Published in Nacional number 530, 2006-01-09



Hedvig Hricak – world innovator in tumor diagnosis

Hedvig Hricak, one of the most renowned American radiologists, Chief of the Radiology Clinic at Memorial Sloan-Kettering Cancer Centre in New York speaks of the most recent research in tumor diagnosis

Hedvig Hricak, a former student and graduate (1970) of the College of Medicine in Zagreb, was in Zagreb recently to attend an important promotion for the Medical College of the University of ZagrebHedvig Hricak, a former student and graduate (1970) of the College of Medicine in Zagreb, was in Zagreb recently to attend an important promotion for the Medical College of the University of ZagrebThe first woman in the USA to be appointed head of the Radiology Clinic of the Memorial Sloan-Kettering Centre in New York, the first woman in the long history of the Ludwig-Maximillians University in Germany to be granted an honorary doctorate, the first female radiologist to be appointed to the Institute of Medicine in Washington – this is only a tiny excerpt from the long list of recognition for Zagreb born Hedvig Hricak who has made a great medical and scientific career in America. For the past six years, she has been Chief of the Radiology Department in the world's best oncology clinic, the Memorial Sloan-Kettering Cancer Clinic in New York, and she is a professor of radiology at the prestigious Weill Medical College at Cornell University.

Hedvig Hricak, a former student and graduate (1970) of the College of Medicine in Zagreb, was in Zagreb recently to attend an important promotion for the Medical College of the University of Zagreb. The Croatian translation was completed of the American BI-RADS (Breast Imaging – Reporting and Diagnostic System), which represents the standardized methodology for interpreting imaging methods used in diagnosing breast cancer. In other words, this manual which will be in use among Croatia's 300 hundred radiologists prescribes the procedures of imaging breasts and interpretation and categorizing mammography, ultrasound and MRI tests. This is particularly important as a national mammography screening project for breast cancer is about to begin in Croatia, in which women aged 50 to 69 will receive one free mammograph every two years.

Thanks to Hedvig Hricak, the American College of Radiology gave its permission to the Croatian Radiologists Association to translate the guide into Croatia. This is the first approved translation of this atlas in the world. The atlas was translated by Dr. Renata Huzjan-Korunić and Dr. Boris Brkljačić from Zagreb.

"I am very happy to have assisted with the BI-RADS atlas. I have always said that it is important to move up in one's career and take a high position, not for the purpose of having power, but because this allows you to help others and assist in launching important projects. Miracles happen when we work together towards a single goal. That was how it was with the publication of the atlas," said Hedvig Hricak, who has also received a series of recognitions outside the USA.

She is an honorary professor of the University of Zagreb, a correspondent member of the Croatian Academy of Arts and Science and an honorary member of the British Institute for Radiology, the Germany Radiological Society and she has received an honorary doctorate from the University of Munich. She is winner of the gold medal from the International Society for Magnetic Resonance in Medicine and the 'Marie Curie' award for the Society of Women in Radiology. Also, as Zagreb radiologists have revealed to us, with her reputation and influence in the US, she has secured funds for scholarships for five young Croatian radiologists from Zagreb, Osijek, Split and Rijeka at the Memorial Sloan-Kettering Centre for complete training in breast imaging – mammograph, ultrasound and magnetic resonance. Three doctors have already completed this six month training program, while another two will soon be heading off to New York. Dr. Boris Brkljacic, Head of Radiology Clinic at Dubrava Hospital in Zagreb is Hedvig Hricak's partner in the Croatian projects and one of three panel members who selected the candidates for the American Training. He commented on how this project is exceptionally important for Croatia, for it will create young experts educated in the best world centers in line with the most recent scientific knowledge and achievements.

The Memorial Sloan-Kettering Cancer Centre is considered to be the best oncology clinic in the world, and its Radiology Clinic is also one of the best in the US. This is a private hospital where not only the best cancer specialists work, but also experts in other fields such as biologists, chemists and physicists to computer experts, for as Hedvig Hricak said, it is difficult to imagine today's medicine without the cooperation and continued scientific research. Her name is associated with several varying directions of research in the field of radiology. According to her colleagues, she was frequently a pioneer in the development of methods and their implementation into common practice. She has published more than 400 scientific papers in the most acclaimed journals, dozens of books and has over 6000 citations for her scientific papers. She is particularly known for her work and research in magnetic resonance in diseases of the urogenital tract, particularly in uterine, ovarian and prostate cancer.

