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Legends in Urology

(15) 3 Jun 2008

E. David Crawford, MD
University of Colorado Health Sciences Center
Aurora, Colorado, USA

When Gabe Haas asked me to describe my work with clinical research in the Southwest Oncology Group (SWOG) in a column called “Legends in Urology,” I was extremely flattered. “Legends” just sounds so impressive and conjures up ego building. I think about a Las Vegas show that I have seen many times over the years called “Legends,” which has outstanding impersonators of the best performers of our times. Of course the final performer is the King himself, Elvis. I think about kings in urologic oncology and there have been so many. I believe that most of us who have been in the field for more than a decade would recognize Willet Whitmore as one of the most respected leaders. What a terrific person! There are a number of lectureships, staging systems, and procedures named after him, and he is known for certain quotes (eg, “Is treatment sufficient for those in whom it is necessary, and necessary for those in whom it is sufficient?”). He is a legend. Yet when I am a visiting professor and ask residents “Who is Willet Whitmore?” most do not know. How sad, yet it makes me realize that there are few legends in Urology that live on in the field and are remembered. So best be a living legend, and continue to contribute.

The SWOG Genitourinary (GU) Committee has been very successful over the years because of all the great members on the committee. SWOG and the other cooperative groups have been an incubator for cutting-edge clinical trials as well as launch pads for academic careers.

In 1980, I became the Chairman of the SWOG GU Committee after it received an unfavorable review during a site visit. The committee was just formed after a split from a combined gynecologic/GU committee. An outstanding medical oncologist, Ronald Stephens, led the very small committee at that time. I had just finished my fellowship with one of the real legends in urologic oncology, Donald Skinner, and began my first academic position at the University of New Mexico. We all know that Dr. Skinner is an outstanding surgeon. He also appreciated clinical research. He really imprinted the importance of clinical research on me. I was fortunate to have a supportive Chief of Urology, Tom Borden, in New Mexico, who got me involved in a cooperative group called SWOG. I wrote a protocol for advanced seminoma involving chemotherapy, and Dr. Ron Stephens felt I had some talent and arranged for me to become the chairman of the SWOG GU committee. At that time there were only a couple of urologists, Jim Gottesman and Richard Klugo, who were members of the committee. The rest were medical oncologists. Within a couple of years we began some important phase III clinical trials and successfully put together a program called the “Urologic Cancer Outreach Program” (UCOP). This was a funding mechanism to bring urologists into the cooperative group program along with their institutional medical oncologist and radiation oncologist. The timing was right because at that time, both the urologic-run prostate and bladder groups were no longer being funded.

The SWOG GU Committee has been quite successful in the arenas of bladder, prostate, and renal cancer. There have been 6 presentations of our phase III studies during the plenary sessions of the American Society of Clinical Oncology (ASCO) meetings and at least 15 manuscripts published in the New England Journal of Medicine. We are proud that our studies have set the standard in a number of therapeutic areas.

Many of today’s leading urologists started out as young investigators in SWOG. This is what several said about their experience.

The cooperative group mechanism was and continues to this day to be an important part of that program as the gold standard for establishing new treatments in urologic oncology. The exposure early in my academic career to so many of the leaders in our field instilled a strong appreciation for multi-disciplinary research and teamwork and accelerated my “learning the ropes” of managing clinical trials.

Seth Lerner, MD Professor of Urology
Department of Urology, Baylor College of Medicine
Houston, Texas

The seminal work by SWOG evaluating BCG immunotherapy resulted in a major shift in the treatment of non-muscle invasive bladder cancer in the United States. It was the clinical trials of SWOG that demonstrated the superiority of maintenance BCG therapy and the necessity of maintenance therapy for prevention of disease progression.

Donald Lamm, MD
Clinical Professor, University of Arizona
President, BCG Oncology
Phoenix, Arizona

I spent the early part of my career in the Eastern Cooperative Oncology Group (ECOG) but because at that time the chairs and co-chairs of ECOG’s and SWOG’s GU Committees usually attended each other ’s semi-annual meetings as guests, I saw first-hand how David Crawford led SWOG’s GU Committee. He always had considerable interest from, and participation by his committee’s members. I received tremendous support from David for several trials that I had a major part in designing, EST 3886 (adjuvant castrative therapy vs observation for N+ prostate cancer after radical prostatectomy) and EST 2886 (adjuvant IFN vs observation for local/regionally extensive, completely resected renal cell carcinoma). David’s support of and interest in someone in a rival group, was a great help to my own academic career and has served as an important role model for me.

