This is the interview of Robert M. Byers for the American Head and Neck Society History Committee. Date of interview, January 30, 2004.
Randall Weber: This is Dr. Randal Weber interviewing Dr. Robert Byers. The date is January 30, 2004. So, Bob, thanks for your willingness to come in and do this interview this morning. The Society wants to develop an archive of the memoirs of all the senior head and neck surgeons that are in the country today so that the next generations of surgeons will have some of the milestones and the contributions by individuals such as yourself. I am pleased that we are here today to go through some of these questions that will then be placed in the archives. Starting back at the very beginning, what or who got you interested in the field of surgery to begin with?
Robert Byers: Randy, first of all, let me thank the Society for including me in the ancestral hierarchy of the Society. Maybe someday they’ll create a Hall of Fame of head and neck surgeons.
RW: You’d certainly be a member of the Hall of Fame, Bob!
RB: This is a question that brings back a lot of memories. I think I wanted to be a surgeon all my life. I can’t recall ever wanting to be anything else. When I was in high school, I had the opportunity to actually first-assist the surgeons at our local community hospital. It wasn’t a big hospital, obviously, growing up in a small town of about 5,000 on the eastern shore of Maryland. The surgeons were very anxious to have someone who was interested and enthusiastic about surgery to come in and help them and as it turns out, during the course of my high school career I actually did cases. I did appendectomies, I did closure of wounds and some minor surgery so I was really pumped. That gets to the next question about who would you identify as persons who influenced you and mentored your career. I certainly recognize one of the surgeons that I particularly developed a close relationship with, John Fisher in my hometown, who took me under his wing and gave me an opportunity to see a real surgical practice in a rural environment. This was during high school! Then I would continue in the summer when I came home from Duke.
RW: What town in Maryland did you grow up in?
RB: Elkton, Maryland.
RW: What about your training as a general surgeon? What aspect of that influenced you to go into head and neck. Back when you were in training, that wasn’t a natural career path for a general surgeon.
RB: No, general surgery was referred to laughingly as the specialty of the skin and its contents, and I did pinned hips, did suprapubic prastatectomies, hysterectomies, as well as all of the usual GI and vascular procedures, so that head and neck was just a small part of it. It wasn’t until I got to M.D. Anderson that I really became focused on head and neck, and that was fortuitous in itself because then the section of head and neck was just a rotation for the general surgery fellows. There wasn’t any head and neck fellowship. I just got enthralled with it. I liked the technical challenge and what anatomical knowledge was required to do that kind of surgery. With Dick Jesse, Jay Ballantyne, and Oscar Guillamondegui as mentors, it was just like connecting the dots.
RW: So, Oscar Guillamondegui was already on faculty? Dr. Jesse was here, and Dr. Ballantyne was on faculty. Was Dr. McComb still here?
RB: Yes. He was no longer Chairman, Dr. Jesse was Chairman, but he was still operating and still seeing patients. He didn’t last long; after a couple of years he retired, but it was very interesting to talk to him and hear his conversations about being at Memorial and learning radiotherapy and then coming here and working with Gilbert Fletcher. They developed the first combined head and neck surgery radiation group.
RW: That must have been interesting to watch Dr. McComb operate, given that he was a radiation oncologist in his training.
RB: Yes, it was. He didn’t have that desire to be so meticulous and bloodless that we developed later, but he certainly was tuned in to how you deal with radiation problems and radiation failures, so that it was a very informative experience and from a different perspective.
RW: Of all the individuals, who was the person who influenced you the most, or who was your mentor or role model back in the early stages of your career?
