Melvin J. Silverstein on DCIS, breast cancer surgery, and building the first free-standing breast center

Melvin J. Silverstein, now Medical Director of Hoag Breast Center and the Gross Family Foundation Endowed Chair in Oncoplastic Breast Surgery at USC, sat down with Stacy Wentworth, radiation oncologist and medical historian, to reflect on his career.

Silverstein founded the Van Nuys Breast Center in 1979. As he saw more and more and more patients with what was only recently coming to be known as ductal carcinoma in situ (DCIS), he wrote the first major textbook on the disease and developed the Van Nuys Classification for Ductal Carcinoma in Situ of the Breast as well as the USC Van Nuys Prognostic Index.

“I became wildly passionate about DCIS. I thought about it all the time,” Silverstein said. “I thought about it when I went to sleep.”

Wentworth, a radiation oncologist at Duke, asked Silverstein about a time when his science was challenged by the medical establishment:

“Somewhere in the mid-nineties, we came up with the Van Nuys classification, then we came up with the Van Nuys Prognostic Index,” Silverstein said. “And in the end we figured out if you got a low score, it didn’t make any difference whether you got radiation therapy or not. So essentially, small, low grade, well excised tumors didn’t do any better if they got radiotherapy. Maybe they had a teeny bit lower local recurrence rate. There certainly was never any difference in survival. And in fact, nobody’s ever shown any difference in survival, no matter how you treat the disease.”

Silverstein debated against radiation oncologists at conferences for years, and his arguments stirred up visceral responses, he recalls.

“Pro-radiation therapy were all the radiation oncologists from academic centers. That was Jay Harris, who was I guess my arch rival in this. He once, after one of these talks, came up to me, smiled at me and said, ‘You’re killing patients.’ Which broke my heart,” Silverstein said. “It was a terrible thing. He said to me after not giving radiation therapy, but it turns out in the long run, everybody’s come on board. And clearly now it’s 25, 30 years later, some people have finally agreed that they all don’t need it.”

Recent trial results have confirmed Silverstein’s analysis that not all patients with DCIS need radiation.

Today, Silverstein runs the USC breast fellowship program, which has an emphasis on oncoplastic surgery—the first of its kind.

Reflecting on his career, Silverstein offers words of wisdom for early-career clinicians: 

This oral history interview is available on Spotify, Apple Podcasts, and YouTube.

Selected photographs from Silverstein’s personal archives appear at the bottom of this article.

Episode transcript

Katie Goldberg: The Cancer History Project is an online archive of the history of oncology, collaboratively curated by the institutions and people who shaped it.

We have over 60 partners, spanning academic cancer centers, government agencies, advocacy groups, and even the occasional podcast.

Visit us online at cancerhistoryproject.com to dig through our archives

I’m your host, Katie Goldberg.

This month, we’re joined by Dr. Melvin J. Silverstein, founder of the very first free-standing breast center in the United States, who wrote the first major textbook on ductal carcinoma in situ—also known as DCIS.

Silverstein is something of a controversial icon. He spoke up for his science when the scientific establishment disagreed with him—and then, years later, it turned out he was right.

But first, thank you to our project sponsors, the American Society of Clinical Oncology and the University of Texas MD Anderson Cancer Center. 

Silverstein founded the Van Nuys Breast Center in 1979. The first free-standing clinic of its kind, Van Nuys set the model for breast centers in the U.S. and abroad. 

But before we dive in, let’s set the scene: 

It’s 1980. The mammogram is a brand new technology—until now, all breast cancer was found by palpation. If there was a lump, you’d go into the OR for an open biopsy—a surgery to find out if your lump was cancerous. And if it was? You might wake up to find out you had a radical mastectomy. 

Then mammography came around, and for the first time you could actually see what the lump was—and even see things like calcifications that couldn’t be felt by palpation. 

And that’s where DCIS comes in. Ductal carcinoma in situ means there are cancer cells found in the milk duct, and they haven’t spread. Sometimes it’s called stage 0 breast cancer.

So then the question became, how should we treat this new disease? Most surgeons favored treating DCIS just like aggressive, invasive breast cancers, with mastectomy and radiation. Or, if you were lucky, a breast conservation approach. But radiation was a given.

Mel Silverstein wasn’t so sure about that. He felt that, in some cases, radiation wasn’t necessary. And that’s where it got contentious. By the mid-90s, he had the data to prove it—by cataloguing and studying the characteristics of the DCIS he found and treated in thousands of patients, Silverstein developed the Van Nuys Classification for DCIS and the USC Van Nuys Prognostic Index. 

Silverstein’s conclusions that not every patient with DCIS needed radiation was controversial for years. He debated many acclaimed breast cancer researchers on this issue at conferences around the world. Recent trial results including the COMET trail published in December of last year and the growing use of predictive tools like DCISonRT show that he was right all along. Like all cancer, DCIS is a unique disease requiring personalized decision making in each patient. 

