say what did a TORPEDO study, what was its endpoint? What has it shown? What were the conclusions and do we agree with those conclusions? Right?
Dr. Steven J. Frank: So, one of the things that we identified in terms of the endpoint was a 12-month endpoint. And that 12-month endpoint was looking at feeding tube dependence and weight loss is and they were also looking at a University of Washington quality of life health assessment. So it’s one point in time, right? And they used data from additional different trials to come up with the right number of patients to see if they could come up with something that was statistically significant in terms of reduction for IMPT. What the overall study was, it was a negative study, meaning at 12 months after the treatment, both IMPT and IMRT arm had 1.7% feeding tube rates at 12 months and the quality of life instrument was not significantly different between the two arms. Okay, so that’s all the trial show, right?
David Raubach: Okay.
Dr. Steven J. Frank: It also showed that the this was always going back to it showed that the survival and the local regional control was consistent between the two arms. And so this is a confirmatory study that demonstrated that IMPT is comparable to IMRT and can be considered non-investigational.
David Raubach: Okay. Right.
Dr. Steven J. Frank: That’s so that’s an important point.
David Raubach: Yeah.
Dr. Steven J. Frank: Now what the what this what the study did not go into detail on was how many feeding tubes and what the feeding tube rate were for these patients at the end of their treatment.
David Raubach: Right.
Dr. Steven J. Frank: That’s an important metric of how patients are suffering during the course of their treatment and these patients because nobody wants a feeding tube.
David Raubach: Right. Right.
Dr. Steven J. Frank: And if you put a feeding tube in somebody that’s because they can’t sustain their nutrition and hydration on their own.
David Raubach: Right.
Dr. Steven J. Frank: And that is truly a toxic total toxicity burden endpoint that I think cannot be overlooked in this trial. And what we what I saw on the presentation yesterday was that from a quality of life the quality of life was significantly worse for patients with IMRT at the end of treatment.
David Raubach: Okay. Okay.
Dr. Steven J. Frank: And 6 weeks after those the I mean there was a significantly different amount of suffering that the patients were undergoing that was more consistent with IMRT than IMPT.
David Raubach: Okay.
Dr. Steven J. Frank: Now they didn’t show statistics on that yet. What they did show was a bar graph and they showed significance in bar graph in terms of patients being able to swallow and sustain themselves. What was also talking to the principal investigator David Thompson after the study he also commented to me that over 50% of patients in IMRT were at the end of treatment at feeding were feeding tube dependent.
David Raubach: Oh okay.
Dr. Steven J. Frank: Now you had only 53 patients were in the arm.
David Raubach: Right.
Dr. Steven J. Frank: It was a 2 to 1 randomization. Y so half of those patients were gastrostomy tube dependent which implies to me that that is considerable amount of toxicity, right that these patients are undergoing. And you have to remember in our trial we had 40% that weren’t in a treatment and also in our trial we had 27% that from the IMPT. So it’s almost a cutting by almost half of the patients that can’t sustain their nutrition and their weight during the course of treatment. So I think you know those are the elements that we have to tease out a little bit more. They only had a median follow-up of 24 months. So you know we didn’t see the curve separating in terms of survival until after 3 years.
David Raubach: Okay.
Dr. Steven J. Frank: So we don’t have that information from this study. What we are planning on doing which I think is exciting is we’re going to do a meta analysis with this data our data and also there’s two other randomized trials that are taking place in Europe okay in oropharynx cancer that are looking at this as well. There’s one Danish study called the DAHANCA that’s also accruing and there’s another study from the Swedish study which is also accruing as a phase 2 study. The other ones are phase three studies. So we’ll have a lot of interesting data to help us understand not only the survival but the outcomes and the one data that I didn’t present but we are publishing soon we’re submitting for publication is that this that the is the cost effectiveness.
David Raubach: Right. Right.
Dr. Steven J. Frank: And that’s going to be very important from a health economic standpoint to help not only our country but other countries look and understand that even though proton therapy is more expensive, it is cost effective. By reducing the toxicities and improving the survival and getting patients back to work.
David Raubach: So it sounds like with the TORPEDO study, what ended up happening is the feeding tube dependence resolved over that 12 months post treatment. And that’s how you go from the half of the patients had feeding tubes down to the one, what was it, 1.7%, right? Yeah. It’s in Is that pretty typical? I mean, do you see that, I guess, even with the proton patients, the 27% that needed feeding tubes in your study, would there have been a resolving of that issue, I guess, over 12 or 18 or 24 months, right?
Dr. Steven J. Frank: And then so we see I think like 2.8% of patients having feeding tube feeding tubes for IMRT and 0% at a year.
David Raubach: Okay.
Dr. Steven J. Frank: And so that’s why as an endpoint that’s they created something that was I don’t know if one can say that that’s that might be what the health care system in the UK is looking at.
David Raubach: Yeah. Right.
Dr. Steven J. Frank: They’re like well we just want to see what the one-year endpoint is. But that doesn’t tell the story of what the patient is going through over the trajectory of their treatment and their follow-up.
David Raubach: Okay.
Dr. Steven J. Frank: And I think our trial has done that. You know, we didn’t push one primary toxicity because the problem with having a specific endpoint like a toxicity like that is that then everybody looks at that and tries to prevent those end points from happening.
