Master of the Whipple Gave Hope, Extended Lives

OncologyLive, Vol. 19/No. 16, Volume 19, Issue 16

John L. Cameron, MD, is most commonly associated with the refinement of Whipple procedures; these extensive surgical operations became far more successful thanks to his dedication.

John L. Cameron, MD

In his exemplary practice of medicine, John L. Cameron, MD, lives by a few guiding principles.

“I have a few statements I’m fond of, and the first is, ‘If you pick a profession you love, you never have to work a day in your life,’” he says. “Taking care of patients, helping them, performing surgeries, and dealing with their families—it’s the best job there is.”

His next favorite, he adds, addresses the ongoing learning process inherent in medicine. “‘Good judgment comes from experience, and experience comes from bad judgment.’ Even though you make mistakes, you learn from them and get a little smarter.”

These are fitting phrases for Cameron, the Alfred Blalock Distinguished Service Professor in the Department of Surgery at The Johns Hopkins University School of Medicine and the world’s foremost expert in the Whipple procedure, a surgery that treats the highly fatal disease known as pancreatic cancer. He has completed more than 2000 Whipple operations, or pancreaticoduodenectomies, more than anyone else in the world.

Named for Allen Oldfather Whipple, MD, who wrote about it in 1935, the procedure treats pancreatic cancer by removing the head of the pancreas, a good part of the duodenum, some of the bile duct, the gallbladder, and nearby lymph nodes. Sometimes the whole pancreas, duodenum, and part of the stomach are taken out. It is a complicated process, taking up to 6 hours or longer, that requires long periods of recuperation in the hospital. According to a journal article on the subject, the Whipple is considered “one of the most challenging surgical procedures, which requires the highest level of surgical expertise.”1

Although the Whipple is a difficult operation, it gives some patients with pancreatic cancer hope when little else avails. Cameron’s work performing the Whipple and teaching others to do it well have helped extend the lives of many patients with pancreatic cancer. Today, the 5-year survival rate for patients who have had the operation is about 25%; for those who are treated before the cancer has spread to the lymph nodes, 5-year survival rates are closer to 40%. In the 1980s, when Cameron began performing the operation, about 25% of those who had a Whipple died. Now, at Hopkins the rate is 2% or below. Without the Whipple, pancreatic cancer would claim far more victims.

A Hopkins' Legacy

A colleague quoted in a 2012 Baltimore Sun story about Cameron’s 2000th procedure noted how deeply Cameron has influenced others. “A lot of surgeons do the operation well because [Cameron] trained them,” according to Julie A. Freischlag, MD, who succeeded Cameron as chair of Hopkins’ Department of Surgery and currently serves as chief executive officer of Wake Forest Baptist Medical Center and dean of the Wake Forest School of Medicine in Winston-Salem, North Carolina.Cameron decided to specialize in performing the Whipple when, in 1984, he became chairman of the Department of Surgery and director of the Section of Surgical Sciences at Hopkins, where he had worked since attending the Johns Hopkins School of Medicine. He earned his medical degree in 1962, served his surgical residency from 1962 to 1970, and served as a clinical and research fellow for the next year. He also spent 2 years, from 1963 to 1965, as a research surgeon for the US Army at the Walter Reed Army Institute of Research.

Cameron became chairman of Hopkins’ surgical department following a meteoric rise from assistant to associate to full professor in just 7 years. “It was, at that time, a record,” Cameron says. He recruited colleagues to join him at the surgical department. That was in the mid-1980s. “I had to promise them they could do all the surgery in their fields that they wanted,” he says.

That left him to focus on pancreatic cancer, which at the time had very little to offer patients in terms of treatment or long-term survival. “Nobody wanted to operate on the pancreas, because if you did a Whipple, which was recommended for only 25% of all patients with pancreatic cancer, everyone died,” he recalls. “When I became chair, I picked pancreatic cancer to focus on because there were virtually no 5-year survivors.”

Once Cameron began doing Whipples, the success rate began to improve. Better technique, improved selection of candidates for surgery, superior anesthesia and postoperative care, and repetition have all contributed to reduced mortality for those undergoing the procedure.

“People always ask me, ‘How many Whipples do you have to do before you know how to do it?’” says Cameron. “I say, ‘I don’t know—I will let you know when I get there.’ I used to do 5 a week. It’s a long operation and you have to resect a lot of organs.” He performed his final Whipple operation on Sept. 29, 2016—his 80th birthday. Cameron, now 81, still works in the hospital. About 350 Whipple operations are done at Hopkins each year, he says, with younger surgeons doing most of them.

In the 1980s and 1990s, he worked to refine the procedure, publishing multiple randomized studies on different techniques with his colleagues, he says. “The program I started in the mid-1980s focused on pancreatic cancer, and we now have more money devoted to basic research and clinical activities on pancreatic cancer than any other hospital in the world,” he says. “We have one of the best training programs in the world. We have turned out probably 20 surgeons, mostly in pancreatic cancer, who have become leaders in surgery and the chairs of surgery departments around the country.”