Dr. Silverstein is interviewed by Stacy Wentworth, a radiation oncologist at Duke and a cancer historian. You might know Dr. Wentworth from her podcast, Less Radical, which tells the story of Bernie Fisher, another controversial and visionary breast cancer surgeon.

Today, Mel Silverstein is the Medical Director of Hoag Breast Center and the Gross Family Foundation Endowed Chair in Oncoplastic Breast Surgery at USC. In 2000, he established the USC breast fellowship program, which has an emphasis on oncoplastic surgery, the first of its kind. 

To read more about Melvin Silverstein visit the link in the description of this episode. 

Stacy, why don’t you take it away—

Stacy Wentworth: Thank you Dr. Silverstein for joining us on the Cancer History Project podcast. I’d like to just sort of start on what got you interested in medicine and your journey to medical school and then to surgery.

Melvin Silverstein: I got interested in medicine I think when I was seven or eight years old and had a flu-like illness, and the doctor came to my house and he poked me and listened to my lungs and looked in my throat and he gave me a shot of penicillin. My mother had to boil the water and cook the needle for about 20 minutes. And once he left and he cured me, I kind of got interested in medicine.

Stacy Wentworth: That’s amazing. And where did you go to college and medical school?

Melvin Silverstein: I went to undergraduate school at Johns Hopkins in Baltimore, and I went to medical school at Albany Medical College, and then I trained at the Boston City Hospital.

Stacy Wentworth: And when you entered Boston City Hospital, you entered as a surgery resident. What attracted you to surgery?

Melvin Silverstein: Well, that’s kind of an interesting story also, I thought I wanted to be an internist. I wanted to be an endocrinologist. And back in 1965 when I applied for residency, you had to apply for an internship, and it could be a medical internship, a surgical internship, or a rotating internship, or pediatric internship. You could apply for any of those. So I applied for all medical internships. And then in my first rotation of my senior year, the intern got sick, so they made me the acting intern. They paid me $2 a day, which was a lot of money to me then.

And I got to write orders and perhaps a week into the rotation we had to go to the OR to take a sebaceous cyst off some guy’s arm. And the first year resident let me do it and I excised it with a shaky hand and sewed it back together with his help. And when I walked out of the operating room, I felt incredible. I felt like I cured somebody and it completely changed my thoughts. So I went to the chairman of the department who was a very scary guy, and I said, “I want to be a surgeon and I’m not coordinated and I’m scared I can’t do it.” And he looked at me kind of in an angry way and he said, “Silverstein, can you tie your shoes?”

I said, “Yes, sir.” He said, “You can be a surgeon, get out.” And that was it. I had his blessings and I went and took a surgical internship and residency, and that’s the story.

Stacy Wentworth: And I’m not familiar with Boston City Hospital. What is it now? And what was it then?

Melvin Silverstein: Right. So it doesn’t exist anymore. It was built in the late 1890s. And when I got there, it was a complex of 26 buildings all connected by tunnels. And all three medical schools were at this hospital, Harvard, Tufts and BU. And it was quite an incredible place because all the editors of the New England Journal worked there. You could go on rounds with Franz Ingelfinger or Jerry Casser or any of these amazing people.

And I believe maybe 10 years after I left, which was 1970, it was torn down and they built a new place called Boston Medical Center, which became a BU facility. But when I was there, all three medical schools were there. So it was competitive, it was fun. You had friends from every school and you had three different surgical grand rounds and three different medical grand rounds. It was quite an incredible place.

Stacy Wentworth: That sounds like it. Just to have… I remember in a previous conversation you said that everybody ran around with the latest copy of the New England Journal of Medicine in your pocket, and to have-

Melvin Silverstein: And the Lancet, they were both $25 a year and you could have both of them folded in your pocket. And if you were lucky, you got to say, “Well, in this week’s New England Journal, so-and-so said…” And you could one up somebody.

Stacy Wentworth: I love it. And so you were off to surgical residency in training then, which was right about the time of the Vietnam War? Yes?

Melvin Silverstein: Yes. So was I was there between 65 and 70, and the Vietnam War was booming at that point, and there was a draft for doctors. So you had kind of two choices. You could do nothing and you would be drafted and then they would use you wherever they might want to use you, or you could volunteer to go into the service and apply for a thing called the Berry program. That was a congressionally developed program, which allowed them to figure out and they’re going to say, “We need so many neurosurgeons, so many general surgeons, so many internists and so on.” They could figure it all out and then give deferments on a lottery basis to the people who applied.