David Raubach: Right. Right.
Dr. Steven J. Frank: And specifically the nice thing about having a survival endpoint is that you can just take care of your patient. You don’t have to worry about toxicity endpoint one way or another because it’s not the primary endpoint and you get a more I would say you get a less biased assessment of how patients do on the continuity of their care throughout their journey through treatment.
David Raubach: Yeah.
David Raubach: So talk a little bit about you mentioned the cost burden of caring for patients and dealing with these side effects. The cost to an employer the cost to the family the cost to a health system. I think you’re involved in some research right now looking at that and trying to measure what that cost difference might be. And you’ve also done some research with the University of Texas as well and their employee funded health plan. I think I described that accurately. So talk just a little bit about what you’ve seen historically and this data that you’re working on right now.
Dr. Steven J. Frank: Yeah. So I think cost, you know, cost effectiveness is a critical element, especially when you have a more costly treatment that you’re trying to bring to the patients. We have to be able to determine, you know, not only that we’re going to improve their outcomes, but that it’s cost effective, especially for proton therapy that, you know, building these systems is extremely expensive and we need to make sure that we can justify that expense. So there are different elements that patients go through in their journey of treatment. There’s the initial reaction of course but once you start that treatment patients are typically around the average age of our patients was under 65. So the majority of patients were under 65. The median age was about 61. So these were patients that are not retired and are at the peak of their you know projected outcome in terms of productivity.
David Raubach: Right.
Dr. Steven J. Frank: In their life, right? That’s this is phases of importance. So, they want to continue to work. They’re not looking to take time off, right? Per se. And this is a major disruption in their lives. Also the family’s lives. You know, usually the they if they have families, their kids are moving into high school and moving into college age. And so, and some are less than that. They’re, you know, in elementary. So there these are families that are you know looking to continue to maintain that sustenance and continue to grow right and so when patients have to have feeding tubes that’s a as I mentioned before that’s a an assessment of total toxicity burden.
Dr. Steven J. Frank: Okay, that means that they simply cannot eat enough food drink enough water control their pain to be able to sustain them and clearly they’re not going to work when they’re having a feeding tube, right. And so that all of a sudden from an employer standpoint that has cost implications because now you’ve taken a product productive employee and pulled them out of the company right so to speak and sometimes you know these people might be running their own companies you know so you know that and that has impact for families the spouse or the significant other is now trying to become the caretaker for these individuals and so they you many of these are double income families. And so now you’re compromising some of the care and some of these patients have to take some of these caretakers have to take FMLA.
Dr. Steven J. Frank: So that also impacts employers even though they’re not the patient, right? So because they got to take care of the patient. So I think that’s those are two elements of economics that we’re trying to model and better understand and those are costs that don’t show up in the direct cost of care.
David Raubach: That’s correct.
Dr. Steven J. Frank: They do not show up in the direct cost of care, you know, but it’s still a measurable cost to society. It’s a measure cost society and it has financial toxicity to the patients, right? And then you’ve got the cost of coming to proton centers where they have to, you know, come out and that’s true at least at our institution. Many people come for far and wide both in nationally and internationally. So there’s a cost to that as well. Getting an apartment, buying different types of foods and things to that degree. Then after treatment patients want to get back to work quickly, right? And what we’ve been able to demonstrate in some of we collected six different patient reported outcome metrics.
Dr. Steven J. Frank: One is a work productivity index. And so we’re able to monitor how patients return to work or do not return to work and are unemployed. And what we’ve seen is a significant difference in the amount of patients from the beginning of treatment to the end of treatment returning to work in the IMPT arm.
David Raubach: Okay.
Dr. Steven J. Frank: Versus the IMRT arm.
David Raubach: Okay.
Dr. Steven J. Frank: And more patients that were unemployed in IMRT out even out to three years.
David Raubach: Oh wow.
Dr. Steven J. Frank: Following treatment. So recovering following the treatment is also you know immeasurably has you know has to be measured as well.
David Raubach: Right.
Dr. Steven J. Frank: And then what we tried to do and model in our cost effectiveness analysis was we looked at the taxes that people would pay if they’re working.
David Raubach: Okay.
Dr. Steven J. Frank: We also looked at what would Medicare have to pay patients who are unemployed, right? If they’re not able to get back to work, right? So those elements also fit into a model that help us better understand cost to society in terms of the overall treatment, right? In the University of Texas system as you mentioned we did a particular study looking at how can we get Blue Cross and Blue Shield to pay for the pay for the treatment and then we would come back to UT system University Texas system which pays for all of the care and it’s a self-funded system for the patients as well as their family members, okay, but primarily the patients in this particular study.
Dr. Steven J. Frank: And looking at what that would mean to the premiums and what we found between IMRT and IMPT is that the patients had less hospitalizations.
David Raubach: Okay.
Dr. Steven J. Frank: Less emergency room visits. So there were less cost. We anticipated more cost because of the expense of the treatment. But actually we saw a negative difference in what they would do to those premiums. And so what the UT system did based on that study was they said that these particular indications we were going to approve. So this was across multiple disease sites on multiple disease sites and there was a generalized approval of proton therapy for those diagnosis for all patients who were employees and their family members.
David Raubach: Okay.
