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Humberto Torloni

Humberto Torloni: Oncology – a look behind the scenes

Entrevista_04-Dr-Torloniléo RamosAbout to turn 90 in March 2014, the physician who helped lay the institutional and conceptual foundations of oncology in Brazil shows up every day, enthusiastically, to work on the lower basement level of the A.C. Camargo Hospital—renamed the A.C. Camargo Cancer Center in 2013—one of Brazil’s leading centers of research and specialized care in that field. As if he were panning for gold, Humberto Torloni reviews the ledgers containing records of people who have been treated since the hospital opened for business in 1953, when he and his team detected a change in the epidemiological profile of cancer in Brazil. As the data are analyzed, new treatment directives emerge from what is probably the biggest Brazilian bank of data and tumor samples. “As you sow, so shall you reap,” he says.

Humberto Torloni was still in medical school when he helped raise money to establish the Cancer Hospital, a project conceived and directed by surgeon Antonio Prudente. As a young doctor, Torloni specialized in pathology, headed the hospital’s team of pathologists—“I started by washing dead bodies”—developed methods and tools, and helped train the young researchers who now hold positions of leadership in the medical schools and research centers of São Paulo and other Brazilian states. In 1962, he moved to Geneva with his family and, while at the World Health Organization (WHO), coordinated a team of pathologists from different countries who established new criteria for what had been a chaotic body of terminology regarding tumors, standards essential for prescribing treatments and comparing cases. He then worked at the Pan-American Health Organization (PAHO) in Washington D.C., and later at the Brazilian Ministry of Health, where he became acquainted with Daniel Ludwig, an American millionaire who wanted to sponsor a cancer research center in Brazil. Torloni helped Ludwig select the hospital that would house the research center and choose its director, Ricardo Brentani, who many years later would become president of FAPESP. At Brentani’s invitation, Torloni returned to the hospital in 1984 as program coordinator of the Ludwig Institute for Cancer Research.

Age:
89
Specialty:
Anatomical pathology
Education:
Paulista School of Medicine, now Federal University of São Paulo (Unifesp) (undergraduated), 1948
Institution:
A.C. Camargo Cancer Center (São Paulo)
World Health Organization (Geneva, Switzerland)
Pan-American Health Organization, PAHO (Washington)
Ministry of Health (Brasília)
Ludwig Institute for Cancer Research (São Paulo)
Scientific production:
52 articles published in indexed journals (PubMed)

Smoking a pipe several times a day, good-humored and provocative, Torloni pays no attention to academic titles nor does he have a Lattes curriculum vitae, although the PubMed database lists him as author or co-author of 52 scientific articles. He calls himself a “chef at the Grand Hotel,” because he has always worked in the wings, behind the scenes, at major health care institutions. Doctors and researchers who have questions or need to handle something urgently often seek him out. A born humanist, in one of his lectures in November 2013, he reminded his audience that the relationship of mutual trust between doctor and patient must be given priority over technology. His ideas as to how to practice medicine put down roots in his own family: a son and daughter are physicians and another an administrator; one grandson is also a doctor and another an administrator and attorney. It’s a family blessed with a long lifespan. His father, Matheus Torloni, for whom an overpass in the neighborhood of Jabaquara is named, lived to be 102. Torloni is an uncle of actress Cristiane Torloni.

What do you do at the hospital now, at age 89?
I search my memory in order to write our history. The chart that the girl over there [points to colleague Hirde Contesini, at the opposite desk] is writing on is just like the one that’s on my desk. Hers is from 1958 and this one is from 1959. We use these charts to record all the data transcribed from patient medical records. We want to build a database of all the cases this hospital has treated from 1953, when it was founded, until 2000. Everything since 2000 has already been digitized. What we are doing is based on the tumor classification codes listed in WHO reference books, the CID-10 and CID-O There are about 800 types of tumors, and a number of sub-types. The file card that summarizes each case treated is digitized. This helps us as we try to make fewer mistakes; it helps a doctor develop the best treatment based on the morphological, cellular, and molecular characteristics of each tumor. It’s a race against time, because the ink on the cards is fading, and two or three charts accidentally got wet and are stained. The data will be recovered by reading microfilms. All the cases identified that may be of interest to the clinical corps will be reviewed using blocks of paraffin that hold samples of the tumors removed from patients. They will be re-analyzed using immunohistochemistry and other molecular techniques that we didn’t have at the time of the initial diagnosis.