With her associates, Hedvig Hricak set the basis of MRI and magnetic resonance spectroscopy in prostate cancer. Based on the varying content of chemical parts (choline, citrates and creatine) in cancer tissue and normal prostate tissue, this method can be used to precisely establish the position and size of the tumor in the prostate and its spreading in the prostate and surrounding organs. Based on these imaging tests, the optimal therapy can be planned for each patient (operation or radiation) and following treatment, where needed, the patient's condition can be monitored and reveal the re-appearance of a tumor. The Radiology Clinic at Sloan-Kettering uses the PET-CT device which can show a tumor and precisely establishment the spread of metastasis of various tumors. Today, Hricak is one of the pioneers in the field of molecular imaging, which shows the processes at the cell and molecular level, a method considered to become the future of modern radiology.

NACIONAL: You have been Chief of the Radiology Clinic in the Memorial Sloan-Kettering Hospital in New York since 2000. Though this is an exceptional oncology institution, was it difficult to leave California and the renowned clinic of the University of California San Francisco, where you were for 20 years?

- It wasn't easy. The University of California, San Francisco (UCSF) is an exceptional colleague and over 20 years, you become accustomed to your surroundings and way of life. Besides, my son Petar is very happy in San Francisco. It was a great dilemma to decide whether I wanted to leave the job I love and my very pleasant life in California, or whether I would accept a great challenge, to pack up and start over. It is a great responsibility to be Chief of the Clinic, but an opportunity to create something important. In San Francisco, I was head of the abdominal imaging unit and my colleagues would constantly tell me that I needed to advance and become Head of the Radiology Clinic. I was offered positions at various universities in the US, but since I have dealt only with oncology since 1986, I knew it would be best if I took a position in a hospital oriented towards oncology. I actually wanted to go to Memorial Sloan-Kettering. When the Chair position opened up there, all at once I was excited, confused and frightened. I knew that my CV was solid and that I likely had a chance, but you never know how the committee will react. There were many candidates, and I couldn't believe it when they picked me. Many were surprised that they chose a woman, because up until that point, there had never been a woman chair of such a department in the US. I was happy, though, that no one seemed surprise that I was a foreigner. In the US, that is completely normal.

NACIONAL: You say that throughout your career you have had the great fortune of working with the right people you could learn from. Today, how much are you able to help and work with young physicians and specialists?

- The most you can give to your profession is to secure education for younger generations. I like to work with young doctors, I like working with people from around the world. We are a big family. I have "kids" everywhere, and they call me whenever they need something. Furthermore, it is the best of the best that come to learn, and I have frequently had a lot to learn from them as well. Of the Croatian radiologists, the only one to come to San Francisco was Miljenko Marotti, who today is Head of Radiology in Vinogradska Hospital in Zagreb. Specialists come to American hospitals today thanks to scholarships they received back home. Unfortunately, it is very difficult to get such a scholarship in Croatia. Since working at Memorial Sloan-Kettering, I have been able to secure scholarships, and so now we have radiologists from Croatia coming for training.

NACIONAL: This hospital deals with very advanced scientific research. Can you describe what this includes?

- Today in radiology, the ordinary x-ray is of less significance. I work most on magnetic resonance and in imaging prostate tumors. I am also involved in gynecological research – tumors of the ovaries and uterus. I also do a lot of work on the CT and PET. Unfortunately, there is still not PET in Croatia, but I hope that one will soon be purchased. This is a highly sophisticated device with positron emission tomography which images the metabolic activity of the cell using short-lived radioisotopes. Today, the most frequently used radioisotope is that which shows the metabolism of glucose – sugar. Considering that cancer has an accelerated metabolism of sugar, we can then see where cells are reproducing at a faster rate. We can see the activity of the tumor, how aggressive it is. The more aggressive the tumor, the higher the glucose content, and therefore we can determine a special therapy regime individually for each patient. Today, the ideal combination for complete diagnostics is the CT and PET, and of course the MRI.

