EDWARD LAWS Interviewed by Peter Tishler, MD, July 2012 Dr. Laws, it’s a pleasure to be here on July 25, 2012 for an interview. As we start could you please tell us your name and academic and hospital affiliation? Sure. It’s a pleasure for me to be here too. I am Edward Laws. I am a neurosurgeon here at the Brigham. I am Professor of Surgery actually, because neurosurgery is part of the overall surgical enterprise here still as it was in Dr. Cushing’s days. Thank you. I am going to ask you some questions of a personal nature as a start. You have devoted your life to neurosurgery and particularly neuroendocrinology and neurooncology since graduating from Johns Hopkins Medical School in 1963. What motivated you to choose neurosurgery? Ah, well, when I was a first-­‐year medical student at Johns Hopkins we had a number of very important neuroscientists who were teaching us our basic science, and I have to be frank with you, it’s the thing that excited me the most and the thing that I got a good grade in as opposed to many other of our basic science courses. So I got sold on neuroanatomy, neurophysiology and neurobiochemistry. And in the summer, in those years, we had an opportunity to have a summer research fellowship from NIH. It was ten weeks and it paid $500, which was wonderful. And so I tried to find a job for the summer and lo and behold there was a research job open in neurosurgery. And so I spent the summer with the neurosurgery department doing research on histochemistry of brain tumors. And that really iced it for me. So I found that so exciting that I continued that research every elective period that I had and continued my relationship with the neurosurgeons at the time. How wonderful. Who were your mentors as you developed this? 1 Well my primary, my chief was a man named Daryl Warder, and he had come to Hopkins from the University of Chicago. He was the fellow who worked out the thalamic architecture in physiology, first in the primate and then in the human. So he was very famous at the time, a very stern man, kind of dour. He liked baseball. But it was hard to have an informal conversation. He really was a marvelous person and a very good teacher. One of his faculty was a fellow who came to Baltimore from Hungary and had trained in Edinburgh with Norman Dott. His name was George Udvarhelyi, and he took me under his wing with this research opportunity initially and then clinically as well. And he was really very interested in pituitary surgery and pituitary physiology. And through him I met the endocrinologists and worked well with them, and when I became a resident first at the City Hospital and then at Johns Hopkins, I was involved with the very first transnasal pituitary operations. And that has been the foundation of my career basically -­‐-­‐ multidisciplinary work with endocrinologists and others, ENT people, etc., and using this extracranial approach that Dr. Cushing had promulgated here at the Brigham. Let me ask you some questions about your faculty membership. After being a faculty member of a number of outstanding medical institutions, you joined the Department of Neurosurgery at the Brigham in 2007. Why did you join the Brigham? Well, it was almost irresistible, I think, for a person of my interests and background. So the chair of neurosurgery at that time was a fellow named Arthur Day and he knew that I had gone to Stanford to develop a multidisciplinary neuroendocrine program, and had done that and it was very successful. And I liked Stanford, but to be honest I really was not the West Coast person and I missed a lot of things about the East Coast and my roots here. So he called me up on the phone and said, “We have an opportunity here at the Brigham for you to come and develop a multidisciplinary program like you’ve done at UVA and at Stanford,” and I said, “Gee, I’d love to do that.” And I checked with my friend Peter Black, who had been doing pituitary surgery here before but had been phasing out as he became President of the World Federation of Neurosurgical Societies, and it was okay with him so here I am. Has this environment been gratifying for you? Unbelievably gratifying. It’s the most collegial place I’ve been, and I’ve been to a lot of places. And I think the interaction that we have with our colleagues in medicine, in endocrinology in particular, in ENT, in radiology and pathology, it’s just wonderful, and the best neurology department, I think, in the world is really right here. Let me ask you some questions about your role in neurosurgery here at the Brigham. What advances and achievements in neurosurgery have come from your department since you’ve been here or even before if you know? 2 Sure. Well, there is a rich history of innovation that goes back to Dr. Cushing. Really the development of neuropathology, the classification of brain tumors as we still use it. With Dr. Matson the introduction of pediatric neurosurgery. All of that happened here in this environment. We had wonderful advances in radiation therapy of brain tumors before I came and in neurooncology in general and in the use of the intraoperative magnetic resonance unit. So since I’ve been here, I’ve kind of introduced transnasal endoscopy. So we use an endoscope, a pencil-­‐thin device, through the nose and can operate on tumors of the skull base. Most of them are pituitary tumors but all kinds of other things, as I did today, as a matter of fact. So that’s been a terrific advance and it’s growing. We went from a 2-­‐D endoscope to a 3-­‐D endoscope, which has been very exciting. And I have been doing these cases now in our new AMIGO suite, which is the latest iteration of intraoperative image guidance with the magnetic resonance image. Has the Brigham and its administration been supportive of neurosurgery and of your patients? I would say capitol Y Yes. I mean we’ve been very fortunate in having tremendous support from the institution and from our colleagues. Wonderful. What is your role in the department? Well, currently I am the only professor in the department, and I have enjoyed being involved with the promotion committee for professors, which they asked me to do, and I have enjoyed very much. I am currently the residency program director. I have