Human Radiation Studies: Remembering the Early Years, Oral History of DR Nadine Foreman, M.D., Conducted August 19, 1994

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HUMAN RADIATION STUDIES: REMEMBERING THE EARLY YEARS Oral History of United States Department of Energy Office of Human Radiation Experiments

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her Openness Initiative. As part of this initiative, the Department of Energy ,undertook an effort to identify and catalog historical documents on radiation experiments that had used human subjects. The Office of Human Radiation Experiments coordinated the Department’s search for records about these expenments. An enormous volume of historical records has been located. Many of these records were disorganized; often poorly cataloged, if at all; and scattered across the country in holding areas, archives, and records centers. The Department has produced a roadmap to the large universe of pertinent information: Human Radiation Experiments: The Department of Energy Roadmap to the Story and the Records @OE/EH-0445, February 1995). The collected documents are also accessible through the Internet World Wide Web under h t t p ://m.ohre. doe.gov . The passage of time, the state of existing records, and the fact that some decisionmaking processes were never documented in written form, caused the Department to consider other means to supplement the documentary record. In September 1994, the Office of Human Radiation Experiments, in collaboration with Lawrence Berkeley Laboratory, began an oral history project to fulfill this goal. The project involved interviewing researchers and others with firsthand knowledge of either the human radiation experimentationthat occurred during the Cold War or the institutional context in which such experimentation took place. The purpose of this project was to enrich the documentary record, provide missing information, and allow the researchers an opportunity to provide their perspective. Thirty audiotaped interviews were conducted from September 1994 through January 1995. Interviewees were permitted to review the transcripts of their oral histories. Their comments were incorporated into the final version of the transcript if those comments supplemented, clarified, or corrected the contents of the interThe Department of Energy is gratefid to the scientists and researchers who agreed to participate in this project, many of whom were pioneers in the development of

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Medical School; Work With Dr . Soley at UCSF ......................... 1 Treatment of Hyperthyroidism ....................................... 2 Radioiodine as a Therapeutic Agent ................................... 4 Duties at UCSF and University of Iowa ................................ 5 Selection of Patients for Radioiodine Project ............................ 5 Communication With Patients ....................................... 6 Work With Dr. Earl Miller .......................................... 6 Connections to Donner Labs and the AEC .............................. 7 Work at Highland Hospital .......................................... 9 Radioiodine Treatment of Diffuse Toxic Goiter, Myxedema ............... 11 Metabolic Unit at Highland Hospital; Collaborations; Other Research ....... 10 Treatment of Polycythemia Vera; X-Ray Therapy ....................... 13 Reflections on Miller, Soley, Stone, Others ............................ 15

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The opinions expressed by the interviewee are her own and do not necessarily reflect those of the U.S. Department of Energy. The Department neither endorses nor disagrees with such views. Moreover, the Department of Energy makes no representations as to the accuracy or completeness of the infonnation provided by the interviewee.

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Interview with Nadine Foreman, M.D. Interviewer:Anna Berge (Lawrence Berkeley Laboratory, Archives and Records Office) ORAL HISTORY OF DR. NADINE FOREMAN, M.D. On August 19, 1994, Ms. Anna Berge of the Lawrence Berkeley Laboratory Archives and Records Ofice interviewed Dr. Foreman at her residence in Sebastopol, Dr. Nadine Foreman was selectedfor the oral history project because of the position she held at the University of California, San Francisco (UCSF). This oral interview covers Dr. Foreman ’s work on the radioiodine project conducted at UCSF during the late 1940s, and her career in general. Nadine Foreman was born in Berkeley, California. Dr. Foreman received her undergraduate degree from the University of California, Berkeley (UC Berkeley) and her M.D. from UCSF. In 1947, after completing her internship and residency, Dr. Foreman received a fellowship from the U.S.Atomic Energy Commission (AEC) and worked with Dr. Earl Miller and Dr. Mayo Soley on a radioiodine project. This project studied the use of radioiodine in the treatment of thyroid disease. In 1948, she went with Dr. Soley to the University of Iowa and helped him establish a thyroid clinic. However, after Dr. Soley’s untimely death in 1949, Dr. Foreman returned to California and took a position in the Metabolic Research Laboratory at Highland Hospital in Oakland, California. She has since retired from this position and now lives in Sebastopol, Medical School; Work With Dr.Soley at UCSF BERGE: This is an interview with Dr. Nadine Foreman by Anna Berge of the Lawrence Berkeley Laboratory Archives and Records Office on the 19th of August, 1994, at her residence in Sebastopol. I thought maybe we could start if you could tell me a little bit of background: where you’re from, what you were doing before you came to UCSF Hospital, and how you ended up at UCSF Hospital. I’m a local product. I was born and raised in Berkeley. I went to Berkeley High School, UC Berkeley, and UCSF Medical School, and, following an internship and a year of residency, I was asked to join Dr. Soley in the thyroid’ clinic. That was Mayo Soley: he was a professor of Medicine at UCSF. They were in the initial phases of exploring the use of radioactive iodine for the treatment of hyperthyroidism.* I worked part time with Dr. Soley in the thyroid clinic, but the bulk of the time was spent with Earl Mille? in the Department of Radiology, where we did the clinical work and the ancillary studies that went along with both diagnosis and treatment of hyperthyroidism. ’ an endocrine gland located at the base of the neck and secreting two hormones that regulate the rates of metabolism, growth, and development overactivity of the thyroid gland, resulting in increased metabolism rate For the transcript of the interview with Miller, see DOEEH-0474, Human Radiation Studies: Remembering the Early Years; Oral History of Radiologist Earl R. Miller.M.D.(July 1995).