NACIONAL: What is molecular imaging, something you do at Memorial Sloan-Kettering?

- Memorial Sloan-Kettering is one of the centers where this is done. This means imaging the process at the molecular level. Everyone will remember the early x-ray images where very little could be seen. In the past 25 years, radiology has changed drastically. At the end of the 1970s, ultrasound began to be used, and quickly afterwards computer tomography began and enabled us to better see the anatomy. Then a new method was introduce – MRI. With the development of the computer, radiology changed greatly. Today, we can often view a three-dimensional image. We have seen that we can exceptionally show the organ anatomy, and the next step is the ability to show the function of individual organs and tissues. PET and spectroscopy in MRI give us insight into metabolism. The new phase is a desire to make a diagnosis at the cell and molecular level. That is molecular imaging. Some of these processes are hypoxic – a lack of oxygen, angiogenesis – the creation of new blood vessels in tumors or gene expression imaging. This is actually a combination of radiology and tumor biology. For the time being, most of the research is conducted on animals, but I think that in a few years time we will be able to exactly see the tumor biology in all detail. The better the diagnosis, the better the treatment. Imaging is the infrastructure of medical diagnostics.

NACIONAL: How has the diagnosis of breast tumors improved in recent years?

- It has improved greatly, for in addition to mammographs we also use the ultrasound and MRO. This has greatly aided early diagnosis, and so the survival rate is much higher. The next step is the application of molecular imaging, and we hope that this will revolutionized the process of diagnosis of breast cancer. The combination of improved diagnostics and new therapy give hope that breast cancer will become a chronic disease. Here minimal invasive surgery will also have a special place. These are operations under control of imaging methods, which are carried out for various types of tumors. This is a phenomenal area and is certainly the future. In Memorial Sloan-Kettering, we have two new large projects: the first is a new large centre for breast tumors. I have to stress that we practice a team approach in medicine, disease management teams, which means that the oncologists discusses the disease with surgeons, radiologists and pathologists. The new breast centre will be organized in the same way. The second is the large project of „image guided therapy“. We will have give new operating rooms with new equipment: a combination of CT angiography and ultrasound, PET-CT and ultrasound, intervention MRI and MRI equipped with a high focus ultrasound used in cancer treatment. We will have robots and virtual navigation, which guarantee maximum precision during the operation. It's like “Star Trek”.

NACIONAL: How many radiologists work in your department and how many modern devices are there in your clinic?

- Five years ago, when I came to the clinic, we had 29 radiologists, and now there are 71 with 35 specialists, meaning 106 all together. We have about 500 employees in the Radiology Department. In terms of equipment, our department is very well equipped. We are a large private oncology hospital and that cannot be compared to Croatia. In addition to the conventional devices and ultrasound, we have 7 MRI machines, 12 CT and 4 PET CT machines.

NACIONAL: You mentioned the future of treating cancer is nano system biology. What is that?

- Thanks to spectroscopy, for example we can see where the tumor is positioned in the prostate, where it has spread and how aggressive it is. This helps us in determining how aggressively to treat the tumor. This is only the beginning. In addition to molecular imagine, we would also like to see gene expression imaging. Today, we know that prostate cancer has about 300 genes and 1000 proteins and that is why our current methods are not enough. Nano system biology and nano vector technology is the future; it is modern radiology of the 21st century.

NACIONAL: Where else has progress been achieved thanks to molecular imaging?

- Take a look at the bone marrow transplantation. This operation has been conducted for years, but doctors never knew exactly where those stem cells were going. Thanks to molecular imaging, we can see this for the first time and we can monitor the situation in the days following the transplant. That is gene expression imaging. We are also working on an optical CT. We can already see the cell nucleus, chromosomes. These are unbelievable things, still in the experimental phase.

NACIONAL: Zagreb radiologists are thrilled with your work. How did you achieve all this?

