AN AMERICAN STATHOPOULOS

January 6, 2011 — For the past 10 years, Steven Vogl, MD, a medical oncologist in private practice in the Bronx, New York, has attended the Annual San Antonio Breast Cancer Symposium (SABCS).

And at all of these meetings, Dr. Vogl has repeatedly left his seat, walked to microphone stations, and asked questions of speakers after their presentations.

"Vogl, New York," he says into the microphone, to identify himself and introduce his question. "Why say more?" he told Medscape Medical News about his verbal signature.

Dr. Vogl's questions, spoken in a distinctive New York accent, are often blunt and probing. Dr. Vogl has a freedom of speech that comes with being a community-based physician who is outside of the hierarchies of academia and industry. As any meeting-goer will tell you, Dr. Vogl does not kowtow to fame and status — renowned researchers and department chairs are addressed in the same manner as fellows and assistant professors.

"Some people like my questions, some don't," Dr. Vogl said. "I get some dirty looks — 'Oh, him again'."
A "famous" breast cancer oncologist told Dr. Vogl that he instructs his junior faculty to ready themselves for questions from the floor in San Antonio. "You've got to be prepared to answer Vogl," the eminent academic tells his young investigators, citing the ultimate challenge.

Dr. Vogl acknowledged that presenters and moderators have mixed reactions to him. "Sometimes, people moderating a session look to other microphones when they see me standing up," he explained.

His friends also have mixed feelings about his inquisitiveness. "I have a friend — she is a radiation oncologist — and she won't sit next to me in San Antonio because of my questions."

But for all of the people who avoid him at meetings, Dr. Vogl has developed, over the years, plenty of fans, including people in high places.

Last year at the American Society of Clinical Oncology (ASCO) annual meeting, while Dr. Vogl was trekking through the hallways of the gargantuan McCormick Center in Chicago, he was approached by Douglas Blayney, MD, who was president of ASCO at the time. "A lot of people like your questions," said Dr. Blayney, who is from the University of Michigan in Ann Arbor. "Keep asking them."

In 2009 at the SABCS, Dr. Vogl sat near Kent Osborne, MD, who is from Baylor College of Medicine in Houston, Texas, and is codirector of the meeting.

"Are you coming to the meeting next year?" Dr. Osborne asked.

"I hope I live until next year," answered Dr. Vogl, who then acknowledged that he would be present again.

The 2010 SABCS had 7900 attendees, including Dr. Vogl, of course. Many of the attendees were in the main auditorium at the San Antonio Convention Center on December 9 for the meeting's first general session oral presentation.

At the end of the presentation — on a phase 3 trial comparing the aromatase inhibitors exemestane and anastrozole in postmenopausal women, Dr. Vogl, as is his custom, asked a question. But he was interrupted! — by none other than Dr. Osborne, who was also in the audience and temporarily took over the program.

Dr. Osborne thanked Dr. Vogl for his annual contributions to the breast cancer meeting, which is the largest of its kind in the world. He then presented Dr. Vogl with a Lucite plaque that reads:"We gave the award to Dr. Vogl because of his consistent attendance at the meeting over many years and, more importantly, his astute and thoughtful questions during the question and answer periods after each talk," Dr. Osborne told Medscape Medical News in an email.

"He is a practicing clinician but has a unique ability to understand basic science and clinical research and to recognize the importance and/or the problems with a presentation," added Dr. Osborne.

The director of the SABCS also touched upon one of Dr. Vogl's gifts: "He can boil everything down to the important take-home message related to a given talk."

Finally, Dr. Osborne praised the medical oncologist from the Bronx in a manner that Dr. Vogl would surely object to: "Everyone respects his judgment and interpretations."

For His Patients

Dr. Vogl said that he has attended the SABCS annually for the past decade because "I treat a lot of breast cancer patients." He has also gone to ASCO annually since 1975, and he attends, on a biannual basis, a conference on adjuvant therapies in New York City.

Dr. Vogl attends meetings both for himself and his patients, he said.

He sees himself as an advocate and champion of patients. "It's the only chance I get to defend patients against drug companies," Dr. Vogl said about his tendency to be highly critical of some presentations.