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Setting: August 19, 1994, Sebastopol, California Interviewer: Anna B e g e (Lawrence Berkeley Laboratory,Archives and Records Office) BERGE: Can you tell me a little bit more about your work with Dr. Soley? FOREMAN: We saw patients in a clinical setting in the Outpatient Department [of the UCSF Hospital], for the most part. Some were inpatients. [We] evaluated thyroid function; if there was a g ~ i t e r , ~[we] attempt[ed] to estimate its size and weight. Dr. Soley had done quite a bit of this, confinning his clinical impressions with patients that went ultimately to surgery, where he was able to get an anatomical corroboration of his guess as to how much the gland ~ e i g h e d . ~With that information, plus doing tracer6 uptake studies with radioiodine [("'I)], you could come up with an estimate as to dosage-in other words, how many microcuries' of radioiodine would actually enter the gland and have an effect upon it. Treatment of Hyperthyroidism With respect to the patients that underwent surgery, how did that work? Did he do the studies? I don't know anything about that kind of surgery. Is it that they take out the thyroid? The traditional treatment for hyperthyroidism, prior to radioiodine and about the same time as antithyroid drugs, was to treat the patient with elemental iodine: which would produce a remission' or amelioration of symptoms and permit a surgeon to then remove most of the thyroid gland. That usually was a cure, but not always. Antithyroid drugs came out, t o e 1 guess it would have been in the late '30s or early '40s. Those, too, were used in cooling down the thyroid to make it possible to remove it safely from the patient. Dr. Soley would examine the patient preoperatively and estimate how much that gland should weigh, based on its volume; and then, when the surgical specimen was removed, they could tell pretty much how much was left. Of course, they could actually weigh what was taken out and attempt to correlate those two. He got to be pretty good at estimating weights. I forgot: why do you need to estimate the weight? In an attempt to quantify the dose of radioactive iodine being administered. If you knew how much the thyroid was going to take up'O-for example, if it was going to take 90 percent of what was given-and you knew the weight of the gland, you could figure how much radiation per gram of tissue was actually being administered. It was, I suppose, fairly crude, but at least it gave an ability to compare one patient with another, or one group of patients with another group of patients. an enlargement of the thyroid gland on the front and sides of the neck The thyroid would be weighed after being surgically removed. a radioactive tag on biomolecules, used to study biological or chemical systems a measure of radioactivity equal to one millionth of a curie two atoms of iodine forming a molecule a temporary or permanent decrease or subsidence of the manifestations of the disease