And what are you finding?
I see a lot of mistakes in diagnosis; these used to be very common, owing to lack of experience. In one case of a breast abscess, a kind of tuberculosis, they removed the breast, thinking it was cancer. They didn’t need to do that. We learned from the mistake. When I see a case like that, I tell people that it is a teachable moment, because that no longer happens now. There’s a lot of information about non-cancer in the middle of all this. Patients came here afraid of cancer, but what they had was blastomycosis [a fungal infection], schistosomiasis of the rectum, tuberculosis, leishmaniasis, Hansen’s disease, congenital syphilis—but they all thought they had cancer. We also find cases of skin cancer and Hansen’s disease, for example. Today, infectious diseases are under control, but we still have the chronic ones. In 2007, when I left the Ludwig Institute because Ricardo Brentani was no longer the director, I said I wanted to work at the hospital and salvage what they have here. In the first analysis that I did, with very little data, we reviewed 225,000 patient record cards, 49% of which were cancer; 50,000 of the cases were male and 61,000 were female. We reached simple conclusions. For example: of 16,000 cases of breast cancer, the great majority were in women and only 11 in men. To write up the history of any cancer you have to go after this information. In 50 years, we had 1,051 cases of cancer of the penis that had reached an advanced stage, and the mortality rate was extremely high. We were surprised, because the cancer occurred in an atypical location and in young men. Who were those men? All of them were young laborers who had come from the North and Northeast looking for work and developed cancer here. They became infected with HPV and they infected the women, who could then develop cervical cancer. The importance of our work here is writing the history based on facts.

How did you get started at the Cancer Hospital?
I entered the old Paulista School of Medicine [now Unifesp] in 1942, and graduated in 1948. My father was a carpenter and cabinet-maker, an Italian immigrant who left Italy in 1897, at the age of 16, because his brother had said he wanted to be a priest. In those days, when some member of the family expressed that desire, the entire family devoted its lives to that cause, and my father didn’t want that. He emigrated first to New York (Brooklyn) and went to cut ice on the Hudson River for use in the iceboxes of that time. After two years he decided to go to Argentina. He didn’t like it there and came to Brazil. He got married in a town in inland São Paulo and had ten children. My mother was born in the south of Spain, in Malaga, and had come here as a child. She married my father and started having children when she was 16. One day my father opened a ledger he had kept that showed how much he had spent on each child. He said, with good humor, that if he had invested in burros he would be a rich man surrounded by burros. That kind of thing teaches leadership. Leadership is achieved in two ways: through respect, or through fear. We are nine brothers and a sister. One of them, Hilário Torloni, was vice-governor of São Paulo between 1966 and 1971. I was born in 1924 in Itapuí, a town in the interior of the state that used to be known as Bica de Pedra. I went to high school in Santos, where my father worked as a representative of coffee growers.

And why did you choose medicine?
I didn’t know what to do. My brother Hilário was already studying medicine and one day I went to the pension on Avenida Rio Branco where he had a room. I took a course, applied to the Paulista School of Medicine and the University of São Paulo (USP). I was accepted at Paulista. At the time, I had to help my brothers with their schooling. And so I got together with a colleague and started to sell study guides to students who didn’t like the theoretical classes. By then, my father could no longer make a living from coffee in Santos so he opened a trade school in Brás, on Barão de Mauá. I worked there from 7:00 p.m. to 11:00 p.m. The children in the family who had already graduated were hired as teachers and their wages paid the tuition for the others. We all graduated. The three oldest were accountants and have already passed away. Hilário and I are doctors. My sister Tereza is a teacher and lawyer. Geraldo, father of the actress Cristiane Torloni, decided to go into the theater. My father said he could do whatever he wanted, as long as he brought home a college diploma. Geraldo earned a law degree from the Largo de São Francisco Law School, gave the diploma to my father, and then took up theater. Another brother was a professor at USP, and still another worked at the Technological Institute of Aeronautics in São José dos Campos.

