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From the Townsend Letter
August / September 2008

War on Cancer
by Ralph W. Moss, PhD

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Because of a long-time interest in medical hyperthermia, on a recent trip to Houston, I visited with Joan M. Bull, MD, professor at the University of Texas (UT) Medical School and director of its Division of Oncology. Dr. Bull is an unlikely advocate of an "alternative" approach to cancer. She graduated with a BA in biology from Stanford University and obtained her medical degree from Stanford Medical School. After interning at the University of Chicago Hospital, she returned to Stanford for a residency in Internal Medicine and also completed a fellowship in medical oncology.

For the next ten years, Dr. Bull held research positions at the National Cancer Institute (NCI), first as Medical Officer, then Special Research Fellow, Senior Staff Fellow, and finally Senior Investigator in the Division of Cancer Treatment. She worked on the celebrated MOPP protocol for Hodgkin's disease with Dr. Vincent J. DeVita, Jr., then the NCI Director (Moore 1973). It was while she was at the National Cancer Institute – again at the suggestion of Dr. DeVita – that she began to research the use of heat against cancer. In 1980, she came to the University of Texas (UT) Medical School in Houston as an associate professor in the Division of Hematology/Oncology of the Department of Internal Medicine. There she began her research program in whole body hyperthermia.

Dr. Bull is now a professor of Internal Medicine and, since 1995, has been the Director of the Division of Medical Oncology. She is presently also Director of the Oncology Clinic at Hermann Hospital, which is an administratively separate institution that is physically attached to the UT medical school. She is also an attending physician at the M.D. Anderson Cancer Center (also in Houston) and is the author of 91 PubMed-listed articles, most of which discuss the use of heat as a cancer treatment.

With so many impressive credentials, it may seem odd to find her included as one of the "complementary and alternative" (CAM) practitioners in Houston. Dr. Bull herself rejects any suggestion that she is an "alternative" practitioner. She is, after all, thoroughly orthodox in her background and training. But her abiding interest in heat therapy for cancer, as well as in treatments that modulate the immune system, has unarguably led her in an unconventional direction. She is offering something outside the mainstream, albeit under Food and Drug Administration (FDA)-approved clinical trial protocols at a major medical center.

I have heard the name Joan Bull in connection with hyperthermia for many years. Her first studies of whole-body hyperthermia were published in the 1970s (Bull 1979). But whereas other American practitioners of this treatment have either retired or dropped out of the field, Joan Bull has stuck with it, sometimes to the bemusement of her colleagues, who cannot understand why she finds the field so compelling. (I happen to share her enthusiasm for hyperthermia.) Here's a revealing statistic: of the seven clinical trials of whole body hyperthermia for cancer that are listed at the National Cancer Institute's clinical trials database (, all but one are being conducted by Dr. Bull! (The remaining one is being run by a German research team.) So, for reasons that are hard to fathom, Joan Bull now has the field of whole-body hyperthermia almost entirely to herself in the American academic community.

I first met Dr. Bull at a Comprehensive Cancer Care conference in Arlington, Virginia, in 2001. But my recent visit to Houston was the first time that we had a chance to get to know one another and for me to learn details about her work. She took time out from a very busy schedule to talk about what she calls "thermal therapy." (She avoids the word "hyperthermia" because it has two separate and unrelated meanings in medicine and is thus ambiguous. Many lay people also confuse hyperthermia with hypothermia, which is a dangerous drop in body temperature such as may occur through prolonged exposure to frigid outdoor temperatures.)

The first thing to understand is that everyone who seeks admission to Dr. Bull's program at the University of Texas first has to be enrolled in a formal FDA-approved clinical trial. There are presently three such trials that are actively recruiting. (You can find more details on these at They are as follows:

1. Chemotherapy with whole body hyperthermia for treatment-resistant breast, endometrial, cervical, and ovarian cancers
2. Hyperthermia with chemotherapy to treat inoperable or metastatic neuroendocrine tumors; small cell lung cancer; non-small cell lung cancer; gastric cancer
3. Hyperthermia with chemotherapy for locally advanced or metastatic pancreatic cancer

Let us look in detail at trials #2 and #3, since they are most comprehensive. Patients in these trials receive an intravenous infusion of the FDA-approved drug gemcitabine (Gemzar®) over a period of 30 minutes on days 1 and 8 of the treatment. They also receive the drug cisplatin by intravenous infusion over six hours on day 15, followed by low-dose subcutaneous injections of the immune modulator interferon-alfa on days 16 and 17. Patients then undergo long-duration, fever-range whole body hyperthermia (thermal therapy) over six hours plus more gemcitabine (Gemzar) over 30 minutes on day 17, as well as daily, self-administered, low-dose interferon alpha injections.

This course of treatment is then repeated every four to five weeks, assuming there is no disease progression or unacceptable toxicity. This unique combination of fever-range whole body thermal therapy (abbreviated FR-WB-TT) and chemotherapy is sometimes referred to as "thermochemotherapy." Although Dr. Bull describes the temperature as "low range," the body is actually heated to a core temperature of 40º C (or 104º F), using a German-made Heckel HT2000M radiant heat device. Some German CAM clinics raise the temperature higher, but Dr. Bull believes that fever-range temperatures are sufficient (along the lines of the cancer remissions effected with fever therapy a century ago by William B. Coley, MD).

