DEC. 14, 2009

Sharper image: Glazer transforms radiology

A gold medal goes to the department chair for his X-ray vision on advances in imaging

BY BRUCE GOLDMAN

Gary Glazer, MD, chair of the radiology department since its relaunch in 1989, got an early dose of his own medicine.

His first exposure to radiology was as a child. “My father was one of the original pediatric radiologists in the world and a founding member of the Society of Pediatric Radiology, and my mother was a nurse,” he recalled. “So health care was a topic of dinner-table conversations virtually every evening at my home. My dad would tell remarkable stories about how he would use radiology to solve diagnostic puzzles, to rule out a disease or make a specific diagnosis that was unclear using other methods.”

Evidently something clicked. This year Glazer, the Emma Pfeiffer Merner Professor in the Medical Sciences, won the Radiologic Society of North America’s Gold Medal, one of no more than three awarded annually by the 40,000-member-strong organization. The award was presented on Dec. 1, during the RSNA’s annual meeting in Chicago.

“This is the highest honor the RSNA can give to a radiologist,” said Hedvig Hricak, MD, PhD, incoming RSNA president and chair of radiology at Memorial Sloan-Kettering Cancer Center in New York. “It goes to individuals who have had a great impact on our specialty.”

Glazer received the award at a time when efforts to enact health-care reform are placing greater emphasis on the role of imaging in the practice of medicine. He is advancing the development of innovations that could greatly expand the diagnostic use of new radiological imaging technologies – which are improving at an exponential pace. He is also calling for safeguards against needless use of costly imaging tests, and at the same time assuring that doctors continue to have sufficient access to these vital tools. And he is encouraging radiologists to work more directly with patients.

Glazer brings a history of precedent-setting research to these new challenges. Typically, Hricak said, the Gold Medal is awarded for scientific achievements over the course of a lifetime, and Glazer certainly has plenty of those under his belt—including many accomplished before he’d reached age 35.

Early in his career, Glazer did trailblazing research using two exciting and then still relatively new technologies—computed tomography and magnetic resonance imaging—to help distinguish normal from pathological lung and lymph tissue, and to noninvasively categorize different stages of tumors in abdominal cancers. The CT and MR criteria he derived for staging lung cancer and characterizing liver and adrenal tumors are still in routine clinical use today.

Within six years of taking his first faculty position at the University of Michigan, he was a full professor in that school’s radiology department. At one point, his radiology residents there voted him an Outstanding Teacher award. In 1984, at age 34, he was elected to the Society for Body Computed Tomography, which at the time had only 30 or so members worldwide. Over the course of his career, he has authored more than 155 scientific articles and three books.

Radiologist with a vision

However, the RSNA is honoring Glazer not just as a researcher but as a leader, Hricak said. “One of Gary’s greatest contributions to our field has been in his role as the chair of Stanford’s Department of Radiology. He has created a model department. Under his leadership, the department has become one of the most innovative and influential scientific-imaging centers in the United States and in the world.”

In 1986, Stanford approached Glazer with an offer of a position created by a fission process:  The medical school’s radiology department was splitting in two, and the chair of the progenitor department was forking off to lead the therapy-oriented radiation oncology department. The opening at the top of the new, more diagnosis-oriented radiology department needed filling.

Glazer was on a research roll, and wasn’t sure he wanted to slow his momentum by shouldering an administrative function. But he recognized the potential impact that the Richard M. Lucas Center for Imaging at 1201 Welch Road, then still in the planning stages, could have on the field. When Stanford decided to devote the building entirely to housing research efforts of the embryonic department, Glazer knew it represented an opportunity to have a huge impact on the future of imaging.

He arrived at Stanford in 1989 with a vision firmly in mind: no less than putting Stanford at the epicenter of innovation in medical imaging. He started by bringing in two high-profile scientists, Norbert Pelc, ScD, and Gary Glover, PhD. Both professors are still here.

The Lucas Center, where Glazer’s office resides, was completed in 1992. By 1994 it was filled. “We needed to expand it in 1997, and then it filled up again,” he recalled. A second Lucas expansion was completed in 2005, but ran out of space again a few years later. The department has added labs in a building on the other side of the campus.

On Glazer’s watch, the departmental faculty headcount has grown to more than 20 faculty members. The department now has some 400 researchers, clinicians and technicians who are working to advance medical imaging.

“Had Rip Van Winkle fallen asleep in a radiology room 40 years ago and awakened in 2009, he wouldn’t understand where he was,” said Glazer. “In 1969 CT and MR imaging had not yet been invented. Since these Nobel-winning developments, people have been pushing the envelope at pretty much a Moore’s Law pace: a doubling of information content every year and a half. Over three decades, that makes for radical change.” That’s no overstatement. An 18-month doubling time comes to a one-million-fold improvement over three decades, spelling speedier scanning and processing times, superior spatial resolution and the ability to image three-dimensional volumes of tissue instead of just planar cross-sections.