And you?
In 1946, in the fourth year of my program, I was thinking about what I should do in medicine. I didn’t want to be a surgeon, because I realized that people’s lives were at the mercy of the scalpel. I thought about ophthalmology, but the equipment was extremely expensive. I was wondering whether I should go abroad when I saw an ad in the newspaper. The Paulista Association to Fight Cancer needed money to build a hospital. They were having a gincana, a kind of contest, for medical students and the prize was a study grant to be awarded at the end of the year, to use wherever you wanted to go. I wanted to win the grant and go abroad, because that was unusual and anyone who came back from there did well.

So what did you do?
Where do you find money, I wondered. In the banks. I visited the banks, but the wealthy mama’s boys who were my competitors had already been to all of them. Since I was giving classes in Brás at night, I went to the outskirts of the city to visit factories and textile mills. I went all over Brás, even to São Bernardo do Campo. To raise funds, Antonio Prudente had established the “day of work.” Employees who contributed the sum corresponding to one day’s pay would, if they contracted cancer in the future, be treated free of charge after the hospital was up and running. Using this incentive, I visited the factories. I would tell the head of the human resources department about the campaign and he would authorize me to speak about it in the cafeteria at lunchtime. People didn’t have to give anything at the time, they only had to notify the HR chief and authorize the donation. I went back in three months to collect the money. I also used the school system, talked to the teachers, principal, and pupils. Because I had to study, work at night, and still raise money, I failed three exams and had to retake them. The final day of the campaign arrived. The treasurer’s office was on Rua Benjamin Constant, the site of Antonio Prudente’s medical office. We had to leave the money there with the cashier. I thought about it and deposited only part of the money I had raised, because I figured that the wealthy guys would add more money from their own pockets if they knew by how much they had fallen short of their competitors. I talked to Nicolau, my oldest brother who was an accountant, and convinced him to open an account with me at the savings bank – Caixa Econômica Federal – in Praça da Sé. If something were to happen to me, the money would be turned over to the Paulista Association to Fight Cancer. I took only 10% of what I had raised to the cashier, and left 90% in the bank. There were only 10 competitors. On the final day of the contest, I went to Caixa with Nicolau, picked up the money and the vouchers, and went to the cashier. We arrived a little before 6:00 p.m., and the cashier was already waiting for us. I asked how much had been collected in all, and said that there was more money in the suitcase. He asked me if I were crazy, walking around with so much cash, and I explained that it was all in the bank. The cashier took me to meet Prudente, who asked what I wanted to do and said that they needed people in anatomical pathology, which would mean working directly with surgeons. I said I didn’t know whether I would like that. He suggested I talk to the chairman of the department of anatomical pathology, Moacir de Freitas Amorim, who had done an internship in Germany and was a fan of German pathology. Prudente recommended me and Amorim said I could start by learning to wash cadavers. I washed, I learned to suture, to perform autopsies—all this during the undergraduate years. A black man with white hair named Davi was doing the autopsies and showed me the ropes. We became friends. Since I was composing crib notes at the university and giving classes at night, washing cadavers suited me just fine. That apprenticeship was vital when I took over the department of anatomical pathology at the hospital.