- I don’t like to talk about myself, but if you ask me what I believe in and what principles I have followed in my life, that is first and foremost excellence. I have always tried to do everything to the best of my ability. Regardless of whether I’m cooking lunch, choosing something to buy in a store or working on a medical case, everything has to be excellent. I think it’s not worth starting anything if you can’t make it as good as you possibly can. The second thing I believe in is justice. It is important that everything I do is right. The third is education, the greatest thing we can receive and give to others. My advancements in my career have enabled me to do things for others. The success of the doctors in my department is important to me. There is an American saying “All politics is local,” which means that leaders are already seen at the local level. You have to first prove yourself in your circle. People will respect their boss if he or she is consistent and if they know what they can expect from him or her.

NACIONAL: How is living in New York different from the years spent in San Francisco?

- It was not easy in the beginning. There were many things I missed – most of all the clean air and blue California sky. We also left a beautiful house with a view of the entire city and ocean. It was very important for us to live in greenery in New York. We didn’t want to live outside the city, like many others, but took an apartment next to Central Park. It’s also close to the hospital so I can walk to work. That’s important because I often work more than 12 hours a day.

NACIONAL: Your husband Alexander Margulis is also a radiologist and has quite a name in American medicine. He was Chair of the Radiology Department and later Vice-Chancellor of the University of California San Francisco, and his new book “Be in Charge”, a manual for leaders in all walks of life is now a big hit in the US. How did you get your husband to agree to the move, considering his career in San Francisco?

- At that time, my husband had more freedom. As Vice-Chancellor of UCSF, he was responsible for long-term planning, he built the new campus. He reduced his professor duties at Cornell University in order to begin a completely new career – writing. In addition to “Be in Charge”, the first issue of which was completely sold out, he is now writing a second book.

NACIONAL: You began with research at the Henry Ford Clinic in Detroit after completing your specialization. How did you, as a young doctor at Vinogradska Hospital in Zagreb, decide to move to the US, especially since you had a small time.

- My first husband and I, as young doctors, wanted to complete our specialization abroad. Like many other specialists, we thought we’d go away for a year or two and come back, but life changes. Considering that my son Petar was only 13 months old when we left in 1972, I didn’t work for the first three years. It’s difficult to imagine me at home watching soap operas, but that was a nice period. Nine years later when I packed a suitcase and took Petar and our Dalmatian dog and moved to San Francisco, the change was a big one, but you learn to love California quickly. Today Petar lives in San Francisco and is a real California boy.

NACIONAL: What does he do?

- He’s in computers, and he is very successful. For the past eight years, he’s been working for George Lucas Films on “Star Wars”. I always say he’s playing, that his job is also his hobby.

NACIONAL: Who are some other special people in your life, who has helped you or been a particular influence?

- I think it’s most important to have a mentor that you trust. My mentors were always very strict experts, they had high standards, but helped me along. When I began at the Henry Ford Clinic, the Head of Radiology was William Eyler, also editor of the largest radiology journal – Radiology. He returned my first scientific paper for revisions 21 times – and that time there were no computers so I had to retype everything. And he taught me. I think I have had a lot of luck in my life, I’ve always been in the right place at the right time. It’s difficult to say whether or not I was ready or whether I just knew how to recognize the moment in which something was being offered to me. At the time I was doing my specialization, ultrasound was just getting started. I found a way to get educated and so my first papers and experiments were on the ultrasound. In San Francisco I started working on MRI in its infancy. When I came to Memorial Sloan-Kettering, molecular medicine was just getting started and again, right place at the right time. I love change and do not fear it. My mother says I am like a cat, always landing on my feet, and my grandmother always said that everything happens for a reason.

NACIONAL: As Department Chair, how much of your work at the clinic is with patients?

- Unfortunately, I don’t have enough time for that. I do a lot of administrative work because it’s an enormous department. I also work on research and teaching specialists. My colleagues call me in when they need expertise on difficult cases, particularly in diagnosing prostate or gynecological problems. Twice a week we hold a meeting of the board for DMT tumors, where specialists decide together on treatment for individual patients, and I regularly participate there. So I am always up to date on what is happening in my field of medicine and have the opportunity to help in diagnosis if needed.

NACIONAL: You said that you are always setting new goals for yourself. What is next?

- You’ve caught me a little off guard. I don’t know. Perhaps because I’m now working on a lot of new things which need to be finished, and I love that. Until then, a new challenge will certainly appear.