Prof. Neville Hacker: honesty, empathy, collegiality and dedication
Editor’s note
In about 1984, under the leadership of Dr. J. George Moore, 50–60 experts from the main UCLA campus, Cedars Sinai Medical Center, Harbor (LA County) General Hospital, Martin Luther King Jr Memorial Hospital and Kern County Medical Center, commenced to write the book Hacker & Moore’s Essentials of Obstetrics and Gynecology. At the same time, Prof. Neville F. Hacker was invited by Dr. Moore to edit the book. In the past three decades, Prof. Neville F. Hacker has persistently devoted his efforts to this book series as an editor.
Gynecology and Pelvic Medicine (GPM) is honored to have an interview with Prof. Neville F. Hacker. In this interview, Prof. Neville F. Hacker has shared with us the stories and the features of the book, his impressive stories in UCLA, the development of the first multidisciplinary Gynecological Cancer Centre in Australia at the Royal Hospital for Women, as well as his experience and insights in this field of Obstetrics and Gynecology.
Expert’s introduction
Prof. Neville Hacker, AM, MD, FRANZCOG, FRCOG, FACOG, FACS, CGO (Figure 1), a Founder of Australian Gynecological Cancer Foundation, is Professor of Gynecological Oncology, Conjoint, at the University of NSW. Graduating from the University of Queensland with First Class Honours in 1967, Neville trained in Obstetrics and Gynecology in Brisbane, and then trained in Gynecologic Oncology at the University of California in Los Angeles (UCLA), where he stayed for 9 years.
Neville was Director of Gynecological Oncology at UCLA 1984–1986, before returning to Australia to establish the Gynecological Cancer Centre at the Royal Hospital for Women in Sydney. He retired from clinical practice at the end of 2018. He is a former President of the International Gynecologic Cancer Society, former Chairman of the Oncology Committee of the Royal Australian and New Zealand College of Obstericians and Gynaecologists (RANZCOG), former President of the Society of Pelvic Surgeons, and a former Member of the FIGO Cancer Committee.
Neville has received many honours, and was a New South Wales finalist for Australian of the Year in 2008. He was made a member of the Order of Australia in 2012 for services to medicine. Other awards include the 2007 Ernst Wertheim Prize of the Austrian Gynecological Cancer Society for Lifetime Achievements, the 2008 International Gynecological Cancer Society’s Award for Excellence in Gynecological Oncology, the 2013 inaugural Jeanne Ferris Award from Cancer Australia for contributions to Gynecological Oncology, and the inaugural 2013 Robert Sutherland AO “Making a difference” Award from the NSW Cancer Institute.
Neville has written over 200 peer reviewed articles, over 30 book chapters, and edited two textbooks, both in their 6th editions.
Interview questions
I had received a Queensland State Government Fellowship on graduating from High School. The Fellowship provided me with a salary as a Medical student but meant that I was required to serve 5 years in rural hospitals in Queensland after graduation. This was an effective way for the Government to help staff it’s country hospitals.
After an intern year at the Royal Brisbane Hospital, I was sent to Gympie Hospital for 2 years in 1969 as a Resident Medical Officer. The Medical Superintendent of the hospital, Dr Bruce Robertson, was a very good surgeon, and I found that I enjoyed assisting him at surgery. I also learnt that I had a natural talent for surgery, and that I enjoyed operating myself, as opposed to watching someone else operate. Over those 2 years, I was able to learn how to safely perform major operations such as abdominal hysterectomy, cholecystectomy, appendicectomy and Caesarean section.
In 1971, I was sent to Atherton Hospital in Far North Queensland as Medical Superintendent for 3 years. Here, I was basically functioning as a country general practitioner, covering all medical, surgical and obstetrical aspects of General Practice.
It was during those 3 years that I decided that I wanted to pursue a career in Obstetrics and Gynecology, because it combined interesting aspects of both medicine and surgery. My wife and I also enjoyed the country lifestyle, and I enjoyed the challenges of General Practice, so I decided to train in Obstetrics and Gynecology and then return to Atherton as a GP-Obstetrician/Gynecologist.