Dr. Steven J. Frank: And so that was published. That’s very that was a very exciting demonstration of collaboration between MD Anderson and the University of Texas system where we’re one of 14 institutions within the University of Texas.
David Raubach: Okay.
Dr. Steven J. Frank: And so that was is an exciting collaboration to demonstrate improvement of care and also helping the UT system reduce the cost of healthcare.
David Raubach: Yeah. Okay. That’s amazing. Well, it’ll be really exciting to see more of that data get published as well. And you know, it’s important the these are big capital investments that we make at MD Anderson, at our center, at the Oklahoma Proton Center. And so it is important to justify the cost that’s being committed to these projects. And I think one of the ways to do that is to show that ultimately the cost to society, the cost to payers, the cost to employers can be reduced by treating patients with protons versus treating them with even state-of-the-art photon treatment like IMRT.
David Raubach: So, we’ve talked a lot of science and a lot of medicine. And obviously you’re doing some amazing things from that standpoint, but I also think that you have a really fascinating background and story. So, in the few minutes that we have remaining, I do want to talk a little bit just about how you ended up in medicine, how you ended up as a radiation oncologist. And so tell us just a little bit about Steven Frank and how you ended up where you are today. And you have to make sure that you talk about playing baseball, too. So, since that’s near and dear to my heart, don’t leave that out.
Dr. Steven J. Frank: You know, I was very fortunate to have been brought up in an environment of medical care.
David Raubach: Yeah.
Dr. Steven J. Frank: My father, who is my hero. He just recently passed away this year, but he was an internist and cardiologist. He grew up in a town of Huntsville, Alabama. His father was a football coach and he ended up my father ended up playing football at Alabama where he was Bear Bryant’s first fullback at Alabama in 1958 and he was a Phi Beta Kappa at the University of Alabama and which there’s not many football players that are Phi Beta Kappas and if you go into the program there’s like listed like 10 of them my dad’s name you know you know so it’s really.
Dr. Steven J. Frank: But he decided to go to medical school forgo his senior year he then became a cardiologist and moved to Atlanta with my mother. Then they met at the University of Alabama and he developed the largest internal medicine group which was called the Lauria Medical Group over time and I had a chance to watch him and his love of taking care of patients, right? And so that sort of imprinted upon me where, you know, of what it meant for someone to really love what they were doing, right? And love the ability to touch patients, take care of them, and have that relationship with patients. And so I think I knew early on that medicine was something that was something that I had wanted to consider and wanted to do in my life. And I ended up going to school at the University of Pennsylvania.
David Raubach: Okay.
Dr. Steven J. Frank: Ended up going on a Navy ROTC scholarship.
David Raubach: Okay.
Dr. Steven J. Frank: And as you applied, I also played baseball there as a catcher for several years.
David Raubach: Why did you join the Navy?
Dr. Steven J. Frank: So, I joined the Navy because I saw what the expensive colleges were.
David Raubach: Okay.
Dr. Steven J. Frank: Well, two things. You know, when you go in high school, they give you these little personality assessments.
David Raubach: Yeah.
Dr. Steven J. Frank: You know where they and you take this test and then it tells you what you should consider doing based on that system. So two things came out of that.
David Raubach: Yeah.
Dr. Steven J. Frank: One was military.
David Raubach: Okay.
Dr. Steven J. Frank: So military popped up as something that I should consider that you know that I should consider. And the second was a farmer.
David Raubach: Oh wow. Okay.
Dr. Steven J. Frank: So you know and so I thought that was really I’m like you said wow I’ve got to do one or the other, you know, and we’ll come back to farming in a minute because, you know, that’s an interesting one. But, so I applied to the Naval Academy. Didn’t get into the academy, but I did apply also for an ROTC scholarship because I recognized the expense of college at that time. And, I felt that there was an opportunity for me and that going to medical school, if I really want to still go, then I could have the Navy pay for not only college, but then pay for medical school. And so that would be a potentially a good track.
Dr. Steven J. Frank: So I went into the ROTC and what I came to appreciate was that I took all the premed classes, I was also a history major in college.
David Raubach: Yeah.
Dr. Steven J. Frank: And that the more I talked to physicians who were in the Navy, the more they told me that from the time that the decision of what type of field that you wanted to go into may not be your decision.
David Raubach: Oh, okay.
Dr. Steven J. Frank: So, and they might need this type of physician, not that type of physician. So, they recommended finish your commitment and then if you still want to go into medicine, do it at that time.
David Raubach: Okay.
Dr. Steven J. Frank: So between the sophomore and junior year of college, you have this period of time where they take you and they give you an opportunity to look at every type of discipline in the Navy from surface ships.
David Raubach: Mhm.
Dr. Steven J. Frank: To aviation to the Navy Seals to the Marine Corps. And so those all these different areas you’re exposed to.
David Raubach: Okay. Okay.
Dr. Steven J. Frank: And to and I didn’t mention submarines. So that was so those are the areas. So when I went out to the I went out to the west coast, San Diego for submarines for the Navy Seals and then went up to Whidbey Island up in Washington State to fly jets and was down to Camp Pendleton for the Marines.
Dr. Steven J. Frank: And after that summer I got off the submarine.
David Raubach: Uhhuh.
Dr. Steven J. Frank: And I said, I will never go back on one of those again. I mean, who in their right mind would actually go on a submarine, you know? I mean, and paint a picture for people that haven’t been on a submarine. I mean, you know, so submarine, you know, they’re about the size of a football field.