RB: As I progressed through my general surgery residency at The University of Maryland, Dr. Robert Buxton, who was the Chairman of General Surgery and also the Chairman of the Division of Surgery, was the single most influential mentor. He is who stimulated my pursuit of excellence in surgical technique. He gave us five Penrose drains when we started our residency, and that’s all we were allowed to use. He used 5.0 silk in all his surgery so when you assisted him if you broke many knots when you were tying, he would make you go back to the bedposts to practice more. He demanded a respect for tissue and for the anesthetized patient. When I got to Anderson, Oscar Guillamondegui and Dr. Ballantyne mirrored this same desire for meticulous technique, so I just kind of flowed into their way of doing things. The only change that occurred for me was the use of the electrosurgical knife – the Bovie. That was a new wrinkle that I had to master in the early days. Oscar told me he had to master it too because he didn’t use it either before he came. Everyone who comes to our shop has to pick up on that technique, but it is very helpful in reducing blood loss. I was the first one to use it to cut the skin. I showed that with the proper setting, there was no adverse effect on healing.
RW: What year did you start not only your training in head and neck surgical oncology, but what was your first year on faculty here?
RB: I was a fellow from July 1970 to June 1971 (General Surgery fellow); then in July 1971, I began a six-month rotation on the Head and Neck service, but Dr. Ballantyne got sick, had a problem with his heart, and so after only three or four months of my Head and Neck experience, Dr. Jesse said “Byers, you’re off the bench.” I came on the faculty in January 1971, and I’ve been there ever since. It was a defining event because I was headed back into private practice in Harrisburg, Pennsylvania.
RW: Do you have any favorite stories or recollections about your mentors? That was sort of in the early days of contemporary head and neck surgery, so there must have been some exciting things going on.
RB: Guillamondegui, Jesse, and I were avid hunters. We liked to bird hunt and every time it would start getting close to duck and geese hunting season, Jesse would come by the OR and go “Honk honk honk….it’s almost time!” We’d all get excited and start planning our clinics and OR time so we all could do some bird hunting. One really funny story had to do with Oscar. He has a rather prominent nose, actually a large nose. One of the nurses in our clinic asked him to give her the name of a plastic surgeon who was very good and could do a rhinoplasty on her. He said, “Well, I’ll tell you…” and he gave her a name. She said, “Oh really, how do you know he’s so good?” Oscar was a great kidder. He replied, “Well, he did MY nose!” She didn’t know what to say. He finally started to laugh, and she realized he was just kidding. It was an exciting time. Oscar had a Volkswagen at that time, and he would pick me up at my house and we’d drive to work. All the way to work and all the way home, we would discuss the cases and problems and ways that we might do it differently. It was really a challenging time for me and I think for Oscar too! We had this enthusiasm – We questioned everything, nothing was sacred. It was just a wide-open field of things to think about and do. It was a time to innovate, a time to question, a time to develop and to perfect.
RW: What was the practice of head and neck surgery in oncology like when you first started?
RB: Radical surgery. The Memorial Hospital’s influence was pervasive. The whole emphasis was on cutting. We, however, never liked to put much stock on surgical atlases. We liked to develop our own procedures based on our knowledge of the anatomy and the biologic behavior of the cancer.
RW: What role did radiation therapy play in that sort of mix of treatments at that time?
RB: Palliation, primarily. Maybe some primary treatments for vocal cord cancers, but primarily it was used for patients that we didn’t think had much of a chance for surgery.
RW: At that time, there weren’t a lot of turf battles over how patients were going to be treated. It was mostly …..
RB: The thing with Dr. Gilbert Fletcher – he had the vision of marrying or blending surgery with radiation, and Dr. Jesse shared the same vision. So the turf battles at Anderson between surgery and radiation really didn’t exist. Any disagreements were based on personalities, not therapy; Fletcher could be overbearing at times. But we had a unique opportunity, and I suspect the reason was because we had a large volume of patients so we didn’t have to fight over two larynx cancers or fight over two oral cavity cancers. We had enough that we could satisfy our needs from the standpoint of surgical and radiation oncology training, and yet at the same time focus on what’s best for the patient.
RW: So that was kind of the underpinnings, I think, for multidisciplinary care. It was not an adversarial relationship, but more of a cooperative relationship at that time.