"I think a large number of studies are being done to answer narrow questions that are of interest to drug companies," he explained.

His current frustration with drug companies revolves around the timing of the use of drugs, such as zoledronic acid (Zometa), pamidronate (Aredia), and denosumab (Xgeva), that treat bone metastases in breast cancers.

"No one knows when to start or stop these drugs. It's not in the drug companies' interest to tell us, especially when to stop them," Dr. Vogl said.

Dr. Vogl is critical of the pharmaceutical and health insurance industries and the regulation of the healthcare system in the United States. "We have the best government money can buy — and the insurance and drug companies have bought it," he said.

But he saves his most potent vitriol for the insurance companies. "Insurance companies have no interest in giving good service. They treat sick people like dirt," he told Medscape Medical News during a 7 pm phone interview that took place after a long day of seeing patients.

Dr. Vogl works in a relatively small office with a nurse, medical assistant, receptionist, and an accountant/office manager who happens to be his wife, Amalia. Her job is "hell" because she has to deal with the insurance companies, he said.

"You have to have somebody who will figure out what insurance companies will pay for and to challenge them," he said of his wife's role.

"That's the reason academic departments all lose money — they don't have someone who will go after the insurance companies," he said.

Free of Bosses and Employment Worries

Dr. Vogl knows quite a bit about academic medical departments; he used to work at the Albert Einstein College of Medicine in the Bronx.

After graduating from the Cornell Weill Medical College in New York City, being a resident at Jacobi Hospital in the Bronx, and completing a fellowship in oncology at Mount Sinai in New York City, Dr. Vogl served as an instructor, assistant, and associate professor at Albert Einstein. He resigned in 1982 for reasons that he chooses not to discuss.

As an investigator, Dr. Vogl participated in a number of Eastern Cooperative Oncology Group (ECOG) trials, including studies of platinum chemotherapy for a variety of malignancies, such as head and neck and ovarian cancer. At one time, he was chair of the ECOG Gynecologic Genitourinary Committee. "I made some noise," he said about his time as an academic and investigator. In short, Dr. Vogl is not your typical community-based physician. He is very familiar with clinical trial designs, statistical methods, and so on.

Not being an academic is freeing, reported Dr. Vogl

"I am not dependent on anyone for funding and I don't have to worry about offending a boss or drug company," he said. "If I had to worry about my next job or grant, I would have to be more circumspect."

Even though Dr. Vogl is a free agent, beholden only to his patients, he maintains high standards for himself. "I try very hard to phrase any questions politely, succinctly, and in good English," he said.

He approaches his time at meeting microphones with the consciousness of a performer. "I try to have a minimum of bombast. Occasionally, I use a one-sentence preamble with a question," he said, describing his technique.

"For instance, this year in San Antonio at José Baselga's presentation on lapatinib and [trastuzumab] for the treatment of HER2-positive patients, I asked a question with the preamble: 'Sometimes you learn more from patients who don't do what you want them to do than you do from the ones who do what you want'."

Dr. Vogl explained that, in this trial, the toxicity of lapatinib caused many patients to go off drug because of diarrhea and to subsequently have a dose reduction. In the end, the investigators found that they had the same positive results with patients who received less drug and had less toxicity, said Dr. Vogl.

Inherited Traits?

Dr. Vogl is the son of Austrian immigrants who met in New York City at a night school class they had both enrolled in to learn English. Both parents arrived in the United States in 1941.

About his father, Dr. Vogl said: "There's a legend that my father beat up an SS man [and had to subsequently flee Austria]."

About his mother, Dr. Vogl said that, as she was fleeing Austria and Europe, she had to take a train across Germany. "The German inspector looked at her suitcase, which was so neatly packed that the inspector said, 'I'm not touching this," and the future Mrs. Vogl went on her way undetained.

So Dr. Vogl certainly has had models of combative courage and purposeful orderliness — helpful traits for a medical doctor questioning and battling the status quo.

In the end, like most human beings, Dr. Vogl enjoys friendliness and harmony. "After I received the award in San Antonio, there were lots of smiles. Everybody was smiling at me."