I commenced training as an Obstetrician/Gynecologist in Brisbane in 1974, which was the year Fellowship training in Gynecologic Oncology started in the United States. The two senior gynaecologists doing cancer surgery in Brisbane at the time were Prof. Eric Mackay and Dr. Keith Cockburn. They travelled to the US in 1976 to investigate this new Fellowship training and returned convinced that this was the way forward.
They asked me if I would go to the US to undertake this training. I would never have thought of training in Gynecological Oncology and had already arranged to go to the UK to undertake 1 or 2 years of additional training. After some thought, my wife and I agreed that I would undertake this training, and Prof. Eric Mackay was able to arrange a Fellowship training position for me at the University of California, Los Angeles (UCLA) through his friendship with Dr. J. George Moore, the Chairman of the Ob Gyn Department.
After completing training in 1980, I was offered a position on the faculty at UCLA. As Gynecological Oncology was not recognized as a subspecialty by the Royal Australian College of Obstetricians and Gynaecologists (RACOG) at that time, I accepted the offer to stay in Los Angeles, progressing to become Director of Gynecologic Oncology there in 1984.
The basic training is unchanged since my era, except that the Australian and New Zealand Colleges have now amalgamated. Official subspecialty training was introduced by the RACOG in 1987, so a gynecologist wishing to be an oncologist can now enter 3 years of subspecialty training after 5 years of general training in Obstetrics and Gynecology.
My experience with the management of vulvar cancer was based on the Stanley Way approach, which involved an en bloc radical vulvectomy and bilateral groin dissection. Patients were in hospital for weeks while granulating and epithelializing their groin wounds. The separate incision approach had been started by Dr. Ralph Byron, one of the Surgical Oncologists at the City of Hope Hospital in Duarte, California, USA. The latter was one of the rotations for the UCLA Fellowship, and I was able to operate with Dr. Ralph Byron himself. The procedure had also been adopted by Dr. Leo Lagasse and Dr. Jerry Moore at the main UCLA campus hospital, and I was impressed with the easier post-operative recovery of these patients. I was interested to know whether they would have comparable survival to the patients having the en bloc approach, so I reviewed the first 100 patients treated by separate incisions at the two hospitals. I did this research purely out of interest, but in doing so, I found that I enjoyed research, and that I could write effectively. When we published the article on separate incisions, it was very controversial, but over the next decade, the technique was widely adopted, without any randomised trial.
Since the first paper by Dr. Tom Griffiths on cytoreductive surgery for advanced ovarian cancer in 1975, no one had written on the subject. Griffiths, who became a good friend, claimed that if patients could be “optimally debulked”, (residual nodules 1.5 cm or less), they had a better survival, regardless of their initial tumor burden. When I looked at the UCLA experience, we found that the initial tumor burden was important, and this was confirmed in all subsequent publications.
Although I did this initial research out of curiosity, I found the research and writing both easy and enjoyable and the success of these early papers stimulated me to continue. I could see clearly that major advances in medicine would come from the basic research laboratory, but my personal interest was in clinical practice and clinical research. I was happy to facilitate laboratory research by supporting researchers with tissue specimens and clinical guidance.
My earliest mentor was Prof. Eric Mackay (Figure 2), who was appointed the Chair of Obstetrics and Gynaecology at the University of Queensland in 1965, when I was in the 4th year at Medical School. I believe Eric had a greater breath of knowledge about all branches of the specialty than anyone I ever met. Eric was a great teacher, and a great surgeon. He was very helpful to me with challenging cases when I was working for 5 years in country Queensland, and he then secured me a training position in Brisbane in Obstetrics and Gynecology in 1974, when I decided to specialise in the field. He did much of the cancer surgery in Brisbane at the time, and as I mentioned earlier, he went to the US with his oncological colleague Dr. Keith Cockburn, to look at the new Fellowship programs in Gynecologic Oncology. He was mainly responsible for encouraging me to train in the subspecialty, and for arranging the Fellowship position for me at UCLA, through his friend Jerry Moore. Eric and his wife Gae have been very good friends for over 40 years and he is still alive and in pretty reasonable health at 94 years.