done that before and I am doing it again. At the Brigham, it’s particularly exciting because the residents are superb. They all have the opportunity to do two years of basic research and the opportunities in this town and this environment are spectacular. We have very bright residents, very talented people, they are doing great work in neuroscience and they are fun to work with. So most of the time that job is okay – it’s a little bit bureaucratic, as you probably know, but I can deal with that. Is the neurosurgery residency a sought after and effective program? I think you’ve alluded to that already. Yes it is. It’s very interesting that I had a big role in the American College of Surgeons at one time as President of the College and Chair of the Board of Regents, and we lamented the fact that fewer and fewer good students were going into surgery in general. We haven’t seen that much in neurosurgery. We still have large numbers of outstanding candidates and are essentially always matching wonderful young people. How wonderful. Can you name any individuals as outstanding mentees of yours? 3 Since I’ve been here, I’ve had three fellows doing pituitary surgery and I’ve had others at other institutions. So one of them is the chief at the John Wayne Cancer Institute and has just taken on the most recent of my fellows as an associate. So that is exciting. Does he have a name? Sure, Dan Kelly and Garnie Barkhoudarian, my recent fellow. The first fellow Gabi Zada is at UCLA doing the same job that I am doing here -­‐-­‐ he created a multidisciplinary pituitary system and is doing neurooncology and pituitary surgery. And the second fellow, Zach Litvact, is a faculty member at George Washington University where I worked at one time as well and filling the same kind of role – doing brain tumors and pituitary tumors. So I am very, very pleased with that. A fellow that I trained with at UVA, Dan Prevedello, is the man at Ohio State and has a program just like this. Well that brings up the next category, which is the future of neurosurgery and the newly appointed Chief of Neurosurgery is a man named Antonio Chiocca, who is currently at Ohio State. When will he arrive and what is his expertise? Well, he is a wonderful fellow and goes by the name Nino Chiocca. He was for some years at the Mass General. He trained there and was on the faculty there and he did really pioneering work in viral therapy and gene therapy for malignant brain tumors, so he is extremely well known. And he went to Ohio State about six years ago, and he’s built an amazing research and clinical setup there. Five labs. Different strategies for dealing with malignant tumors for which we still have no good treatment, as you know from Ted Kennedy and others. So he is coming here with the support of this wonderful institution to carry on with neurooncology as his primary interest. I think he is really a breath of fresh air and will do great things for the Brigham and I hope for all of neurosurgery. We have a young fellow named Travis Tierney who is doing deep brain stimulation, and just two weeks ago we did our first case of profound depression which seems to respond to deep brain stimulation in a certain area of the brain. So it’s very exciting. It’s a pioneering kind of thing. And of course he’s treating movement disorders and Parkinson’s disease and all that – I had done that at one time too, but again it’s part of the future – the ability to target any part of the brain and to alter its function, the more we learn, I think, the more we can apply that knowledge to things that we currently don’t treat very well. How wonderful. Have you contemplated doing neurosurgery for the rest of your lifespan, to 100 years? Actually, my thinking about that is that as long as I have the skills and the mental capacity and as long as I can teach people things that may be useful to them, I would like to continue working. I would discuss that with my wife and she has always been a great supporter of mine. 4 What do you predict for the future of neurosurgery at the Brigham and nationally? Well, I think at the Brigham we will again become an important or the most important, I hope, national center for brain tumors of all kinds. With the Farber here, with our collegial interaction, with neurosurgery, neurooncology, neurology, neuroradiology, radiation oncology, the proton beams in town, we have a great working relationship with them, I think we will be – and with Nino’s innovative treatment trials – the place to go if you have a malignant brain tumor. And we are already a place of renown for meningiomas and pituitary tumors from some of our other colleagues. So I think the future is very bright with regard to neurooncology. The other thing is spinal surgery, which you know is an important part of neurosurgery, and we have now two outstanding spinal surgeons who are able to reconstruct the spine, to take all kinds of tumors out of the spine, and we do that with the Farber. And who are they? So John Chi is the fellow who does a lot of the oncology work with the Farber, and Michael Groff who came here from the BI is a quintessential surgeon for degenerative disease and for reconstruction as well. Do you think that neurosurgery is going to be affected by any of the attempts to limit the costs of medical care and refine the economy? That’s a very good question, Peter. At one time in my career, the National Health Service in Britain was not treating patients with glioblastomas or people with strokes neurosurgically. They were treating them, but not surgically, and that was the original coffin. Kaiser did that for a short period of time out on the West Coast as well. They wouldn’t treat strokes, they wouldn’t hospitalize strokes, they wouldn’t treat malignant brain tumors. I don’t think it will come to that. The stratification of procedures was tried, and that didn’t work very well. I do think this whole question about spending a lot of money at the end of life is one that we haven’t addressed very well. And I think that when we know that someone has a very limited quality of life and life expectancy, perhaps we can back off a little bit on the super aggressive treatment. But I don’t see it going farther than that. I hope it won’t. 5