RB: Absolutely. They both had the same focus. In fact they went all over the country preaching the gospel. It was almost like an evangelistic thing – advocating the best of both! That became the rallying cry of our institution – “less radiotherapy and less surgery, combine them, and make the result the best of both.” The patients I think were the beneficiaries, although Jesse and Fletcher got a lot of publicity from it.
RW: There must not have been a lot of good options for reconstruction then either, so you were doing very radical procedures without optimum reconstruction.
RB: In addition, trying to put radiation on top of radical surgery was too hard for the patient. So we decided that maybe you could do less surgery, and never was it more exemplified than surgery in the neck – a radical neck dissection followed by full dose radiation – an impossible combination.
RW: A lot of wound problems, carotid blowouts….
RB: Weekly carotid blowouts. So we began to learn bit by bit how to deal with patients who had had radiation therapy. We could not be as radical after radiation failure. But the whole premise was to combine less radiation pre-operatively, or more importantly, combine surgery with post-op radiation. As time went by, we got away from pre-op radiation. Dr. Fletcher, to his credit, was amenable to that. Most radiotherapists were uncomfortable with being in the post-op position. They liked to treat first. We were able as surgeons to convince Fletcher that there might be a role for radiation after the surgery, tailor the radiation to the areas where residual disease was likely. I think to Fletcher’s credit, he was open-minded and flexible. The common belief was that radiation had to be given in an oxygenated field, so it wasn’t good radiation biology to give it in the post-op setting. The scarring and fibrosis created an anoxic environment in the tissue. I think we showed that it was not so. Dr. Jesse always emphasized that the surgeon’s ego has to be secondary. The team-player concept was best for the patient.
RW: And I’m sure there was no chemotherapy that was effective back then either, was there?
RB: No, it was just used as palliation and it made a lot of people sick.
RW: What were the drugs? Was it methotrexate?
RB: Bleomycin, methotrexate, 5-Fluorouracil were used intravenously. We even tried infusion. You can’t perfuse the head and neck, but we infused 5-Fluorouracil. Dr. Jesse was very instrumental in promoting selective intra-arterial infusion combined with XRT. We had some amazing anecdotal results. Complete responses.
RW: Even back then you were looking at neoadjuvant chemotherapy along with radiation.
RW: We keep recycling concepts every few years. Is there anyone else who had a strong influence on your career? If so, how?
RB: My wife. She kept me motivated, focused, and humble.
RW: Is that because she could put up with you?
RB: She was the support. She took care of the house, she took care of our four sons. She allowed me to focus on my career. If your wife isn’t really tuned in to your career thing, you’re not going to have that same confidence and comfort level. My wife would be highest on my fan list.
RW: Are there any particularly memorable experiences from your career that you would like to share at this time.
RB: What stands out very prominently is my Viet Nam exposure. I spent a year there with the 1st Marine Division in Danang treating all kinds of trauma, and maybe that’s what made me gravitate towards cancer because I really left Viet Nam never wanting to see another emergency room or any kind of trauma again. I figured that cancer surgery would be more controlled, precise, and less stressful. I often think of all the patients that I have cared for who exhibited courage, abiding faith, and everlasting hope. It gave me a profound feeling of worth and humility to know these kind people. I will be forever grateful. Last, I apologize for this, but it was just so emotionally uplifting to me when I got a standing ovation at the Head and Neck Society meeting in Boca Raton in 2002. I just never dreamed that I would receive such an accolade from such an awesome collection of my peers. I was just overwhelmed.
RW: Well, it’s a well-deserved honor, Bob. How has the practice of head and neck surgery changed over the years?
RB: I think that the practice primarily has changed from the standpoint of more and more emphasis on improved reconstruction. We are now involved in a tremendous effort toward understanding the biologic behavior of cancer and how it can be modulated. The recent genetic discoveries have great promise. I think we have established the benefit of from radical surgery to combined surgery and radiation, but we are just beginning to develop better drugs to add to the two older modalities in innovative combinations. We are just in the early stages of developing strategies to disrupt the cancer’s defenses, its blood supply, and its ability to invade and disseminate.