David Raubach: Okay.
Dr. Steven J. Frank: But they’re filled with so much equipment that two people have to turn side by side to walk down.
David Raubach: Oh my gosh.
Dr. Steven J. Frank: Walk down a passageway. You know we call it a hallway but in the submarine it’s called a passageway and then when you’re actually sleeping the height of your bunk is about from your elbow to the top of hand and then go the width is about the width here and so wow that’s where you that’s your sleeping quarters and you know what that reminds me of we’re here in San Francisco and I went out to go visit Alcatraz a couple days ago I mean it’s like that’s the picture that’s coming to my mind is these little prison cells almost.
David Raubach: I mean, there was probably to do this, right? There was probably more space there.
Dr. Steven J. Frank: Yeah, it actually probably was. We had three officers in one state room. So, you know, we’re all sleeping on top, you know, and so they so I was just like this is I mean I’m like who in the world would actually do this?
Dr. Steven J. Frank: And when at that time I thought, you know, I spent some time with those Navy Seals and I was like this is the coolest thing I’ve ever done. And so for about a year I trained and worked out and with the marine group at Penn.
Dr. Steven J. Frank: And then I took all the exams, asked all the exams, but my eyesight they came to me and they said, “You were disqualified because your eyesight needs to be 20/70 correctable to 20/20.” And I had about 20/100 at the time.
David Raubach: Oh no.
Dr. Steven J. Frank: And you couldn’t do any of the stuff that we do today. And they didn’t have any of that stuff.
Dr. Steven J. Frank: So then they said, “What else would you like to consider?” And they said, “We looked at your grades. Why don’t we send you down to Washington DC and see if you go into the submarines program?” Because every submariner has to meet with the admiral, the head of the chief of naval operations and the vice admiral of the navy.
Dr. Steven J. Frank: So, you have to get approved by that. You have to have an interview. They do you do several interviews. These are technical interviews. They, you know, whatever class work you’re doing, physics, chemistry, whatever it was, they do interviews and they test you. And then the second day is you meet with the admiral and then if they accept you, then they, you know, you sit, you sit across from a desk and I can remember the admiral saying like, you know, you’re a history major. What are you doing here? We got all these people from Caltech, Illinois, Naval Academy, they’re all engineers. I don’t want to send you down there and fail at a nuclear power school.
David Raubach: Right?
Dr. Steven J. Frank: So, I’m sitting I’m like the last person you know waiting and there’s a desk an administrator behind the desk. They finally call my name and I come and I go up and I sit down and they’re either tell you you’ve been accepted into the program or you haven’t. And I had gone down to, you know, when I thought about considering this, I went down to Kingsland, Georgia to the USS Pennsylvania with my parents.
David Raubach: Okay.
Dr. Steven J. Frank: And I met the captain of the submarine. And they rolled at me and really went down and after spending some time really intellectualizing and thinking where do I want to spend the next 5 years of my life?
David Raubach: Yes.
Dr. Steven J. Frank: What I came to realize is that everybody on that submarine are very well educated and probably the brightest of all the military are on these submarines. And that really attracted me to be with the highest caliber and quality of what the Navy had to offer in terms of you know my opportunity to spend that type of and so that sort of drew me a little bit. And I thought I would consider it, you know. So I sat behind the administrator’s desk. She said, “Congratulations. You’ve been accepted.”
David Raubach: Oh my gosh.
Dr. Steven J. Frank: That’s She said, “Go down the hall. You have to pick whether you’re going to go surface Navy or sub or subsurface Navy.”
David Raubach: Yes.
Dr. Steven J. Frank: East coast or west coast.
David Raubach: Okay.
Dr. Steven J. Frank: So then I ended up picking submarines and going to the east coast.
David Raubach: Okay. What and so at that point did you know kind of what the next 5 years were going to look like or you sort of do.
Dr. Steven J. Frank: It’s pretty mapped out for you. You have to go to nuclear power school which is a six-month school. That was in Orlando and you know that was pretty intense because there were engineering classes that I had never taken before.
David Raubach: Yeah.
Dr. Steven J. Frank: And you really you working I was working from 4:00 a.m. to 10:00 p.m. each day. It was quite extensive and people were bailing out and it was Well, you had a history background.
Dr. Steven J. Frank: You hadn’t taken a bunch of math classes, you know, but it was it was amazing experience and I met some, you know, some incredible people. And then after you pass that, then you go to a nuclear prototype facility where you get hands-on operation of a nuclear reactor.
David Raubach: Okay?
Dr. Steven J. Frank: And then you have to pass that and that’s a six-month program working shift work 12-on, 12-off okay for 6 months and then if you pass that then we then I went up into they have a warfare school up in Connecticut where you have three months of tactical warfare from a submarine and then they have one final test.
David Raubach: Okay.
Dr. Steven J. Frank: They put you into a submarine escape system.
David Raubach: Okay.
Dr. Steven J. Frank: And they flood the system. It’s in a pool. They flood it down. You have to wear the device which is what that was created called Dr. Stany had this device and it’s like you put it over, you know, like a life preserver.
David Raubach: Yeah.
Dr. Steven J. Frank: But the life preserver has a hood.
David Raubach: Okay.