This progress opens up new possibilities. “Form and function are intertwined in biology,” Glazer said. From a routine CT or MR scan, you can image a tumor to get a clear picture of its shape and density. Continuous improvements in resolution open a new door for radiologists, said Glazer: “We think maybe we can use that information to infer something about the tumor’s fundamental biology”—and perhaps make predictions about what drug to hit it with.

Glazer and his colleagues are looking to take imaging even further, by using it to reveal molecular events taking place inside a person’s body early on in the disease process. Bolstered by biology-oriented young radiologists like nuclear-medicine physician Sam Gambhir, MD, PhD, the department is pioneering a new approach called molecular imaging, whereby radiology is employed to get some idea of what’s happening at the cellular and molecular levels. “This is a lot easier to do in very small systems or in the test tube than it is in a human being, where you have to look deep within the tissue and deliver a molecular imaging agent to its target without toxicity,” Glazer said.

In a recently published study in Proceedings of the National Academy of Sciences, Glazer, Gambhir and departmental collaborators showed that ultrasound delivered to specific body regions can trigger the release of biochemical markers from diseased tissues, making these markers more detectable as well as helping to pinpoint their source. Using such a method to find out exactly where in the body tumor cells are hiding could allow earlier detection of cancer well before obvious symptoms emerge.

“Imaging is a very powerful method to detect and characterize abnormalities in the human body,” said Glazer. “Yet we still aren’t using the newest techniques to their fullest clinical advantage. Take coronary-artery imaging. My father died of myocardial infarction. The chance that a CT scan of his coronary arteries would have shown clinically significant blockages is extremely high. We just need to be able to use these tools cost-effectively.”

Is imaging sometimes overused? “There’s no question that’s true,” Glazer responded. “If people are serious about spending money judiciously, one major fix ought to be to prohibit self-referral”—when a physician prescribes an imaging study using a machine in which the physician has an ownership interest. “More-stringent rules that prohibit this except in unusual circumstances would make a big difference in the overall cost of care in this country. In addition, fear of malpractice suits leads to the practice of defensive medicine and overuse of imaging. Radiology as a discipline needs to take the lead in developing appropriateness guidelines to prevent these influences from causing unnecessary imaging studies.”

Glazer voiced a contrary concern: throwing out the baby with the bathwater. “I worry about the spigot to medical imaging being closed. Who would want to return to the days when exploratory surgery was used to solve diagnostic challenges, when an imaging test could deliver a correct diagnosis within minutes? Hopefully, cooler heads will prevail, and there will be a thoughtful approach to this, not a kneejerk response that simply looks at the cost side and concludes imaging’s not worth it.”

A more personal touch

Meanwhile, he is working to move his department toward what he calls patient-centered radiology. “Radiologists are often invisible to patients,” he says. “Patients never see them. This is suboptimal for the radiologist, who doesn’t have the full benefit of the interaction with the patient and of knowing what the problem is from the patient’s point of view. And it’s very suboptimal for patients, who experience a lot of anxiety while waiting for the results of their imaging studies.”

A couple of years ago The New York Times ran a highly publicized article about a woman with breast cancer who had a CT scan to see whether the disease had spread. “This patient didn’t hear the result of that study for three weeks. Imagine what shewas going through.”

His interest piqued, Glazer called the writer and got permission from the patient to find out more details of the process. “What I found out was what my instincts told me: That exam was actually read within one hour of when it was performed. It was completely normal. Why make patients wait for two weeks to get results that are available the same day the study was done?

“In what other area of medicine do you go to a consultant, and that consultant’s mute? I don’t know of any. Do you know of a cardiologist who says, ‘I can’t talk to you about your heart problem, talk to your referring physician’?”

To promote the interaction between the radiologist and the patient, “we designed an outpatient imaging center from scratch,” said Glazer. The Stanford Medicine Imaging Center, launched in 2008 in Palo Alto, is architecturally designed to bring the walls down so radiologists can efficiently interact with patients. “At a minimum, the radiologists introduce themselves to their patients and let them know that the result will be available within a matter of hours to the referring physician. In some cases, the radiologist doesn’t just say hello, but gives the patient at least a preliminary result of the imaging study on the spot. The patients seem to like it very much.”

Such interactions involve a big cultural change for the discipline of radiology and for medicine, since referring physicians do not expect radiologists to discuss imaging findings with patients. “Our colleagues in other departments at Stanford are enthusiastically working with us, though,” said Glazer.

So with all these changes—and the future of the profession in flux—would he advise a young medical student to go into radiology?

Glazer smiled and did not hesitate a second before answering. “My son is a radiologist,” he said.

Stanford University Medical Center integrates research, medical education and patient care at its three institutions - Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu/.