No longer running the surgical department, Cameron now does as life directs him. “I have been goal-oriented most of my life, but when you’re 81 years old, you don’t set many goals. I just continue doing what I do, being a surgeon. I’ll still run the clinics and see patients and go to conferences and participate in clinical research.”

Familial Influences

He has held many other leadership roles, including with the American College of Surgeons, the Society for Surgery of the Alimentary Tract, the Southern Surgical Association, the Society of Clinical Surgery, the Society of Surgical Chairs, the Halsted Society, and the American Surgical Association.Born and raised in Brighton, Michigan, a suburb of Detroit, Cameron moved at age 9 with his father, Duncan; his mother, Mary; and his siblings, Duncan and Sara Jane, to Detroit so his father, a general practitioner, could complete surgical training. “My father had grown up in modest circumstances and was the first person in his family to graduate from college.” He worked his way through studies at Wayne State University in Michigan as an oiler on Great Lake freighters, says Cameron, referring to bulk carrier ships that carried materials like limestone, ore, coal, grain, salt, and iron to and from industrial ports across the Great Lakes.

The elder Cameron shaped his son’s path. “I grew up in the generation where most of the time, you did what your dad did,” says Cameron. “My dad said, ‘Why don’t you apply to Harvard?’ It was the only college I applied to, and I was accepted. I didn’t know then how hard it was to get into.”

On the train from Michigan to Massachusetts, Cameron lugged “a big foot locker I could hardly drag,” he recalls. “I got to [Boston’s] South Station and then took the subway to Harvard Square, and I dragged my foot locker to the dorm. There, I saw 16 other freshmen sitting around, reading the New York Times. I had never heard of the paper. It didn’t have comics in it, and I couldn’t figure out why they were interested in it.”

For his classmates, students who had graduated from Phillips Exeter Academy and Andover prep schools, “Harvard was a natural step. But for a kid from Michigan, it was a big thing,” Cameron says. Going to Harvard changed his life, he says.

“My first year, I was so afraid because all these sophisticated people from the East were there, so I did nothing but study,” he recalls. But he eventually discovered he could hold his own against the other students, both in class and out, “I demonstrated to myself that I could do just as well,” he says. “So, I eased up and enjoyed my final 3 years there.” He graduated from Harvard in 1958, then entered the Johns Hopkins University School of Medicine, where he has worked for virtually his entire career.

Family: His Proudest Accomplishment

Along the way, Cameron met and worked with many people he considered great role models in medicine, including Hopkins’ former chiefs of surgery Alfred Blalock, MD, and George Zuidema, MD, and his mentor and friend R. Robinson Baker, MD, a Hopkins’ surgeon and oncology professor.Despite his long academic career at Hopkins and becoming the world’s Whipple expert, Cameron says his greatest contribution has been his 4 children, Duncan, Heather, Shannon, and Andrew. His oldest son, Duncan MacTavish Cameron, holds a PhD in clinical psychology and practices in Texas. His eldest daughter, Heather Cameron Lowe, became an elementary school teacher. His younger daughter, Shannon Cole Brown, holds a PhD in epidemiology and joined Johns Hopkins School of Public Health and Hygiene. And his youngest son, Andrew MacGregor Cameron, MD, PhD, became a Hopkins surgeon and chief of the transplantation division there. He specializes in liver transplants.

“The Whipple operation and liver transplant are the 2 biggest operations someone can perform.” If he weren’t doing Whipples, Cameron says, “I think I would be like my son, doing liver transplants.”

Doris, Cameron’s wife, has been the bedrock of the family; this year the couple are celebrating 58 years of marriage. They met when a high school friend, Jane, set them up in Boston, when Cameron was at Harvard and Doris attended Wheelock College before becoming a teacher. Years later, “Jane developed liver failure and hepatitis and was about to die,” Cameron recalls. “Our son did a liver transplant on her, and she’s living well now.”

Looking Ahead

Cameron relishes the time he spends with family. “We are fortunate that 2 of our 4 children live in Baltimore and work at Hopkins,” he says. “We get together every Sunday evening and have dinner. One child is in Boston, and we get together in Martha’s Vineyard...The last child is in Texas, and we see him at least twice a year.” The couple have many grandchildren.Cameron envisions a future when the Whipple operation will become minimally invasive, as “that’s the direction surgery will go,” he says. “Maybe 60% to 70% [of the procedures] will be done that way in the next 10 years.” He looks forward to seeing other treatments for pancreatic cancer evolve. “The biggest advances will be with chemotherapy and immunotherapy that will result in better outcomes,” he says.

“When I got into the field, pancreatic cancer was one of the worst, if not the worst, cancer you could come down with,” he says. Back then, “there were virtually no 5-year survivors.” Today, with the advent of the Whipple and research efforts focused on neoadjuvant chemotherapy, immunotherapy, and radiotherapy, he says, “it’s improving.”

Are C, Dhir M, Ravipati L. History of pancreaticoduodenectomy: early misconceptions, initial milestones and the pioneers. HPB. 2011;13(6):377—384. doi: 10.1111/j.1477-2574.2011.00305.x.