Dr. Steven J. Frank: And then what it does is when if a submarine goes down, they put you in this pod, then they equalize the pressure. The pressure opens up the hatch and then you escape to the surface.
David Raubach: Okay.
Dr. Steven J. Frank: And you have enough air to allow for you to get up I think it’s like 300 to 500 ft.
David Raubach: Okay.
Dr. Steven J. Frank: But you have no thermal protection on your body.
David Raubach: Yeah.
Dr. Steven J. Frank: The reason that story is important because the first paper I published was when I was up in Connecticut, okay, and I worked with the medical Naval Undersea Medical Laboratory and I looked at the submarine escape system and with the question of is it a practical system?
David Raubach: Okay.
Dr. Steven J. Frank: And I did because when I got to my submarine, I became a Navy I went to Navy dive school. They every submarine requires four Navy divers. So they sent me to the Navy dive school in Panama City.
David Raubach: Okay.
Dr. Steven J. Frank: Where I got that got that training. So then you go to your submarine and you’re there on your submarine for about three and a half years.
David Raubach: Okay.
Dr. Steven J. Frank: You’re assigned to that submarine. It was a fast attack boat. It was called the USS Batfish. I was in Charleston, South Carolina. And we spent we went on deployments that were 7 months at sea in the Mediterranean.
David Raubach: So when you say seven months at sea, you’re literally on the submarine form months.
David Raubach: Okay.
Dr. Steven J. Frank: So you’re in about 80% of the time you’re underwater and about 20% of the time you’re in port.
David Raubach: Yes.
Dr. Steven J. Frank: You know getting resupplied and also it’s important for morale as you can imagine.
David Raubach: Yes. How do you maintain your sanity in a setting like that? What does the day-to-day look like in that setting?
Dr. Steven J. Frank: So there’s it’s about you work on an 18-hour day.
David Raubach: Okay.
Dr. Steven J. Frank: Meaning that you’ve got six hours of shift work on where you’re operating. You know, you have diff they move the officers around. So the officers you might I was you supervise the operation of the reactor in the reactor space in the engineering spaces or you’re up in the control room where you might be in the battle station area which is the compartment that actually drives the as the officer of the deck. So there’s we have 10 officers on the submarine and about 100 enlisted. So there’s about 110 people on the entire submarine together passing each other turning sideways to go down the passageway.
David Raubach: Yeah.
Dr. Steven J. Frank: You know, you become a close talker.
David Raubach: Yeah. Right. Yeah. Yeah. Yeah.
Dr. Steven J. Frank: So you ask, you know, we they have a little bit of area where you can work out. A small little a little area.
David Raubach: Okay.
Dr. Steven J. Frank: Not much, right? But you know, enough. And then you have six hours of maintenance and then there’s six hours of drill time. So really, you’ve got to find these four hours every 18 hours at least to get some sleep.
David Raubach: Oh, okay.
Dr. Steven J. Frank: So that’s sort of how you know and there’s four different cycles of meals. The food is actually fantastic on the submarine. The best chefs in the military or on the submarine.
David Raubach: Okay. Yeah.
Dr. Steven J. Frank: So that helps with morale.
David Raubach: Yes. Yes. As you can imagine.
Dr. Steven J. Frank: So you know, so it’s a unique environment.
David Raubach: So that may have looked different than Alcatraz then. The food it sounds like the so the food was a little bit better.
Dr. Steven J. Frank: Was a little bit better, you know. So it was a great experience, but I think once I think I knew after a couple of years of being on the sub that for a career in the Navy, which you know, which was there’s a career path and by the way, you have to go back to after two years of being on the sub, which is at that four-year point, you have to go back to Washington DC to take your nuclear engineers exam. And that’s and to pass that gives you the equivalent of a master’s degree in nuclear engineering.
David Raubach: Oh, wow. Okay.
Dr. Steven J. Frank: And so everybody, every officer has to go back and do that. If you don’t pass, they give you one other opportunity to take it. And if you don’t pass, then you have to leave.
David Raubach: Okay.
Dr. Steven J. Frank: If you do pass it, then you have the opportunity of staying in, doing a shore tour, and then climbing the ladder to ultimately command your own submarine.
David Raubach: Okay?
Dr. Steven J. Frank: You know, which would be the, you know, the track for an officer of the boat. So I think at that time I realized that being away from home for that long and that period of time and that type of life was not exactly when I thought about you know considering medicine or that type of lifestyle. I felt that medicine was probably the better pathway
David Raubach: Yeah.
Dr. Steven J. Frank: for me.
David Raubach: Right.
Dr. Steven J. Frank: So I took the MCATs while I was on a submarine at sea.
David Raubach: Oh did you really?
Dr. Steven J. Frank: I did. And then and then I applied and then I decided to finish my service and not stay in. And then I got into Emory Medical School in Atlanta and went to medical school at that point.
David Raubach: Yeah. And what at what point did you decide that you wanted to be a radiation oncologist? Because there’s actually quite a connection from a technology and science standpoint with what you’re doing now, especially with proton therapy and particle accelerators and the nuclear submarine that you were on. So, when did you decide this is the specific type of medicine that I want to practice?
Dr. Steven J. Frank: I think I was in my third year of medical school, never even heard of radiation oncology.
David Raubach: Okay.