Edward Messing, MD Professor and Chairman
Department of Urology, University of Rochester
Rochester, New York

I started to participate in SWOG as a resident and had the privilege of working with the leaders in GU oncology and registering patients for clinical trials. Those were the heydays of clinical trials, the 1980s and 1990s. We enrolled dozens of patients a month for the metastatic prostate cancer trials, adjuvant BCG trials, etc. GU was and still is “king of the hill.” We pushed and pushed; we gave silly first-place ribbons and little trophies to those who accrued the most patients. I had the privilege of working with medical oncologists, radiation oncologists, and biostatisticians who taught me far more than any group of folks I’d ever met before. The rest is history. The main point is that under the leadership of David Crawford, SWOG is a democratic organization which allows young people to experience medical science in its purest sense. This is a truly unique opportunity. My career is singularly based on my experience with SWOG. The folks I have worked with as a result have been lifelong friends.

Ian Thompson, MD Professor and Chairman
Department of Urology, University of Texas Health Science Center
San Antonio, Texas.

Prostate cancer has been the most active area of the SWOG GU Committee. We completed two studies in metastatic hormone-naive (stage D2) prostate cancer with approximately 2000 patients (one study resulted in the FDA approval of flutamide) and tested seven new (NCI- and industry-funded) drugs in phase II trials. In my opinion the SWOG GU Committee became the most influential NCI-funded clinical research entity in prostate cancer in the world. I am forever grateful to David for providing me with the opportunity to develop my career and for his friendship which has endured over the years.

Mario A. Eisenberger, MD
Professor of Oncology and Urology
The Johns Hopkins University.
Baltimore, Maryland

David Crawford is the glue that has held the SWOG GU Committee together since its onset. Through a commitment to advancing the role of urologists in clinical trials, David has pushed, pulled, and cajoled us all as members of the committee to write good trials, accrue patients to these trials, and “never give up” despite the emergence of obstacles to success. This committee has produced more clinical trial results, especially in areas that are difficult to study, than any other group that I am aware of. For this we all owe David a great debt of gratitude and thanks.

Robert Flanigan, MD Professor and Chairman
Department of Urology, Loyola University
Maywood, Illinois
Secretary of the American Urological Association

My experience with SWOG early in my career was seminal to the later development of clinical and translational research. The GU Committee, chaired by David Crawford, offered a safe haven for learning the ins and outs of grant applications, IRB submissions, and the design and implementation of clinical trails. David always gave his young colleagues an opportunity to speak up and have our opinions heard, to take a leadership role in a particular organ site, and to propose trials of our own. This was an invaluable if sometimes frustrating experience, as debate would sometimes seem to go on endlessly and progress seemed excruciatingly slow. Nevertheless, the proof is in the pudding and David led SWOG to countless major contributions through critically important clinical trials.

Peter Scardino
Chief of Urology and Surgery
Memorial Sloan Kettering Cancer Center
New York, New York

The SWOG GU Committee under the stewardship of David Crawford has kindled, nurtured, and advanced my career as a genitourinary oncologist and a drug developer. David Crawford had a keen eye for potential and a generous heart for mentorship. The camaraderie and team spirit fostered by David was always apparent. David demonstrated his commitment to drug development and translational research by providing seed funding to complete molecular correlative studies for many of our trials.

Primo N. Lara, Jr., MD Professor of Medicine
University of California, Davis Cancer Center
Sacramento, California

My reward for being the Chair of the GU Committee is receiving positive feedback such as the above comments. In addition, I am proud to be part of a committee where members have established new gold standards for urologic oncology. Combined androgen blockade, BCG for CIS and to prevent recurrence of bladder cancer, neoadjuvant chemotherapy for muscle-invasive bladder cancer, nephrectomy for metastatic renal cancer, chemoprevention of prostate cancer, and Taxotere-based chemotherapy for hormone refractory prostate cancer are just a few areas where we have established Level 1 evidence (the current buzzword).

I would like to thank Dr. Haas and the Journal for the honor of inviting me to describe my work at SWOG.

E. David Crawford
Professor of Surgery, Urology and Radiation Oncology
University of Colorado
Aurora, Colorado, USA

© The Canadian Journal of UrologyTM; 15(3); June 2008 4046