RW: Were you discouraged by the lack of improvement in survival despite all the advances in reconstruction and our combined modality therapy? How have you dealt with that in your career?
RB: As I got more and more comfortable with my role as a surgeon, as I got more and more comfortable with my ability to select the proper treatment for local regional control, I became more and more tuned into the survival outcome. It’s wonderful to have local regional control, to improve the quality of life, but then to have the patients die of distant metastases. If we look at survival as an endpoint, we haven’t accomplished much. It’s always been a frustrating thing for me to have a patient cured above the clavicles and to die of disseminated disease. I think we have focused on quality of life, but survival is an important component of quality of life issues.
RW: What do you think has changed the least in head and neck surgery and oncology?
RB: That’s an interesting question: “What has changed the least?” I can only come up with one thing, and that’s our focus in trying to cure the patient while also trying to relieve their pain and suffering. That hasn’t changed.
RW: So you still think there is a dedicated group of physicians committed to that…
RW: Put your modesty aside and tell me what you think was your most valuable contribution to the field.
RB: As a teacher, whether it’s teaching patient care, surgery, or as a role model in life, I’ve felt most gratified by teaching our fellows, residents, and medical students. It’s a ripple that never seems to cease. The training that I provided for the people that I worked with, they are providing now to people that they are working with, and so on. I would have to rank that as number 1. As number 2, I would say my being a cheerleader for the selective neck dissection has been very gratifying, to see how that’s turned around the radical approaches to more selective and conservative procedures.
RW: I think you are being overly modest about that, Bob. I think you were not just a promoter or cheerleader of the selective neck dissection. I think you helped define the technique, and I think you also helped refine the technique in precisely advocating a specific type of neck dissection given the location of primary. Maybe you could comment on that and some of the studies that you did.
RB: I think, Randy, when we began to analyze what it was about the radical neck surgery that was good and what about it was bad, we quickly realized that if you could preserve certain anatomical structures in the neck that provide function, the morbidity to the patient would be lessened. If you could identify the nodal groups that were at highest risk pending on the site of the cancer and realize that all sites didn’t have the same drainage, at least initially, we could design an operation, a neck dissection to preserve what was needed and to remove what was cancer. We kind of looked like pygmies standing on the shoulders of giants. We could see a lot farther that the giant did because we were standing on his shoulders. Without their efforts we could not possibly be successful. As Dr. Spiro wrote in his Presidential address, less became more. More is what we got out of it because we got less morbidity, and yet we got all the disease too. That’s a major improvement. Also Randy, I think my whistle blowing on the young patient with squamous cancer of the tongue has been a wakeup call for people around the country to realize that these young patients, particularly the female under 30 years of age with no risk factors, are developing a cancer in their tongue in increasing numbers. I think my article was a wakeup call. It wasn’t on everyone’s radar screen to think of cancer of the tongue in a patient who was 19 years of age. Now there are a lot of papers being written and people looking at that issue. I think it needs to be investigated because these patients aren’t using tobacco which has been historically blamed for causing cancer of the oral tongue. We need to dig deeper to find out why.
RW: What do you consider the biggest current threat to head and neck surgery in oncology?