Dr. Steven J. Frank: And a buddy of mine named Chad Levit, he had come back from UCLA doing a rotation and we were in Grady Memorial Hospital.
David Raubach: Okay.
Dr. Steven J. Frank: And we were in the cafeteria and he turned to me and we had gone to high school together. And we he had also gone to em you know he’s at Emory and he said I this is the most incredible field you’ve got to you know he’s always enthusiastic but he’s like this is the most incredible field. It’s called radiation oncology and you know and I was always looking to combine the engineering knowledge that I had with medicine and try to do it in some way. And so I had never heard of this field.
David Raubach: Mhm.
Dr. Steven J. Frank: So I listened to him and I said, you know, I went up to the rooftop where the library was in the hospital and I pulled up in a textbook.
David Raubach: Yeah.
Dr. Steven J. Frank: You know, in of oncology, cancer medicine and I looked up radiation oncology and it was all this physics and I understood I understood all the physics.
David Raubach: Yes.
Dr. Steven J. Frank: And it was very interesting. And then I started thinking, well, I’d like to learn a little bit more about this. And so I looked for where radiation oncology facility was and there was nothing in the hospital.
David Raubach: Okay.
Dr. Steven J. Frank: But it was outside the hospital. It’s like a block down the street.
David Raubach: Right.
Dr. Steven J. Frank: So I went out walked down there. This is at this Grady Memorial Hospital. And I walked in to the radiation oncology facility and I introduced myself and there was a resident there and I said, you know, I just wanted to introduce myself and I’ve heard about this field called, you know, what exactly is radiation oncology?
Dr. Steven J. Frank: And he looked at me and he said, his name was Steuart Bur.
David Raubach: Okay.
Dr. Steven J. Frank: Remember like it was yesterday.
David Raubach: Yeah. Yeah.
Dr. Steven J. Frank: Who’s now, you know, chair chief radiation oncologist in Chapel Hill.
David Raubach: Okay.
Dr. Steven J. Frank: Not Chapel Hill, in Charlotte, North Carolina.
David Raubach: Okay.
Dr. Steven J. Frank: And he said, “Welcome to the best kept secret in medicine.”
David Raubach: Oh, yeah.
Dr. Steven J. Frank: It’s exactly what he said. And we started to talk a little bit. I did a rotation there. Then I went out to MD Anderson. I did a month rotation there. And then I came out to UCSF and I did a month rotation here.
David Raubach: Yeah.
Dr. Steven J. Frank: Because I wanted to see what the field of radiation oncology was like in different academic environments. And after doing that, that’s then that’s when I knew that I wanted to go into the field. And I told my father that I wanted go in radiation oncology. He goes, “You’re not going to radiation oncology.”
David Raubach: Oh, really? Okay.
Dr. Steven J. Frank: He said, “That’s just where we send patients and we never see them again.”
David Raubach: Right. Okay.
Dr. Steven J. Frank: That was how it was perceived in the medical world, you know, about radiation oncology. And to your point, the technology, the patient interaction, I think, you know, really drew me. You’re on that you’re on a destination with a patient and the ability to be part of their curative treatment. It was not just a palliative field. It was a true opportunity to be part of a definitive curative treatment for patients.
Dr. Steven J. Frank: And so I then was fortunate to be matched for residency at MD Anderson.
David Raubach: Okay.
Dr. Steven J. Frank: And then I came out in 2001 for my residency.
David Raubach: Yeah.
Dr. Steven J. Frank: Stayed on faculty and have been there since.
David Raubach: And when did you first get exposed to proton therapy?
Dr. Steven J. Frank: So proton therapy they started building Jim Cox who was the my chair at MD Anderson really believed in proton therapy.
David Raubach: Okay.
Dr. Steven J. Frank: He believed in it so much that he decided to bring make that a big project for the institution. And in 2003 while I was a resident they started to build the facility.
David Raubach: Okay.
Dr. Steven J. Frank: They started to build it. And in 2006 which was the first year I came I had come out in 2005 it was that you know first year and a half we treated the first patient with proton therapy. So I had just come on faculty. I was on both on the head and neck service and I was on the GU service.
David Raubach: Okay.
Dr. Steven J. Frank: So I was split on two different services was a little bit unique at that time as well.
Dr. Steven J. Frank: And then I talked to one of my mentors Kian who was you know was really a leader in clinical trial translational science and just a great human. He I asked him I said you know should we consider treating our head neck patients with protons?
David Raubach: Uhhuh.
Dr. Steven J. Frank: And he said there’s no role for proton therapy in really okay and so because at this time MD Anderson was one of what three proton centers right in the country.
David Raubach: Yes.
Dr. Steven J. Frank: I think it was it was the first proton therapy center comprehensive cancer center okay. And so it was a you know Indiana had been out there but was sort of struggling, Loma Linda, and so I guess MGH was doing protons, so.
David Raubach: Yeah, one of four, that’s right.
Dr. Steven J. Frank: So those were the sort of the ones that existed at the time and but I but I it made sense to me to consider head and neck and so I started doing treatment plans started looking at different ways working with the dosimetrist working with physicists and started really exploring whether proton therapy could actually be beneficial for patients right compared to what we were conventionally doing.
Dr. Steven J. Frank: And at that time we had not gotten fully into IMRT.