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Interview with Nadine Foreman, M.D. Setting: August 19,1994, Sebastopol, California Interviewer: Anna Berge (Lawrence Berkeley Laboratory, Archives and Records ORice) Was it only patients with hyperthyroidism [who were seen at the thyroid clinic], or was it also cancer of the thyroid or other thyroid diseases? I think there were a few cancer patients that were treated. But the difficulty with that is that thyroid cancer didn’t take up very much iodine, ordinarily. It was not a hyperfinctzoning tissue: it was just a hypergrowing tissue, but not -functioning. So there were few, if any, patients treated with it. When I was there, we didn’t have all that many patients with thyroid cancer-one or two, maybe. If you did use patients with cancer, you probably had to give them a You would. And then you have the problem of disposing of the [radioactive] urine. We had to store it until it decayed. Fortunately, iodine doesn’t hang around too awfully long. Why was that a problem in terms of disposal? It wasn’t considered wise to just dump it in the sewer system, especially if you’re giving large doses, because nobody really knew what the effects might be on other systems or others. It depends, I guess, where the wastewater goes. We used to have gallons of that stuff stored around there. If 90 percent of it goes out in the urine within 24 hours, that could conceivably be quite a bit to just flush down the sewer. But as I say, we didn’t happen to have that many thyroid cancer patients when I was there, and most were treated with x-ray therapy and/or surgery. Do you know anything about how they discovered that iodine would help the thyroid disorders? It was generally known that the thyroid was rich in iodine. You know how scientists are when they get ahold of something. Counts were made on the necks of people just to see how much I3’Ia normal thyroid would take up. It was observed that overactive glands took up proportionally more iodine than normal glands; it [(the realization)] evolved fiom We used to do radioautographs also. [We’d] give a test dose prior to surgery; then, when we got the tissue sections [and] the pathologic“ slides, [we] put the slides in contact with dental film. It would make its own picture of the n0dule’~--0r of the gland-in cross-section; you could see if there were little “hot” spots or “cold” areas. The tissue takes its own picture, because it’s radioactive. At what point did they stop having to do surgery as a general procedure? ’ I of or pertaining to pathology, the science or the study of the origin, nature, and course of diseases a small, rounded mass or lump use of photographic film placed over thinly sliced tissue to record, in image form, the radiation tracks from the tissue that pass through the film’s emulsion

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Setting: August 19, 1994. Sebastopol, California Interviewer: Anna Berge (Lawrence Berkeley Laboratory, Archives and Records office) FOREMAN: They never stopped: they still do surgery. Sometimes it’s a matter of preference on the part of the patient. Although 1 personally think radioiodine is the neatest, slickest way to do it. Unless it’s a nodularI4goiter. I think [that] whether it’s thyroids, or breasts, or whatever, lumps are better off in a jar, so you know what you have. That’s my personal opinion, and I think it’s shared by others, depending on the size and nature of the goiter. There are still other exceptions. For example, a pregnant woman-you wouldn’t want to treat her with radioactive iodine. Antithyroid drugs allow you to defer that operation or that iodine treatment. In fact, you can delay deciding on definitive treatment until after a pregnancy. You can keep them under control with an antithyroid drug and then turn them loose, as it were, afterwards and hit them with radioiodine. People have their biases and their preferences. Radioiodine as a Therapeutic Agent BERGE: I think I understand how radioiodine works as a diagnostic tool. Can you explain a little bit how it works as a therapeutic agent? FOREMAN: As a diagnostic tool, you rely on the gamma emission^,'^ which are relatively few in comparison to the [beta] emissions.’6The latter penetrate tissue only one or two millimeters, but if you put a substantial tive tissue will take up most of it and essentially bum itself out. BERGE: What were the normal doses at that time? FOREMAN: Maybe 10 or 15 microcuries for a tracer dose. If you were going to do a[n imaging] scan, you might use 25 microcuries, but a really very small, insignificant dose. BERGE: What was the general procedure for therapy? How many times a week or a month would they be seen? FOREMAN: We tended to aim at a target dose right off the reel.’’ That’s when the uptake is maximal-when you’re going to get maximal concentration in the thyroid and it’s not going to be circulating around every other place. Or going out in the urine. As I say, it would depend entirely on the size of the gland. Obviously, if you had a very large goiter, we would expect to give two or more doses. It would vary. If you had a very small hyperactive gland, you might give as little as five millicuries, or four. But ten or twelve was not BERGE: And all at once. characterized by nodules (small, rounded masses or lumps) highly penetrating photons of high frequency, usually IO’’Hz or more, emitted by atomic nuclei release of electrons or positrons during radioactive decay a measure of radioactivity equal to one thousandth of a curie or one thousand microcuries “Right off the reel” means from the stadbeginning.

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Interview with Nadine Foreman, M.D. Setting: August 19,1994, Sebastopol, California Interviewer:Anna Berge (Lawrence Berkeley Laboratory, Archives and Records Office) FOREMAN: One swallow. FOREMAN: Just like water. Tastes like water, looks like water. Duties at UCSF and University of Iowa BERGE: I forgot if I asked you what your particular function in all of this was. FOREMAN: I was a clinical associate of Dr. Soley-seeing patients, treating patients, some teaching. I was a …