My second great mentor was J George “Jerry” Moore (Figure 3), who was Professor and Chairman of the Department of Obstetrics and Gynecology at UCLA when I was there. He greeted me with a firm handshake and the words “Welcome aboard”, and he always made me feel part of his large team. Jerry was the Chairman of the American Board of Obstetricians and Gynecologists at the time, and his major clinical interest was in oncology. He introduced me to the Society of Gynecologic Oncologists (SGO), the Western Association of Gynecologic Oncologists (WAGO), the Society of Pelvic Surgeons, and to American Gridiron. When Dr. Leo Lagasse left in 1984 to go to Cedars Sinai Medical Center, Jerry promoted me to Director of Gynecologic Oncology. He was keen that I succeed him as Chair when he retired and was disappointed when I returned to Australia. However, he and his wife Mary Lou came to Sydney with me for the first 6 months and helped to get me established. He assisted me in all major operations until I was able to build a team and was a great advocate for me and for the establishment of the unit. I jokingly told Jerry he was my “first Fellow”.
Dr. Jonathan S. Berek (Figure 4) was 1 year behind me as a Fellow at UCLA, starting there in 1979. He and his wife Deb had 3 children about the same age as our 3 children and we became personal friends. Jonathan had gone to Johns Hopkins for Medical School, to Harvard for Obstetrics and Gynecology, and was very enthusiastic and hard working. We both had an interest in clinical research, and we collaborated well together. We published many papers together, and in about 1986, he suggested that we write a textbook together. I felt we were too inexperienced at the time, but he was quite persistent and the first edition of Berek and Hacker’s Practical Gynecologic Oncology was published in 1989. We are presently writing the 7th edition. When I left UCLA in 1986, Jonathan took over as Director of Gynecologic Oncology, and remained in that position until he was appointed Professor and Chair at Stanford in 2005 (Figure 5). Estelle and I spent a very pleasant week with Jonathan and Deb when I was visiting Professor at Stanford in 2015, and Jonathan was the keynote speaker at my valedictory meeting in Sydney last year.
In 1974, the only imaging we had was the simple X-ray. In 1975, we got the first greyscale ultrasound in Brisbane. This was an amazing advance at the time, because it was now possible to determine exactly where the placenta and the foetus were situated without exposing the foetus to radiation. Around the same time, computed tomographic (CT) scanning became available, which made visualisation of all organs in the body very easy. Next came magnetic resonance imaging in the 1990s, which allowed more accurate definition of the exact extent of many primary, particularly cervical, cancers. Finally, the positron emission tomographic (PET) scan became generally available about 15 years ago. This was a functional imaging device, which when combined with CT scanning, (PET/CT) was able identify metastatic cancer nodules less than 10 mm in diameter. When I commenced in oncology, we would warn patients undergoing a pelvic exenteration that there was a 50% likelihood that we would have to abandon the operation because we would find metastatic disease when we opened the abdomen. This rarely happens today because of the PET/CT scan.
The completion of the Human Genome Project in 2003 has opened an incredible range of new targeted therapies which are dramatically changing the prognosis for many cancers. When I commenced subspecialty training in 1978, cisplatin had just become available, and cisplatin combinations proved to be superior to single agent alkylating agents, which were the standard of care for patients with advanced ovarian cancer at the time. Although we subsequently got carboplatin and paclitaxel, they did not really change the prognosis for these patients. Today, the lay person can read about a new “gene therapy” every month in the newspaper. These therapies are based on the genetic profile of the cancer, not the organ of origin of the cancer, so Molecular Tumor Boards are now being held in some centers. It is now reasonable to give patients with advanced cancers hope that a targeted therapy may become available in their own limited lifetime.