David Raubach: Uhhuh.
Dr. Steven J. Frank: And so most of the plans were done using a you know a pencil on a flat 2D image.
David Raubach: Okay. Wow.
Dr. Steven J. Frank: And that’s how we drew our fields.
David Raubach: Wow.
Dr. Steven J. Frank: When we were taking care of patients. So you know the 3D era was just coming into play.
David Raubach: Right.
Dr. Steven J. Frank: And by 2008 we started really moving to IMRT as much more of a standard.
David Raubach: Okay.
Dr. Steven J. Frank: And we in 2008 scanning beam was the first time that we were able to do it and we treated our first scanning beam patient with prostate cancer.
David Raubach: Okay.
Dr. Steven J. Frank: And so that technology was brand new.
David Raubach: Yeah.
Dr. Steven J. Frank: That was 2008. That was scanning beam.
David Raubach: Okay.
Dr. Steven J. Frank: But that was what we call single field optimization. And what single field optimization is of course is that every field gets treated with you treat the entire target volume with every single field. So if you have three fields, each field is treating the entire target volume.
David Raubach: Okay?
Dr. Steven J. Frank: The newer technology that started to evolve was what we call multi-field optimization.
David Raubach: Okay?
Dr. Steven J. Frank: Where every field that you treat treats a portion of the target and that’s much more similar to IMRT, right? And you have inverse planning.
David Raubach: Okay?
Dr. Steven J. Frank: So I treated the our first head and neck patient with oropharyngeal cancer and nasopharyngeal cancer. Those were the first two patients in 2010, 2011 and that’s when it first dawned. It was sort of a light bulb moment for me.
David Raubach: Yeah.
Dr. Steven J. Frank: It was a light bulb moment for two reasons. One because I was able to understand that the physics of proton therapy has a major advantage, right? You know that these patients were able to get through treatment able to maintain their taste, less mucositis on the oral cavity, less weight loss, less difficulty swallowing, right? And it was a true aha moment for me. The second aha moment was a radio aha moment and that was with a 33-year-old female that came in with nasopharyngeal cancer which was an adenoid cystic carcinoma and nobody would treat her. This tumor wrapped around her brain stem and nobody would even treat her with IMRT.
David Raubach: Okay.
Dr. Steven J. Frank: So she came, we sat down. We looked at what a IMPT plan would do and I said we are willing to consider this. Let’s do let’s try it. There were even colleagues of mine that didn’t want their name associated with this patient because they were so everybody was so worried. I mean and it there was a lot of uncertainties at that moment. This was a completely unresectable tumor and in her by the time after her first follow-up visit she had a complete response.
David Raubach: That’s amazing.
Dr. Steven J. Frank: It was unbelievable. And so that’s when I recognized that not only was there a physics advantage with proton therapy with the with no entry and exit dose so to speak or less entry and no exit dose but from a radiobiologic standpoint we were dealing with a different type of radiation drug so to speak.
David Raubach: Right. Right.
Dr. Steven J. Frank: And that was enough to start me on the journey or developing a randomized trial.
David Raubach: Okay.
Dr. Steven J. Frank: And the question became what’s the right space to do this a randomized trial right and there’s not enough patients in the United States with nasopharyngeal cancer. So that couldn’t that wasn’t going to be the right cohort for the United States. Definitely in Asia but not for the United States. But in oropharynx there was a rapid rise in epidemic okay of oropharynx that was happening in both Europe and America. That was probably the number one disease that was you know happening to patients. So that became the group of patients that I thought this may be the best to run a randomized trial on.
Dr. Steven J. Frank: And then that started the development of that trial that we have just completed. Went to the NRG, discussed it with them. They were less inclined to do it. Because probably for two reasons. One, there wasn’t that much proton therapy out there.
David Raubach: Oh, right. Right. Yeah.
Dr. Steven J. Frank: And so most of the NRG groups didn’t have protons. So that they didn’t want to that was not interesting that was an interesting question to them at the time.
David Raubach: Right?
Dr. Steven J. Frank: And so I then went back and started putting the infrastructure together at MD Anderson to initiate the trial. And then when Mayo Clinic got proton therapy, I started collaborating with Rob Foot and then I collaborated with Paul Busy up at Mass General Hospital and we started to develop the consortium.
David Raubach: Okay.
Dr. Steven J. Frank: And that sort of built, you know, as every proton center started coming online, we built out 17 different activated 17 different proton centers with 21 different institutions to participate in the trial. So, and that’s a that’s the 440 patient trial that has led to the completion and then the subsequent reporting out that’s coming shortly.
David Raubach: That’s an amazing story. And to think that all started back in 2006 as you were looking at those first proton therapy plans for head and neck cancers and now here we are 19 years later and it’s kind of the culmination of almost two decades of work on your part.
Dr. Steven J. Frank: That’s an amazing history as it’s amazing as a history major. You’re participating in the history. Well, when you look at the number of patients that were treated at a proton center with head and neck, it was about 3% in 2008, right? When you look at it today, it’s like 35%.
David Raubach: Oh, wow.