So you won the contest and the scholarship. What did you do with it?
I saved it until I graduated. It was a grant for specializing in anatomical pathology. After I trained here, I went to the United States. Prudente knew Lauren Vedder Ackerman, one of the best pathologists in the United States, and he sent me to Washington University in St. Louis, Missouri. The grant was for $300 a month, but it didn’t cover the travel, only the living expenses. Prudente helped me: I went and came back by ship, free of charge, accompanying shipments of coffee. Of the $300, I had $150 left because I got three meals a day free at the hospital and paid only $60 for a pension where doctors from Thailand were staying. I stayed there for a year and half, and came back in 1952, about 10 months before the hospital opened. On return, I had to train a class of pathologists for the hospital. I opened an experimental laboratory behind Prudente’s medical office and did very well because he sent his patients to me. I lived on that money while waiting for the hospital to open. I made a list of everything we needed for the anatomical pathology laboratory of the hospital and warned Prudente: “Open up the kitchen, the laundry room and part of the anatomical pathology department because when they open the surgical center, there may be deaths.” Surgeons, in those days, wanted very much to show who they were. But during the autopsies performed in the hospital basement, we showed where they had been wrong. We did 1,953 autopsies between August 4, 1953 and March 31, 1976, an average of 7.5 per month. The mortality rate was high because the cancer in those cases was already at an advanced stage. Since the cancer hospital had a three-fold mission—care, education, and research—and the system for diagnosis using images was not sufficient to accurately diagnose the disease, we used autopsies as the more realistic textbook. The information was recorded by hand in this ledger and then typed up and archived [he shows the book and the first record]. On August 4, 1953, at 5:20 a.m., a 27-year-old female patient died. While the hospital was being built, we were using the facilities at the Santa Cruz Hospital to prepare and train the team. We came over here in June, and that patient died in August. She had been operated on at 3:00 p.m. by two physicians. She suffered from choriocarcinoma, cancer of the placenta, which is very rare today. The department of anatomical pathology already existed, staffed by four pathologists. The first autopsy I performed was Number 3 here, on August 16. It was a malignant tumor in the humerus of a 60-year old man. Autopsies were performed by whichever pathologist was on duty, assisted by a resident from the department that was responsible for that patient. The results were selected for discussion in the clinical anatomy meetings, held once a month, from 7:00 a.m. to 8:30 a.m., in order to show that the patient was not really suffering from a single disease, i.e., cancer, but had other comorbidities such as chronic renal insufficiency, scars in the lungs from tuberculosis, and perhaps other unexpected factors that played a role in the evolution of the disease. We held 363 clinical anatomy meetings and the proceedings were recorded on tape, transcribed, and then typed up and published in the Revista Brasileira de Cirurgía, and later in the Boletim de Cirurgía.

What were Antonio and Carmem Prudente like?
Prudente was a terrific plastic surgeon. He spent some time in Germany and introduced the electric scalpel into Brazil when he returned. Many tumors were ulcerated and infected. All we had for antibiotics was penicillin and a few others. He used the electric scalpel to reduce the size of the tumor, to cauterize it. He was also a professor at the Paulista School of Medicine. He was extremely well educated, but a very simple man. He had no children and did not show off his prosperity. A devout Catholic, a conservative, his work was his life. Dona Carmem was the engine that pushed him ahead because she was as frenetic as he was calm and serene. She was a journalist, daughter of a cardiologist who was Getúlio Vargas’s private physician. She was from Santa Catarina, wrote several books about her travel experiences while accompanying her husband. He traveled a lot; he had good contacts in other countries. In fact, when he organized the 4th International Cancer Congress in São Paulo in 1954, he brought in for the first time a delegation of oncologists from what was then the Soviet Union. That congress proved life-changing for me.

Why?
Prudente, who had to set up all the infrastructure for the congress, told me I would serve as secretary of the session on standardization of tumor nomenclature. I had to translate a manual with the names of the tumors and the codes. At the time, we had the French, German, and British systems and the WHO wanted to develop a classification that could be used universally. The chairman of the session was an American pathologist, Harold Stewart, but there were representatives from several other countries. I kept taking notes, assisted Stewart and, when the congress was over, he left. In 1957 Stewart wrote me, at the request of the WHO, to notify me of a meeting in Oslo, Norway, to be sponsored by the International Union Against Cancer, UICC, a non-governmental organization. The UICC congress forced the WHO to hasten the effort to standardize international tumor classification, and Stewart recommended that I be the one to attend the new congress. Also at that meeting were representatives from India, Australia, Latin America, and the Orient. I got on a plane and 29 hours later landed in Oslo. The meeting was more policy-oriented, the system, the approach to tumor classification, and I, being rather young, kept quiet as I learned from people who had been my professors in their capacity as authors of textbooks. In 1961, I was invited to attend an international meeting at the WHO in Washington about leukemia classification. The head of the Cancer Unit was a Russian by the name of Aleksandr Chaklin, director of the Cancer Institute of Moscow. I was again the representative from Latin America, but I didn’t understand much about leukemia because the diagnosis is usually done by hematologists. I met people who were famous in the leukemia field, but kept very quiet. Chaklin invited me to lunch and said: “We sent you a letter asking you to recommend a pathologist to work on the standardization of cancer diagnosis nomenclature. You sent us some names, but they were not approved.” He then asked why I hadn’t been a candidate. I asked him whether that was an invitation, and he confirmed that it was. He had already been observing me but I didn’t realize it. That was December 8, 1961. On April 4, 1962, I arrived in Geneva with my wife and three children, to work at the WHO.