So I got a five-year deferment in surgery with the guarantee that I would then go into the army when I was done for two years, and they guaranteed they would use me as a surgeon, not as an ER doctor or some other doctor. So that was the deal. Everybody did it. Everybody tried to go on the Berry Plan because everybody want… You knew you were going to go the service anyway, so you wanted to at least do what you were trained. If you were a radiologist, you wanted to be a radiologist.

Stacy Wentworth: What was the most common surgery when you were coming out of training at that time that you were… Or what were the most common surgeries that general surgeons were trained in?

Melvin Silverstein: Well, the Boston City Hospital was really a trauma hospital when I was there, and there was lots of gunshots and stabbings. And of course we didn’t have CAT scans then or MRIs, and pretty much every injury was an exploratory laparotomy. Today, that’s of course not the case. The most complicated x-rays I could order was an upper GI or a lower GI or an IVP. That was it. We did not have CTs. How it’s possible to do medicine without a CT scanner? It’s hard to understand, but we didn’t have them then. So we did a lot of trauma in that training program.

In fact, I thought I wanted to be a trauma surgeon, and my plan was to go into the service, do my two years, and then come out and take a fellowship in trauma or go to a trauma hospital and become a surgeon there. And it turned out I happened to be a good teacher. So when I was in the army at Fort Belvoir of Virginia, they said, “You’re in charge of the teaching program because all the doctors here need to be learning things. So a meeting occurred at the National Cancer Institute on Immunology and Cancer, and it was led by Dr. Donald Morton. And the colonel at my hospital sent me, he said, “You go there, listen to the meeting, and you come back and teach us what you learned.”

And I went to the meeting and I heard a surgeon talking about immunology and cancer and immunotherapy, stuff I had never heard of in my five years in Boston. And it was a mind-blowing weekend to hear all of this stuff. And I went to Dr. Morton after he spoke and I said, “Sir, this is incredible. I never even heard any of this stuff. It’s unbelievable.” And he said, “Well, I’ve just left the NCI and I’m at UCLA and I started a fellowship program, federally funded fellowship program in surgical oncology. You ought to apply.” And I said, “I’m going to be a trauma surgeon.”

And he said, “When you’re 50 or 60 years old and they call you at two o’clock in the morning to take out a spleen,” he said, “you won’t be so happy then. It’s going to get old.” So anyway, to make a long story short, I visited UCLA, I loved the place, they loved me, and I became the first fellow in Dr. Morton’s program. He’s trained about 170, 180 fellows now, including Armando Giuliano and many other people who have gone, Jack Roth. All people who have gone on to be very important surgeons in the United States. But I was the first fellow.

Stacy Wentworth: So what is it like setting up a fellowship program as the first surgical oncology fellow?

Melvin Silverstein: Well, I don’t know how he did it, but he got a bunch of people around, but I know how I did it. So let’s evolve. And so I spent three years there and then after that I did another year of public health at UCLA. And then what I learned there, I learned about the multidisciplinary approach to cancer. And believe it or not, I never even heard the word multidisciplinary when I was in Boston. In Boston, the training was completely halsteadian. Everybody was a halsteadian trained doctor. Everybody believed Halstead, whatever Halstead said must be true. And everybody believed the surgeon was the captain of the ship. That’s what I learned in Boston.

When I went to UCLA, I saw Don Morton who said, “No cancers got to be treated by a bunch of different people at the same time. We call it the multidisciplinary approach.” And he had a melanoma clinic that had a medical oncologist and a radiologist and a surgical oncologist and a social worker and a nurse and so on and so forth. And doing that for a couple of years gave me the idea this would be great idea for breast cancer. So I started a breast clinic at UCLA. He gave me one morning a week and we did a breast clinic very similar to the melanoma clinic. And when I finished at UCLA, I said, “This is something we’re going to take into the public. We’ll call it a breast center.”

And nobody had anything like that at the time. So I actually went to the administrators of all the major westside hospitals in Los Angeles, St. John’s, Santa Monica, Cedars, Brotman, all the hospitals that were there. I talked to the CEOs. They all said essentially, “That’s a pretty good idea, but it wouldn’t work here because our doctors already know how to treat breast cancer.” And the last thing they know that they want is a young know-it-all from UCLA. So basically I didn’t get anywhere until a couple of years later. So I stayed alive by working a couple of days a week at the City of Hope. And they put me on, they made me an attending and I helped the residents out there.

They had Loma Linda residents. I helped them do cases for a few years. And I then bumped into an old resident of mine from Boston I hadn’t seen in years. He said, “I work in the San Fernando Valley.” Which is this place over the Santa Monica Mountains in Los Angeles that people in Los Angeles never want to go to the valley. And you’ve heard about valley girls and valley girl talk and the way and so on and so forth. So he took me to a hospital out there. Turned out in the valley, there were 37 hospitals at the time, and there was big money in hospitals at the time because everything was unbundled. So for example, if they did a chem profile, and at that time the chem profiles had 12 tests, they charged you $20 a test.