Dr. Steven J. Frank: And it is the leading it is the leading indication that not only at our center but I think nationally and if you look at it internationally, yeah, it is the leading type of treatment that is being used for proton therapy. And I think part of the reason and this is you know it’s one thing if one center you know does it that way right and you know we’ve made an effort we sort of have a motto that no data is left behind. We initially put together prospective databases we published our work quickly. We did case match control studies. We did quality of life studies. We put outcome studies. So we did a lot of that publication. And we did that real time to ensure that we could articulate and communicate what the results and outcomes of patients are.
Dr. Steven J. Frank: And then those studies became validated at Mayo and at other centers as they started to publish their own data. And then when you start seeing repeated data being published, it sort of creates that validation.
David Raubach: Right. Right. Right.
Dr. Steven J. Frank: And that’s what that’s the excitement. Everybody wanted to see a randomized level one evidence because the insurance companies still would not right, you know, pay for it. And even in our trial, we had about 23% crossover of patients in the trial, meaning patients that got randomized to IMPT, but subsequently got treated with IMRT.
David Raubach: Okay?
Dr. Steven J. Frank: And that’s because insurance denied them. And then we had patients that got randomized to IMRT, but that their insurance improved it. And then they refused their randomization and got went and got treated with protons.
David Raubach: Okay.
Dr. Steven J. Frank: So, we added that those two cohorts into the study.
David Raubach: Okay.
Dr. Steven J. Frank: And in fact, we published while we were doing that because I knew that after the trial was over, there was going to be a lot of criticism about the methodologies of the study. And so, we published the methodologies along the way to keep everybody informed and updated as to exactly what we were doing and why we were doing it.
David Raubach: Right.
Dr. Steven J. Frank: And I think that’s been fully transparent. Fully transparent as to what the process was and why we needed to do what we were doing.
David Raubach: My last question, you talked about your dad being your superhero and just the fact that him going into medicine was part of your inspiration to go into medicine. And I know you talked about him passing away recently. You also said that he had discouraged you initially from going into radiation oncology. I imagine that perspective changed over time as he saw all of the great things that you were doing treating patients at MD Anderson with radiation on
Dr. Steven J. Frank: Yeah, I think that’s exactly right. I mean as he started seeing and learning about what radiation oncology really was the impact on patients during their cancer journey and you know whether it was prostate which I also treat whether it was and my you know my mother unfortunately passed away as well from cancer.
David Raubach: Oh wow.
Dr. Steven J. Frank: She had an unknown primary and she ended up getting proton out of MD Anderson.
David Raubach: Okay.
Dr. Steven J. Frank: And was treated by one of my colleagues.
David Raubach: Oh wow.
Dr. Steven J. Frank: And so he saw her journey go through treatment and her and you know her journey she was told that she had maybe 11 months to live and she ended up living two and a half years you know following treatment. So she had a much longer lifespan and journey you know following. So I think he saw it not only in his son.
David Raubach: Yeah.
Dr. Steven J. Frank: But he also saw it in his spouse and his wife and my mother and you know so he’s and I think he definitely came around and I think he came to understand what that benefit and you know and was you know was a big supporter of me you know all along the way.
David Raubach: Well, when I tell people that I work in radiation oncology, of course, I’m not a doctor. But, one of the comments that I usually get is, “Well, isn’t radiation bad?” Right? So, like you think of it, people there’s this perspective that whatever it is, like, oh, well, that’s where, you know, as your dad said, that’s where we send people and they never come back or radiation’s bad.
Dr. Steven J. Frank: But it really is an incredible tool that we have to fight this horrible disease of cancer. It is a very unique and important tool. You know when you think about taking things out and having you know surgery comes with complications as well and prostate cancer is another example and even head and neck I mean that we’ve looked for ways to eliminate radiation in many different capacities but that has not happened. You know and I think radiation should be the primary modality for prostate cancer treatment patients are able to not get incontinent able to sustain their erections better patient satisfaction.
Dr. Steven J. Frank: It’s a and we published our 3,000 patient series recently on prostate cancer and the results are fantastic with protons and so I think that is a great modality when you look at and that’s not going to and chemotherapy is not going to treat that and surgery causes more complications. So there in lies is a great modality when it’s when the tool is used correctly. We’re seeing now that we’re treating more patients with metastatic disease with radiation to get patients a break from all their systemic therapy that causes tremendous amount of toxicity and we might even be able to extend people’s lives longer.
Dr. Steven J. Frank: So that data is starting to mature and in the head and neck space you know when you really start to see for nasopharynx which is epidemic in Asia for oropharynx which is epidemic rise in the United States when you see periorbital tumors and we’ve done a lot of work where we would normally take the eyes out and patients will have orbital exenterations when they have these tumors adjacent to their eye. Now with proton therapy we can not only cure them but we can maintain their clear vision and their cosmesis. So, a huge quality of life, you know, benefit. So I think proton therapy people not just in the United States but in Europe and Asia you’re seeing that rise of head and neck as a leading modality because any amount of radiation that is unnecessary can have long fibrotic and toxic effects to these patients years after their treatment is over.
David Raubach: Well thank you so much for all of the amazing work that you’re doing Dr. Frank, and thank you for sharing a little bit about your personal journey as a being in the Navy and then becoming a doctor and again, thank you for all the work that you’re doing on behalf of patients and the proton therapy community.
Dr. Steven J. Frank: Thank you, David. Thank you for all the great work you’re doing helping educate all of us in the community and about the advantages and the history of proton therapy.
David Raubach: Thank you.
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