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Q&A: Dr. Charles Cox
© St. Petersburg Times, published December 6, 2002
During his nearly 30 years as an oncologist, Dr. Charles Cox has performed more than 7,000 breast cancer surgeries.
But it is his work on sentinel lymph node mapping, which uses dye and radioactive materials to detect whether cancer has spread, that has made him a hot commodity at the H. Lee Moffitt Cancer Center at the University of South Florida.
In November, he was a keynote speaker at the World Congress on Sentinel Node Biopsy in Yokohama, Japan. He has been asked by the American College of Surgeons to head a pioneering program that will mentor future surgeons.
On Nov. 25, his birthday, Cox sat down with St. Petersburg Times staff writer Jay Cridlin to discuss the future of breast cancer treatment and the qualities of a good doctor.
Here are excerpts:
Happy birthday! How old are you, if you don't mind my asking?
I just turned 55 today. Senior citizen.
Did you perform any surgeries today?
I did one bilateral mastectomy, three mastectomies and three lumpectomies for breast cancer. I've been busy.
When did you decide breast cancer would be your area of concentration?
Probably as early as medical school. I kind of gravitated toward my mentor, Samuel A. Wells Jr., who's a renowned surgeon. We had an area in his library that was fertile for investigations, and I spent two years working in that library with his colleagues. I worked on radioactive localization of breast cancer tumors, which really dovetails nicely with this work I've been doing with sentinel node work. It has to do with radioactive markers, radioactive localization, that sort of thing. My training is amazing in how it all came back around to things that I really had an interest in. One step led to another and another and another, and here I am.
Has anyone close to you had breast cancer?
There's no one in my immediate family with breast cancer. I've certainly had the privilege of taking care of many near and dear friends who've had breast cancer and come to me as a surgeon and as a physician and as a friend.
It's amazing, the relationship that a surgeon develops with a patient. It's kind of like an intense affair, as opposed to a longtime relationship. I've looked at every patient I've ever treated as a friend, and I've had to get to that level of basic trust. You don't want to just lay down and let somebody put a knife to you who's not your friend, you know? It goes against your inner nature to have that much trust in someone you don't have some abiding relationship with. So you develop an immediate kinship with these patients, a friendship. Hopefully, that's felt in reverse.
In its heyday, which was a better TV show: "ER' or "St. Elsewhere?'
Oh, by far, ER. St. Elsewhere? No way. ER's much more realistic. St. Elsewhere got a little far-fetched and a little too schmaltzy for reality. ER is pretty reality-based. I spent over eight months of my training in emergency rooms, so I've got to say ER.
You just got back from Yokohama. How do you get asked to speak at a medical conference in Japan?
The conference we were going to was a sentinel lymph node conference. We (at Moffitt) are one of three groups internationally who started this whole process going forward. We have published a great deal on it, and we have probably trained more surgeons on the techniques of how to do this than any other center worldwide. We've trained well over 2,000 surgeons. Probably half the people that were at that conference, we had trained. That's very gratifying.
So how do you get invited? Well, if you're the one who taught everybody how to do it, they want to hear how you're doing. They also want to know if you've learned anything more about it, and we certainly have. We're about ready to do a training course where we'll do mentoring, rather than just teaching directly. The next generation of surgeons will learn from their colleagues, rather than starting from scratch every time.
Tell me about your personal doctor growing up.
Probably more than a physician, there was my father, who was a physician and surgeon and has been an excellent role model for me and my brother. I grew up with it.
I have a number of experiences: going to the hospital with my dad and seeing operations as a youngster, going and meeting with his patients, talking to people. He had been in academic surgery as well. His real forte was training surgical residents. I don't know that I've achieved the same level of skill in training surgeons, even though that's part of my responsibility. I've become more well-known for my outcomes as a surgeon more than my training capacities.
How many diplomas do you have in your family?
I've got two sisters with master's, a brother with a doctorate and myself with a doctorate. We had five siblings, and four out of the five have advanced degrees. My mom was the Maryland Mother of the Year for 1999. It's a pretty incredible family when you think about all the things we've been able to accomplish in a lifetime. My sister has a master's in fine arts, one has a CPA, my brother and I are both physicians and surgeons. We had good parentage. They taught us the value of education and hard work.
How does it feel to be named one of the bay area's best doctors by "Tampa Bay Metro' magazine?
It's certainly an honor and a privilege to be thought of that way and be recognized. Certainly, it's one thing to be recognized away from your center. Sort of like, you never profit in your own hometown. So it's pretty nice to be recognized here in your own local area.
I was told once by my professor of surgery that when Roman conquerors would come back from their conquest, there would always be a slave that stood in their chariot with them as they rode by, accepting all their accolades. And they would say, "Fame is only fleeting. It's not permanent and it's only as good as you continue to make it," reminding them that this was just a momentary part of their life.
What does it take to be a good doctor?
One thing that I notice is that if you are the patient, you assume that you're going to the best doctor. It's interesting; people don't generally like doctors. Doctors make too much money, make you wait too long; they're self-absorbed and are not really trying to help. Everybody will say that about doctors in general. But if you ask them, "What's your doctor like?" "Well, he's the best doctor in the world."
So there's an incongruity: The guy can be a jerk because he makes you spend a lot of money and he makes you wait a long time, but on the other side of the coin, your doctor is the best doctor there is. The reality is, if you don't like the doctor you're seeing, you're going to go see somebody else.
To be considered one of the best doctors means to me that you have a consistent pattern of performance and a consistent pattern of caring. As a patient, nobody cares how much you know until they know how much you care. In other words, it really requires you to show a caring attitude. What do patients remember about their encounter with their physician? What they really care about is that you cared for them and that you spent the time that they needed. Those are the kinds of things that I try to do.
The other side of that is, data is the king. Keeping track of your data and your outcomes and looking at what you've done is part of being an academic physician. If I don't have any data, I'm not going to be going to Japan or anywhere else to present that information. When I've measured it, I've realized sometimes we aren't doing as good a job as we need to. We're continually improving. And that, to me, is more a measure of whether you're doing a good job.
Do you think we will find a cure for breast cancer in your lifetime?
I think that's within reach. I really do. The expansion of knowledge and the tremendous work that's being done with the human genome project gives me great hope.
Have we done anything great? You bet. I've had an effect on literally hundreds of thousands of patients by the discoveries we've made. I've affected thousands more women just by teaching more surgeons how to do the techniques we've perfected. That's what's really neat about it, what makes it all worthwhile.
The reality is, we haven't made huge progress, but each year, it seems like it's getting closer and closer. Microarray technology that's available to us now allows us to literally map the genes that are activated by this disease and hopefully figure out, if not how to change the effect, at least find how to measure the effect and maybe how to down-regulate some of the genetic changes that regulate the growth of the disease.
Hormonal management is just that; it's a down-regulation of the growth of the tumor cells. It doesn't kill the cells, but it doesn't let them grow. And if we can come up with strategies that'll do that, in essence, you cure the patient from the ravages of the disease.
I really have hope that those kinds of therapy are well within our reach. Even in the limited life I've got left in treatment, I think I'll see that happen. I've got a few years left at 55.