So times 12, today you pay $8, you get the whole thing. But back then that’s how it worked. So there was a lot of money in medicine at that time in the eighties. So a guy has got CEO at Valley Hospital liked the idea, he gave me an old building in the hospital. He gave me a salary of $60,000 a year to design and develop and administrate and be the chief of this breast center. And so I did it in this old building and we announced it and all the television stations came and the next day the phones were ringing off the hook and we were never not busy. We were always busy because there was no such thing as a breast center.

And clearly that was something that women wanted. Nobody even knew that anybody would want it, but they did want it, and they came. So business was booming, and that hospital built another building. In 1982, we moved that old breast center, this first breast center, the Van Nuys Breast Center, over to this new building. We took 16,000 square feet and we had 10 or 12 doctors, and then we were busy there for 20 years seeing patients. It was incredible. And we were the first people in LA to aggressively accept breast conservation. So you have to remember, Veronese published the first randomized trial in 1981, and we began to offer breast conservation as an alternative approach to mastectomy.

Well, everybody else did not. They said, “It’s too soon to accept this very early paper.” So we were busy. And the other great thing we did was we got a computer and we figured out how to keep track of everybody, which then generated hundreds of papers over the years.

Stacy Wentworth: How did you come across that computer? A computer in 1981 or 1982 that was-

Melvin Silverstein: It was an Apple 2 plus computer, and all it really ran was a program that I used called Overview, which was like a very primitive form of Excel, and you were able to make a whole bunch of columns and categorize all the things that were out there. And then that evolved into more advanced programs. But as new things came along, for example, HER2/neu oncogene, that wasn’t anything we knew anything about in 1980, but when that became a thing, we added it to the database. So we were able to add things, the database ended up with 300-350 things in it that we kept track of a great deal of the pathology, and that’s really kind of how we got into the DCIS business.

So when we moved into this new building, we got four new mammogram machines and mammograms were a relatively new thing at that time in 1980. And no women had been screened. It was just… So then people said, “It’s not a bad idea if you’re over 50 or something.” But I don’t remember what the age was at that time. You ought to get a mammogram, maybe you have cancer. And so there were millions of women who had never had a mammogram. So when they started coming in, suddenly we started seeing these calcifications and we’d biopsy. Remember in the beginning, all the biopsies were open biopsies, so we would do a wire directed open…

We didn’t have any needles that worked, these gun needles that shoot a piece. I think the first needle was biopsies that needle. I don’t know if that needle is even around till the late 1980s or early 1990s. So for 10 years, we’re doing open biopsies on everything we see, and suddenly we start finding 60 cases of DCIS a year. We didn’t know what it even was. I had never seen a case of DCIS in Boston, in the army, or at UCLA. I never saw a single case of it.

Stacy Wentworth: Can you sort of level set about what was written about DCIS at the time?

Melvin Silverstein: So the only book we had was a book by Cushman Higginson from Columbia, and he had a chapter called Intraductal Breast Carcinoma, and he defined intraductal breast carcinoma as a breast cancer that was more than 50% within the ducts, which is not how we would define it today. Today it’s 100% within the ducts. So many of Higginson’s intraductal breast cancers were really invasive breast cancers with a DCIS component. They didn’t use the term DCIS, so they used the term intraductal breast carcinoma. DCIS is a later term probably invented by Mike Lagios, the pathologist from San Francisco or David Page from Vanderbilt.

Those were the leading pathologists at the time. They understood if it was wholly DCIS, it was a much lesser disease. Most surgeons treated DCIS like breast cancer. Breast cancer in the 1980s was not the nuanced disease that we think of it as today. It was basically one disease and one treatment. It’s quite terrible when you think about it, but that’s really the way it was.

Stacy Wentworth: And women were used to just palpating the-

Melvin Silverstein: All breast cancers were found with your fingers by palpation. They said, “Oh my God, I have a lump.” They’d go see a doctor. The doctor would… There really weren’t any x-rays early on. So the doctors would, no matter what the lump, they could be a 25-year-old with a cyst or they could be a 70-year-old with an obvious cancer. But both of them were taken to the operating room with an OP permit that said excisional biopsy, frozen section, radical mastectomy if malignant. That was the OP permit. So even a 25-year-old young lady might go to the OR not knowing if she was going to wake up with essentially a bandaid over a biopsy or a great big dressing over a radical mastectomy.

Stacy Wentworth: Incredible. As you’re setting up the center, you got the mammogram machines but who was reading the mammograms?