Was Antonio Prudente pleased?
He was thrilled, because here in São Paulo I was just part of the routine, working and training residents in oncological pathology. What I was doing could be done by someone else. Anatomical pathology was not highly regarded in Brazil. Professors Alípio Correia Neto and Benedito Montenegro and others were working with a pathologist as part of their team. Anatomical pathology began to gain prominence when several professors from Europe came to teach at the medical schools in Ribeirão Preto, Belo Horizonte, and elsewhere. There they trained leaders and recognized the value of Brazilian anatomical pathology, which the medical class here did not acknowledge.

What did you do at the WHO?
My job was to systematize tumor classification criteria. The leading researchers in international pathology were meeting to decide on those criteria. I learned a lot. I got to know the international big names in pathology. I was secretary of the meetings. The national societies were responsible for appointing the leaders and we were checking to see whether the appointment was based on personal connections or merit. There were high-level people from all over the world. There was a fantastic leader in lymphomas from Germany, another fantastic leader in leukemia from Paris, and yet another in leukemia from the United States—all in the same room. The coordinator of each working group (breast, bone, etc.) was assigned to standardize tumor classification nomenclature. He sent the slides to the other collaborators to examine and discuss at the meetings. There would be differences of opinion about a comma, a period, a name. It took five years to agree on all the details and produce a definition that included a photograph as an example of what they were talking about. And all the leaders had to agree on the definition. When it was ready, the WHO affixed its insignia to indicate that it was the organization’s official classification. The texts were printed and distributed to doctors and medical schools all over the world. One day I was annoyed because, although mingling with the world’s best pathologists, who had the best slides, I didn’t have a microscope. I complained to Marclo Candau, a Brazilian and director of the WHO, and asked for a microscope. It was tough. A pathologist without a microscope is nothing. I explained that my career path would come to a standstill if I didn’t have a microscope so I could keep up with the work of the sessions. I also asked to be co-author of the books, because I had participated not only in the organization but also in the discussions. Each WHO tumor classification took about five years and involved two or three working meetings with the 10 top specialists in the field. Once the nomenclature and definition of each type of tumor was approved, the lead pathologist worked with me for a week to choose the photograph that best depicted the tumor. We called in a photographic company to make tiny photographs that had the same quality as the histological slide.

With that degree of involvement in oncological scientific research, why didn’t you go for your PhD?
I was never interested. Later they gave me a título de notório saber (honorary PhD) from USP, signed by the governor. I don’t care about those things. I told Ricardo Brentani, who was director of the Ludwig Institute for Cancer Research and the Cancer Hospital at the time, that such things don’t matter to me. You are what you are, not what you appear to be. I was a sort of “chef at the Grand Hotel.”

And no one ever required that you obtain a formal degree?
No. In 1960, two years before going to the WHO, there was a clinical director here in the hospital, Osvaldo Ramos de Oliveira, an excellent clinician whom Prudente had assigned to chair the clinical anatomy meetings. We had met, and that was the year that Osvaldo told me that I should become a professor in the medical school of the Pontifical Catholic University (PUC) in Sorocaba, in inland São Paulo State. I told him that I didn’t have a degree, but he said that would not be a problem. I stayed there for the entire semester. After another year, I was there only once a week, giving a class in histology. That was when I came to fully appreciate the responsibility of being a professor. I told the students that if I couldn’t answer a question, I would know where to find it in the books and we’d read them together. A professor must not deceive people. I gave notice that I hadn’t gone there to stay, that the course was their responsibility. At the end of the year I asked the students to submit their comments and criticisms. These could be anonymous. But everyone signed his or her comments. There was a channel for communication. Later I had to leave Sorocaba and São Paulo to go to Geneva.