RB: This is going to sound kind of contradictory to what I’ve said in all the previous conversations, but I think the biggest threat to head and neck cancer surgery now, is the multidisciplinary strategy. During the era when we had a lot of patients, we could focus on multidisciplinary therapy and also focus on training our residents and fellows to do the surgery. Now, as I was getting close to retirement, the planning conferences were all based on protocol, of radiation and chemotherapy. Where are the surgeons getting their bread and butter cases to do? Larynx cancers are all being initially treated with radiation and/or chemo-radiation. Where are we going to get the cases to do to teach the future and even the current fellows and residents to do the head and neck surgery? With supracricoid resection maybe there will be a resurgence in the surgeon’s role, but I doubt it. The second threat is the compensation to head and neck surgeons. Head and neck cancer doesn’t pay. It’s ridiculous what a fully trained expert head and neck cancer surgeon is getting paid for procedures that last 5-6 hours, require extensive judgment and knowledge about the disease. With the use of a fiberoptic scope to evaluate and treat sinusitis the surgeon is paid 10 times the amount. I think that’s a threat. Who’s going to want to do cancer surgery? Who’s going to want to spend the time and training and the time in the OR. I know it sounds very mercenary, but it is reality.
RW: Do you see any solutions to that, the low reimbursement for the risk and the time expended by the head and neck surgeon?
RB: No, I don’t see any light at the end of the tunnel. I hate to sound pessimistic in that regard but I think it will kill head and neck surgery as we know it today. Radiotherapy and chemo will fill the void.
RW: What do you consider the biggest opportunity for our field at this time?
RB: The biggest opportunity is learning the biologic behavior of different cancers, and why they do what they do, and then developing strategies to combat it. I think if we could tailor the treatment to the biologic behavior…some cancers are small and metastasize. Others are huge, they just grow locally, they don’t metastasize until very late in the course of the disease. If we can control it with local treatment methods , that would be very useful information to know. To be able to predict from the onset would be huge.
RW: Are there particular words of wisdom you would like to convey to current and future head and neck surgeons and oncologists?
RB: Yes. I have listed a number of them here; I hope I don’t take too long but cancer surgery doesn’t pay. Cancer surgeons are in denial of this, and also in denial perhaps of the future role they’re going to play. Surgeons in academic institutions or in academic practices are looking for ways of avoiding surgery, it seems to me. The academic surgeon today is looking more to feather his resume’, to feather his CV, to be promoted, to look for ways of the “in-thing” in terms of protocols and treatments and sometimes neglecting their surgical skills. They look for academic institutions and academic teaching venues in which non-cancerous head and neck tumors and diseasescan be treated. It pays better and it doesn’t require the time and commitment. . The head and neck surgeon that we know from my past is going to disappear off the scene because we are moving towards an era when cost is a huge factor, and what’s going to be done is the cheapest way of treating cancer initially, however in my opinion, the cheapest way to treat cancer is by surgery. I think as long as we don’t stress in our training programs technique, judgment, pre- and post-op care, and to recognize the need for a tailored adjuvant treatment, we’re going to have some serious problems with our future trainees. I think somehow this can only be achieved in institutions where there is a large patient volume and the capability exists within the head and neck department to teach advanced surgical techniques with skill and appropriate selection of cases. It should be required for promotion of their trainees. Adequate volume of the patients with complex surgical problems and early cancers are necessary to accomplish this and that I think is going to reflect on the fact that we don’t need as many head and neck training programs. We don’t need as many head and neck cancer surgeons being produced and consequently we’re going to have to look at it from a manpower standpoint.
RW: Do you think that technical training and patient care has been de-emphasized in the training programs today, perhaps in the prefellowship phase of training and in fellowships, or not?
RB: Yes. I always kind of laughed at the clinical pathologic conferences in the New England Journal because they would always give a very detailed and very long explanation of the diagnostic workup, and then at the end they would say that the patient was taken to surgery, as if their surgery was a generic thing. Well, we all know that is far from the case. What’s done in the laboratory of the surgeon, the OR, is crucial to the success of the treatment. Now if you can develop a silver bullet where cancer is treated without doing any surgery or radiation, just take a pill or take some sort of medicine, that’s great. I wouldn’t argue with that, but I don’t see that in the near future, and I just think that surgery, if done properly and done well, patients will do fine and be much better off from a quality of life point of view.
RW: Thank you very much, Bob. I appreciate your time and your history of head and neck surgery from your perspective, and also your great insights into where the specialty is and where it’s going in the future. Thank you.