Melvin Silverstein: A guy from Europe came. He had been a very important physician in Iran, and he escaped in 1979 when the ayatollah came and took over, and he was the head of the whole hospital system and on the list to be executed. He escaped, and when he came to America, he had to repeat his residency because even though he was professor and had been trained in France, they made him repeat it. So he was at the Wadsworth VA in West LA and he was of course a brilliant guy.

And as a resident there, he taught the other people because he had tremendous amount of experience. And as soon as we got him out of the residency, we hired him in Van Nuys and he was our radiologist from the beginning of the Van Nuys Breast Center till the end of it.

Stacy Wentworth: What was it like seeing those calcifications for the first time? Were you afraid that you’d been missing cancer the whole time, or when did you get a sense that, “Hey, this is different and this is really involved with this intraductal carcinoma?”

Melvin Silverstein: I don’t think we ever thought about the past and what we’ve been missing, but we said, “Oh my God, this is a new finding.” For example, the finding we were used to was a lump in the breast that you could feel, and if it was advanced enough, you could see the lump. And if it was really advanced and it eroded through the skin, you could see the cancer. That’s what we were used to. And suddenly, mammography takes you back years into the evolutionary process of breast cancer so that you can see the cancers before you could feel them. This was a whole new idea.

So we certainly, of course, found smaller invasive cancers that you couldn’t feel, and then we found these calcifications, which Dr. Gamagami, who was our radiologist, knew was a sign of early cancer, so we biopsied all the calcifications. Some of them turned out to be benign, and some of them turned out to be DCIS, and some of them actually turned out to be invasive cancer.

Stacy Wentworth: Yes. So you were doing basically open biopsies. That was a busy clinic just doing the biopsies, let alone the surgical procedures.

Melvin Silverstein: I used to do five a morning, two or three days a week,

Stacy Wentworth: Five open biopsies a morning.

Melvin Silverstein: We developed putting wires in. He’s a guy who invented… We put two wires in and published a paper on bracketing, which became the thing. But we were the first people in the world to do that because when you’ve got a group of calcifications and you put a guide wire in, you can’t be sure how far medial or lateral to go, but it’s like if I was blindfolded and I grabbed your arm, I wouldn’t know whether you were on the right or left of your arm. But if I grabbed both your arms, I know exactly where you are, you’re in between. So we started putting in two wires around things, and this guy was very good at it. He’d come in at seven in the morning, put in the wires.

The patient would be… We had our own operating room in the Van Nuys Breast Center so we could control everything. So we could do a case every hour at 7:30, 8:30, 9:30, 10:30, 11:30, and at 12:30 we went to lunch, and then all the doctors ate together. We did this for literally 20 years. So it was an incredible experience. I never had any kind of an experience like that in medicine again. When I went to USC, everybody kind of… There was camaraderie and all of that, but everyone was kind of on their own in their own little silos. In Van Nuys, we were all together. We had weekly meetings. We had a conference room that we built.

We had weekly meetings where we zipped through all the cases, plus we learned how to do the business of medicine, something none of us ever learned in medical school. We had to run this business, so we learned how to do it.

Stacy Wentworth: Speaking of that, not only the clinical medicine, but I remember from some of the pictures that you shared with me, you also thought about taking care of the whole woman. That when you set up your clinics, it was going to be a different experience. Can you sort of talk about the experience that was previous and then how you decided to do it differently at Van Nuys?

Melvin Silverstein: Well, I do have to give credit to that to my very, very first wife. When I was in a resident, I married a young, incredible woman who was a psychiatry resident. And when I went into the army, she came and visited me one weekend and I took her on rounds and I showed her a 42-year-old woman with a small one centimeter breast cancer that I had done a radical mastectomy on. It was a great big long incision from the top of her abdomen up onto her shoulder, and a big skin graft in the middle, and it was technically perfect. From my point of view, it looked beautiful.

It was as good a case as I could ever do, and I proudly showed her this. And the patient looked at it for the first time because we had just, and started to cry. And my wife at the time, her name was Kathy, sat down with her, put her arm around her, talked to her, shushed me out of the room, spent, I don’t know, 10, 15 minutes with her, calmed her down, then came out of the room and proceeded to, as we say, rip me a new one and yelled and screamed at me and said, “You’re like all the rest of the surgeons.” Remember now, this was the beginning of the women’s movement and women were now becoming really powerful. It’s women who made the one-stage procedure into a two-stage procedure.

They argued and fought to say it’s inhumane to take someone to the operating room and say, “You might have a biopsy. You might have a radical mastectomy.” They say, “Do it in two stages.” It was women who pushed that. Anyway, so Kathy came out, screamed and yelled at me, told me how terrible I was, how I was just like all the surgeons of the last 50 years, and that things needed to change, and I was furious at her. But to be perfectly honest, she opened my eyes that I was just another… It wasn’t that I was an unfeeling person, I was a warm, loving person, but I didn’t know any better. I had no teachers that said to me, “You should be warm and soft and cuddly and understand.”