Laparoscopic and robotic surgery have certainly been of benefit to the patient in terms of post-operative recovery, but the same operation still must be performed.
The faculty voted overwhelmingly to write the book, with each contributing one or two chapters in their individual area of expertise. I was then the Director of the medical student Clerkship Program, and the next day, Jerry came to ask me if I would edit the book with him. I was somewhat surprised, as I was still an Associate Professor at the time. Nevertheless, Jerry and I had an excellent personal and professional relationship, and I was happy to accept the challenge.
It was a wonderful experience. Jerry was very busy with Departmental and American College responsibilities at the time, so much of the responsibility for organising the first edition fell to me. However, he oversaw every chapter, and subedited the section on Gynecology. After he relinquished the Chairs of both the UCLA Department and the American Board, Jerry was able to devote more time to the book. After he retired, he remained committed right up until his death. I have happy memories of spending a few days with Jerry and Mary Lou at their home in Malibu arranging details for the 4th edition while I was attending a conference in the US.
Jerry was a great mentor to me. The monthly faculty meetings at the main UCLA hospital were very social events. They started at 6 pm with a 2-course meal which Jerry had catered, and often went on until after 10 at night. He was always happy to let everyone express a point of view without interruption. He arranged a departmental picnic every year in Will Rogers Park, and our children really looked forward to this event.
A new edition has been published approximately every 5 years. There have been 6 editions to date. The interval between editions is determined by the publisher, but 5 years is a reasonable spacing, as it ensures that each edition is reasonably up to date with recent advances in the specialty.
The main difference between the editions is related to the authors of the individual chapters and the editors for the particular edition. As faculty members retired, another author from UCLA was usually found, although Dr. Richard Bayshore continued to write his chapter on Dystocia and Fetal monitoring long after he retired. When a faculty member moved to another institution, most were happy to continue to contribute to the book, so it progressively became a multi institutional textbook.
I had returned to Australia after the publication of the first edition, and when the 4th edition was being discussed, Jerry Moore’s health was failing. We decided that it was necessary to get another coeditor from the US if the book was to continue successfully. We were very fortunate to be able to encourage Dr. Joseph Gambone to accept this role. Joe was a reproductive endocrinologist, who had trained at UCLA during my time there, and was a good friend to Jerry and to me. He had moved to Colorado in 2003, at the time the 4th edition was being prepared. Joe was a wonderful clinician and a great organiser, and he very successfully oversaw the contributions of all the US authors for the 4th, 5th and 6th editions. As Joe and I were both basically Gynecologists, we felt we also needed an obstetrician as a Coeditor for the 5th edition, and Dr. Calvin Hobel from Cedars Sinai Medical Centre in Los Angles, one of the UCLA affiliated hospitals, agreed to accept this role. Cal had been the subeditor for the Obstetrics section from the first edition.
My other advice would be to keep a balance between professional and personal life. Some get too involved with their patients and other professional responsibilities and neglect their families. This inevitably leads to burnout and/or marital breakdown.
Much of my time this year has been taken up writing and editing the 7th edition of Berek and Hacker’s Gynecologic Oncology, which has also been translated into Chinese. Being retired, I can do this during the day, rather than at nights and on weekends.
My wife and I are going on a Viking cruise in September with some old friends, following which we will travel around Canada for 2 weeks. When the book is finished, I look forward to having more time to read, watch sport and travel.
Acknowledgments
We would like to express our sincerest gratitude to Prof. Neville Hacker for sharing his stories, insights and opinions with us.
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine. The article did not undergo external peer review.
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.org/article/view/10.21037/gpm.2019.09.03/coif). SZ reports that she is a full-time employee of AME Publishing Company (publisher of the journal). The author has no other conflicts of interest to declare.
Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
(Science Editor: Silvia Zhou, GPM, gpm@amegroups.com)
Cite this article as: Zhou S. Prof. Neville Hacker: honesty, empathy, collegiality and dedication. Gynecol Pelvic Med 2019;2:19.