And after the WHO?
I went to PAHO, in Washington. My three children had been 4, 6 and 8 when we arrived in Geneva and had their early education in the public school there, where they learned French. Geneva is a paradise, and we wanted to stay there. But my children would never be able to work there because the Swiss laws are very exclusionary. They attended high school in Washington. At PAHO, in 1972, I joined the office of medical education. Maurício Martins da Silva, a pediatrician from Rio whom I already knew and who was living there, asked me to work with him in research and development. I said, “Great, what about the funding?” He answered: “You have to find it.” We had to create and develop projects and get financing from the American government. I was newly arrived from Geneva, and a pathologist does not have the same number of social contacts as a pediatrician, clinician, or surgeon. So I didn’t think I would survive. But I contacted the medical education and research office of PAHO and talked to Ramón Villareal, a Mexican who was completely devoted to the field. When I was still in Geneva, at WHO, he had told me that he wanted to do a study about education in the field of anatomical pathology in Latin America. He then asked me to develop a questionnaire about how, where, when, and what had to be done to improve education in anatomical pathology at the region’s medical schools. I took a month’s leave from the WHO and traveled to Latin America, visiting anatomical pathology laboratories. I explained that if there was a need, the WHO could help. Since there were no textbooks, the WHO reached an agreement with the publisher and author to translate Arthur Ham’s Histology, a classic in the United States. It later appeared in Portuguese as Tratado de histologia. I worked on the committee that organized the publication. I said that it would be of no use to order slides, because the schools had no microscopes. So I designed a second cover for the book that incorporated a magnifying glass mounted on a black cardboard base on which histology slides could be placed and viewed by holding the cover against the light. This magnifying glass was used for commercial purposes and I adapted it for use by students. I had come up with a communication tool for medical education. That was my contribution to education and research while in Washington, at PAHO.

You were the one who hired Ricardo Brentani. How did that happen?
We wanted to stay in the United States, but I was earning only $4,000 a month and that wasn’t enough to pay for the children’s college education, which would cost $1,500 each. So after 6 or 7 years in Washington, I began to look for another job. I was always thinking about São Paulo, never about Brasília, but Professor João Sampaio Góes, a physician, invited me to take his job at the Ministry of Health and so I came back in 1973. I was working at the National Cancer Division and Minister Paulo de Almeida Machado called me into his office one day. Shortly before then, Golbery do Couto e Silva, the president’s chief of staff for civilian affairs, had authorized Minister Machado to announce that Daniel Ludwig, an eccentric millionaire, wanted to open a cancer research center in Brazil. We scheduled an interview with Ludwig and his attorney. I didn’t know who he was and so made some suggestions about investments in the area of health in Brazil. “I want a center for research into the disease of the century, which is cancer,” he said. He wanted it built in Rio de Janeiro, because every time he got off the plane he saw an enormous college on Ilha do Fundão, which was the Federal University of Rio de Janeiro, UFRJ. I told him that the building also belonged to the government, and he said he didn’t want anything.