At that time in the sixties, we thought about the gallbladder in room three, we did not think about the patient with the gallbladder problem in room three. We thought about the gallbladder in room three or the colon cancer in room four. That’s how we thought a long time ago. That was the surgical training and thinking, it was primitive. So she enlightened me and I evolved over time, and that’s how the Van Nuys Breast Center came to be a warm and thoughtful and very supportive place. We had a full-time psychiatrist in the Van Nuys Breast Center, and his job was to see every single woman with breast cancer, not because she was crazy, but because this was a terrible thing in her life.

And he was amazingly supportive, knew how to do all sorts of helpful things for the family and the children. We made his consultation the same as the medical oncology consultation. It was required. You needed to do it because we thought it was important to the whole patient. And we’ve even published book chapters on the psychiatry of breast cancer from the 1980s that we learned in Van Nuys.

Stacy Wentworth: That’s incredible. I don’t know if this is the right time to feel comfortable about the story that you told me about Rose Kushner, if you feel comfortable sharing that.

Melvin Silverstein: Well, Rose Kushner, of course, was one of the primary women demanding the two-stage procedure, and she used to go to all of the meetings and fight for women’s rights. She was really the first one. She, of course, herself was a breast cancer survivor until, I believe, it came back many years later and she succumbed to the disease, but she moved the process very far forward. Anyway, I was at a meeting in New York City and Jerry Urban, Dr. Urban from Memorial, gave a talk on the extended radical mastectomy. That’s a radical mastectomy, which takes the whole breast, all the muscles, all the axilla, and it takes all the internal mammary lymph nodes. And it was really a debilitating, difficult surgery.

And he explained how his results with that were better than with just plain old ordinary, radical mastectomy. But he referred to the patients as material during this talk. He said, “The material shows this, this and this.” And he showed slides and Rose Kushner in the middle of the talk got up and pounded on the table and said, “We are not material. We are women.” And there was a round of applause in the audience and support for her. And this was the eighties and times were changing. And remember back then there were hardly any women in medical school. There were hardly any women surgeons. And now you’re looking at more than 50% of the medical school graduates are women, half the surgeons are women.

So times have dramatically evolved. She was one of the first people to move that along.

Stacy Wentworth: When getting back to Van Nuys, how were you getting your referrals? Obviously you said that this hospital, there was a lot of competition. Was this word of mouth, were you doing advertising? How was this… The phone started ringing off the hook as soon as you opened. Tell me a little bit about how that momentum started building.

Melvin Silverstein: What happened is that somehow we, the people at this hospital where we did it, made it known to all the local television stations as well as all the newspapers. And they came and covered this opening of this primitive breast center because there was no such thing. And like I said, we were immediately busy. We never advertised because advertising wasn’t a thing until maybe the 1990s plastic surgeons started to advertise. But certainly in the 1980s, doctors did not advertise. It wasn’t thought to be an appropriate thing to do, so it was simply word of mouth. And lots of other doctors didn’t like us because we took their patients.

I once went to a neighboring hospital and gave a lecture. It was called, Why so Many of Your Patients Become Our Patients? Essentially, I showed a beautiful warm waiting room with soft wall hangings and pictures and pastel colors and a very woman-friendly place compared to their offices. And I said, “Look, we have all these specialists. We have a marriage and family counselor, we’ve got a psychiatrist, we’ve got a dietician, we have all these people that take care of their needs. Why wouldn’t they come to our place?”

And anyway, people were not happy with me, the local surgeons, but because they were losing lots of their patients to Van Nuys and we were also the leaders in breast conservation when they were still doing mastectomy. That’s another thing.

Stacy Wentworth: When did you see the tide start to change? Was that with the publication of BO6 that more community surgeons started to do breast conservation, or when did that start to change?

Melvin Silverstein: It took more than BO6. So Veronesi’s Milan one was 81, BO6 was 86. I’d say, you don’t really see much happening until 1990. There’s an NIH or an NCI conference on breast conservation, and they make a statement in that conference paper saying that breast conservation is equivalent to mastectomy and you should be thinking about it for T1 and T2 tumors. That’s as far as they go. And then very slowly thereafter, it takes off. It takes off very rapidly in the big cities, in New York, Chicago, la, Baltimore, Atlanta. It takes off in those cities. But I had friends who were in smaller cities. I had a friend in a smaller city in Mississippi in 2000. He said, “95% of the cases I do are mastectomies.”