He didn’t want anything from the government?
No. He wanted to do something in the private sphere. Since I would be making several trips abroad with the minister of health, Ludwig suggested to me that I visit the institutes that he was already supporting. We only had time to see two, in Lausanne, Switzerland and in London, England. I told him that in Brazil there was an opportunity to conduct very different kinds of research, because we are such a big country that the kind of cancer that occurs in the South isn’t found in the Northeast. When I mentioned cancer of the penis, he was shocked, he didn’t even know that it existed. At about that time, a paper was published by Richard Doll, an important London epidemiologist, calling attention to a virus that could perhaps cause female genital cancer, and here in Brazil we had the major factor responsible for that cancer in men, but didn’t know it was brought on by a virus. Since there were a lot of cases of cancer of the uterus and penis in the Brazilian Northeast, there might be a relationship, but we didn’t have any proof. When I raised this possible subject of investigation with Ludwig, he was enthusiastic about it. I was invited to help the committee select the city, the hospital where the new institute would operate, and its future director. I asked for some time. I sent the official information about several hospitals to Ludwig’s team in New York, and they said they wanted to visit the Cancer Hospital here in São Paulo. The director was Fernando Gentil, who had spent many years at Memorial Hospital in the United States, but did not know Ludwig. The committee came, conducted an inspection, and gave its approval, but didn’t select the person who would head it. I was at the Ministry of Health and agreed to make some inquiries in order to select a director. I conducted an extensive search of researchers who had received grants in health and related fields during the past five or ten years. I identified those who had gone abroad. I looked in serious publications. I came up with about 10 names, sent their scientific résumés along with a spreadsheet of data and my personal observations to the United States, and they asked me to interview the candidates. I already knew Brentani from Washington, from my years at PAHO. I had many contacts at the National Cancer Institute, and since there were Brazilians working there, from time to time the NCI would suggest someone for me to meet and take out to dinner. There was a guy named Brentani, we talked at length, he talked to my wife, he sat on our sofa at home with my cat on his lap. At the time, we knew nothing about Ludwig. Years later, when I interviewed Brentani, he was a professor of oncology at USP. He was an academician, the youngest Brazilian researcher to have had a paper published in the journal Science. When he was chosen, he called me up to tell me so and asked: “And now what?” I responded jokingly, “It’s your fault!” He asked for help in writing a report about what he would need for the new institute. I agreed to help, but not with the writing, because he had an academic degree and his own way of expressing himself. Brentani came to the hospital and discovered that there were a lot of talented people working there who needed just a little help to advance in their academic careers. “The group here is spectacular, why don’t we start awarding academic degrees?” he asked. And he trained a lot of people here. I was invited to serve as scientific director but didn’t accept it, because I didn’t have the updated scientific background needed to do the job. So they offered me the job of program coordinator, precisely because I knew how to build the bridge between the hospital and the academician Brentani. Later I told Brentani that it was too bad that I had come to know him so late in my professional life. He was a dreamer and a very good leader. He had a volcanic temperament. He was responsible for promoting the hospital’s services, education, and research nationally and internationally. The hospital was always supported by its patient care work and by voluntary donations that enabled it to get through difficult times, especially in the 1960s. Since it was very expensive to educate doctors in their specialty fields, the residents during the fifties were subsidized by the Antonio Prudente Foundation. They lived here. The recognition of the education and research being done in the field of oncology led to recognition in the form of projects with Brazilian institutions such as FAPESP and institutions from other countries like Italy, the United States, and England.

Several doctors and researchers say that even today, they consult you when they have questions. What is your role as advisor like?
At any point in one’s professional career, we have to answer certain questions: How was I? How am I? These are questions that force us to analyze ourselves, but not necessarily to self-criticize. In any profession, you have to do that. In November 2013, I gave a lecture here at the hospital about the relationship between doctors, patients, and technology. Today we are talking about a generation of physicians that, if they are not intelligent, are going to hide behind technology in order to earn money, and to hell with the patient. In my lecture I spoke about what the first consultation should be like, of the importance of knowing how to listen and when to speak, of knowing what to say and when to say it. To have patience. Of the absurdity of mistreating the patient. The patient tells his story; it has a beginning, a middle and an end. The doctor must have patience and control over the length of the consultation. If you work under a health insurance plan, you have to see a lot of patients in order to earn R$100. That’s a problem. A sick person has feelings, you have to treat him with dignity because no one goes to a doctor to ask for a certificate, they go because they have questions. It’s no use merely being a specialist in lungs. That’s technique. The patient is the one who knows where his lungs hurt. Something that’s important is social behavior compared with cellular behavior. How the epithelial cells become cancerous; we were born to live in equilibrium but if you consume a lot of fat you get an intestinal reaction because you have destroyed the equilibrium of cell functions. Cancer is the greatest cellular imbalance that exists, because there’s no way out. The cell gets sick, begins to divide rapidly, upsets the others, destroys the skin, the stomach, the bones, and life itself. In my lecture to the doctors I told a story about a patient, a 29-year old domestic servant diagnosed with a benign condition in her right breast. Six years later she came back with a benign condition in her left breast. In 1981 she came back with cancer in her left breast. She had radiation therapy and surgery, and in 1984 came back with metastasis in her bones. By 1985, it had spread to her whole body and in 1986 she died, at age 51. It started when she was 29. For 23 years of her life, 44% of it, her life was connected to the hospital. She was just one of 1,600 cases of cancer recorded in that year. What I’m saying is not just for doctors, pathologists. It applies to sociologists, poets, whoever you want. Because behind every case there is a name, a sex, an age, and an occupation. She was a maid from São Bernardo. We can’t read these records like a robot.

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