First of all, he said, “We’re 60 miles from a radiotherapy center.” So that was another problem. That radiotherapy at that time was 25 or 30 daily treatments five days a week. If you didn’t live nearby, it was pretty tough. Radiotherapy, of course, has evolved dramatically to much shorter courses to partial breast radiation therapy, even to intraoperative radiation therapy. So all that’s evolved to make it a lot easier.

Stacy Wentworth: Well, we’ve come to the nineties and that is where I started reading about the Van Nuys Breast Center, and you started talking about perhaps all DCIS is not the same. So we’ve learned over the course of 20 years that all breast cancer isn’t the same. And now here are these guys at the center in California that begin talking about, maybe we can start thinking about DCIS differently. Do you want to sort of talk about how your thinking and your team’s thinking evolved on the treatment of DCIS?

Melvin Silverstein: I mean, I became wildly passionate about DCIS. I thought about it all the time. I thought about it when I went to sleep. I was very close, like I said, with these two pathologists, David Page in Vanderbilt and Mike Lagios and the three of us, and another guy, a guy named Gordon Schwartz, who was professor of surgery at Jefferson in Philadelphia. The four of us were very progressive breast savers. That was one thing. And we also believed there was a lot of DCIS that could be excised and no radiation therapy given.

And so once there were all these cases, the meetings started to include a segment on DCIS and sometimes all four of us, but at least one or two of us would be invited to every meeting anywhere in the United States and often all over Europe. There was one year I went to speak about DCIS in Europe five times. I went back and forth from LA five times to speak about DCIS at meetings. It was so interesting that, like I say, we wrote our first textbook on DCIS in 1997, and then we updated it in 2002. And each one of those textbooks took two years of my life working nights and weekends trying to put it all together. But it really became my life.

It was kind of more important to me, sadly, than children or soccer games or anything else. So I don’t advise that. And I don’t think modern young doctors are like I was. Modern young doctors take time off for the birth of a child. I kind of resented the birth of a child because it made me skip a day of work. So I just came from another time and I’m not happy about it, but I think about this often. If you change any part of your life, you might change where you are now. So if you like what you have now, you’ve got to accept all the terrible things that went on in the past.

Stacy Wentworth: Well, you were holding on to a paradigm shift in medicine, and I think you’re being generous to say you were asked to speak at these events because I can tell you as a radiation oncologist, we would have a pro and a con of whether women who underwent breast conservation for DCIS needed radiation. And you have a group of people in the audience, 99% of which are radiation oncologists who at that time are very motivated financially and otherwise to give radiation.

And then there would be you or one of your colleagues on stage giving the con that said, “Hey, based on our hundreds of patients over a decade, these women might not need radiation.” Can you sort of talk about that experience? Because I think you were invited to these conferences to fulfill a very specific role.

Melvin Silverstein: So we collected all these patients and we collected all their pathology data. We knew the size, we knew the nuclear grade, we knew the architectural type, we knew the margin width. We measured all of these things and collected them in our database. And somewhere in the mid-nineties, we came up with the Van Nuys classification, then we came up with the Van Nuys Prognostic Index. And in the end we figured out if you got a low score, it didn’t make any difference whether you got radiation therapy or not. So essentially, small, low grade, well excised tumors didn’t do any better if they got radiotherapy. Maybe they had a teeny bit lower local recurrence rate.

There certainly was never any difference in survival. And in fact, nobody’s ever shown any difference in survival. No matter how you treat the disease. You could do a lumpectomy alone with radiotherapy, with mastectomy, it makes no difference. The survival at 10 or 15 years has always been identical. So all we were ever talking about was local recurrence. So we were strong believers that for small, low grade, well excised lesions, you don’t do anything else. And if God forbid they get a local recurrence, you can then re-excise, then you can radiate them. That was our attack on this.

Stacy Wentworth: Who was usually doing the pro-radiation side and-

Melvin Silverstein: Pro-radiation therapy were all the radiation oncologists from academic centers. That was Jay Harris, who was I guess my arch rival in this. He once, after one of these talks, came up to me, smiled at me and said, “You’re killing patients.” Which broke my heart. It was a terrible thing. He said to me after not giving radiation therapy, but it turns out in the long run, everybody’s come on board. And clearly now it’s 25, 30 years later, some people have finally agreed that they all don’t need it. So I debated Larry Wickersham and Norman Wolmark and Bernie Fisher, Bob Cusky. I can’t remember. There were so many people on the other side.

Stacy Wentworth: And you also opened up in addition to this, a training program at Van Nuys where you started to train breast surgeons. So you moved away from stereotactic biopsy, you were doing more procedures, and you started to train breast surgeons at Van Nuys. Correct?

Melvin Silverstein: I actually didn’t really train any breast surgeons in Van Nuys. And in 1998, Van Nuys had kind of run its lifespan and everybody decided to go their own way. And USC recruited me as a full professor of surgery and made me chief of their breast division. So I decided it was time… At that point in time, I probably had 150, 160 publications. I had two textbooks. So I went to USC and I became a full-time academic surgeon. And in the year 2000, I started the breast fellowship with the emphasis on oncoplastic surgery. We haven’t discussed that, but somewhere in the mid-eighties we got interested because we had plastic surgeons in our group.

We got interested in not only doing lumpectomies, but doing lumpectomies in a kinder, gentler, nicer way so that the breast came out as good as we started, and often better. We started using reductions. So if a woman had a large breast, we could take the tumor out, do a reduction, and you could get big wide margins and she could look better than she started. It was a real win-win, which we were used to win-lose or lose-lose in breast cancer, and suddenly we now had win-wins.

Stacy Wentworth: That’s wonderful. And talk more about your oncoplastic work, because I think that’s something that you guys really have continued to do and be innovative in.

Melvin Silverstein: So that evolved from 1985 up until 1998. Then I went to USC and I got established there, and I then started a fellowship in the year 2000. It was a breast surgical oncology fellowship with an emphasis on oncoplastic surgery saying, “Don’t just take out the tumor and leave a big dent, take out the tumor and make it look nice.”

And up to this point, we’ve trained 63 fellows, and believe it or not, I’ll be having dinner with 45 of them this coming Friday on May 1st because this year it’s the American Society Breast Surgeon’s annual meeting, and we always have an annual reunion and a big dinner on the Friday night, and we’ve got 45 fellows coming because this is likely the last one I’m going to go to. I’m kind of getting too old to trudge around the country.

Stacy Wentworth: That’s incredible. And how many of those fellows, if I can ask, are women?

Melvin Silverstein: You wouldn’t believe this, but 61 of 63 are women. In the last 10 years we were getting, I’m going to say 80 to 85 applications a year for the breast fellowship, about five were men and about 80 were women.

Stacy Wentworth: That’s incredible. That’s wonderful.

Melvin Silverstein: And probably heart surgery is just the opposite. I mean heart surgery and orthopedics and vascular were never terribly friendly to women, but breast surgery enormously friendly to women.

Stacy Wentworth: Anything that we haven’t covered or that you think is important for us to talk about moving forward from your perspective?

Melvin Silverstein: Well, let’s see. We talked about Van Nuys, which was actually a paradigm-changing place. We initially just called it the breast center since there were none others, we didn’t think it needed a surname. But then once… It took years, but 10 years later, there were suddenly all kinds of other breast centers occurring, and it was obvious that if a breast center would work, a prostate center would work, a colon, any center devoted to a specific disease is likely to work if there’s a significant amount of that disease.

Stacy Wentworth: That’s wonderful. Anything going into the future that you think… Anything that you feel like you haven’t resolved in your head that we should take the torch forward and think about with DCIS?

Melvin Silverstein: So you know that at 85, I don’t have a lot of future, maybe I have-

Stacy Wentworth: Anything we need to do that we can continue watching for, or do you feel like we have a good handle on DCIS?

Melvin Silverstein: In the DCIS business, you’ve got three randomized trials of biopsy versus treatment. You’ve got Lord, Laura, and Comet, they all need long-term data to come out. Very likely what you’re going to see in the long-term data is that certainly the people who have just a needle biopsy are going to have more recurrences because you’ve left disease behind. Some of it’s going to become invasive, since these are highly selected low-grade patients, most likely they’re going to have small, low-grade tumors that are easily treated. And 10 or 15 years out, you’re going to see no difference in mortality. I think that’s going to happen.

I think the people who use oncoplastic surgery really well now, it’s kind of like the end game in chess. They’ve reached the end game. There’s not a lot more to accomplish. So the only thing we could do better than really good oncoplastic surgery is not to need to do any surgery. To figure out a way how to put a needle in, take out the tumor, do some tests on the tumor, find some abnormality that can easily be treated with a medicine or with focal radiation therapy or focal heat, or some kind of a really non-anatomically disturbing treatment. That would be an exciting road for the future.

And of course, there’s always going to be aggressive, horrible cancers that are biologically often and awful and grow very rapidly, and we need better treatments for them. The HER2 positive cancers are a good example. In the beginning, they were the worst cancers we ever saw. And now if you get one of those, you have a very high probability of completely curing that patient. So we need more of that kind of treatment, and clearly science is heading in that direction.

Stacy Wentworth: Well, we will pick up the torch and keep moving forward. Thank you so much, Dr. Silverstein, for talking with us today. And thanks everyone for listening to the Cancer History Project.

Melvin Silverstein: It’s my pleasure. Thank you for having me.

Katie Goldberg: The Cancer History Project is an initiative of The Cancer Letter, the leading source for information on the issues that shape oncology since 1973. 

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