The synchronization of drugs and heat are very important for the outcome, as Dr. Bull wrote in a 2008 paper: "The relative timing of agents in multiple modality treatments is critically important in achieving tumor control or cures, and in reducing toxicity. Optimizing the relative timing of multiple agents in thermochemotherapy allows use of lower drug doses to achieve maximal anti-tumor efficacy and minimal toxicity" (Bull 2008).

Dr. Bull's website gives the following description of the process:

An array of heat lamps within a soft-sided, reflective chamber directs infrared energy through the skin. Once the desired body temperature has been reached, the space blanket-like sides of the chamber are wrapped around the patient to maintain the temperature for 6 [six] hours. The temperature can be adjusted as necessary by further use of the lamps for additional heating or opening of the blankets to facilitate cooling. Patients are administered a light sedative to assist with relaxation and to remove any irritability resulting from the fever-like state. Care is given to maintain adequate hydration throughout the procedure.

With this whole body heating device, an array of heat lamps within a soft-sided, reflective chamber directs infrared energy through the patient's skin. Once the desired body temperature has been reached, the space blanket-like sides of the chamber are wrapped around the patient to maintain the desired temperature for six hours. The target temperature can be adjusted as necessary by further use of the lamps for additional heating or, conversely, opening of the blankets to facilitate cooling. Patients are administered a mild sedative, says Dr. Bull, to assist with relaxation and also to remove any irritability that might result from their fever-like state. Care is given to maintain adequate hydration throughout the procedure.1

In the US, hyperthermia in general relies on devices that are approved by the FDA, which currently classifies Dr. Bull's type of hyperthermia machine as a "non-significant risk device." This means that it does not pose any significant danger and can be studied without FDA oversight, provided that the sponsor otherwise complies with FDA requirements. As a general rule, non-significant risk devices require only institutional review board (IRB) approval prior to initiation of a clinical study.2 In addition, the chemotherapy drugs that she uses are all FDA approved. Nevertheless, the FDA considers the combination of whole body hyperthermia and chemotherapy to be an investigational procedure. Her treatments are therefore only administered according to research protocols that have been approved by the UT-Houston Medical School's Committee for the Protection of Human Subjects (i.e., their Institutional Review Board or IRB).

Since Dr. Bull is a professor at the University of Texas Medical School, her clinical hyperthermia research only takes up a portion of her time. She does not have a large staff or budget and, consequently, can only help a select few patients. To my knowledge, this is the only whole-body hyperthermia unit in operation in the entire United States. The treatments are administered under the auspices of the University of Texas, and everyone who is treated with hyperthermia comes there as part of a clinical trial. The actual treatment is given at Memorial Hermann Hospital, which is the headquarters of a chain of a dozen or so ultra-modern hospitals in the Greater Houston area.

Hyperthermia is a promising treatment. For many years, it has been widely available in Europe – indeed, it is the main reason that many international patients flock to German clinics for treatment. There, each hyperthermia session is likely to cost you thousands of dollars, not to mention other associated costs. (The cost of treatment at many CAM clinics nowadays runs around $1,000 per day.) By contrast, the cost of the medical treatment for Joan Bull's experimental heat treatment is essentially zero. Of course, this does not mean your final out-of-pocket expenses will be zero. You may face considerable costs for lodging, food and other necessities or incidentals while you and your loved ones are in Houston. Most importantly, you or your insurance company must pay for the radiological, physiological, and laboratory blood work evaluations prior to protocol entry, as well as for the standard chemotherapy given in the Oncology Clinic prior to the thermal treatment, and the follow-up radiological and laboratory evaluations during the protocol therapy. (See Dr. Bull's website

And, especially if the program is successful, you will have to be in Houston for many days during the year. Thus, in a typical month, you will need to be there at a minimum on days 1-4. This same schedule will then be repeated five weeks later. Needless to say, living within easy driving distance would be a big plus in terms of logistics. In the trials, patients are also instructed on how to self-administer daily "metronomic" injections of interferon-alpha. All clinical trials have inclusion and exclusion criteria, and Joan Bull's are no exception.

Patients who are accepted into the program then face an extensive battery of diagnostic tests and charges for standard chemotherapy. Although the actual cost of this is ~$10,000, it is generally paid for by one's insurance. The heat treatment itself, as part of an approved academic experiment, is paid for by taxpayer dollars. So, generally speaking, if one has insurance, the cost to the patient is restricted to personal expenses. This is an outpatient procedure, and so patients and their family members have to secure housing at a nearby hotel and pay for their own travel, meals, etc.

The combination of heat, chemotherapy, and immunotherapy is certainly innovative, especially in the US, where the options for receiving any form of hyperthermia are severely limited. But one thing you should be aware of is that, unlike in Germany, where whole-body hyperthermia (sometimes using identical equipment) is given once or even twice per week, Dr. Bull only gives patients one whole-body hyperthermia treatment per month. She told me that this not so much a medical decision as an economic one. She does not have the staff or the research funds to pay for a more frequent schedule of treatment. In other words, she is doing what she can do within the constraints placed on her by the economics of her situation.

Who benefits from the treatment? Understand, first of all, that Dr. Bull only treats people with very advanced cancers. That said, her best results have been with the following:

  • Advanced gastric (stomach) cancer: she told me of a 3.5 year survivor;
  • Advanced pancreatic cancer: she told me of a greater than fourteen-month complete, biopsy-proven response;
  • Small-cell lung cancer (SCLC): she had two cases that also survived 3.5 years, one of whom then died of cardiovascular disease without any evidence of cancer.
  • Another patient had a complete response that so far has lasted more than a year and a half;
  • Other neuroendocrine (hormone-producing) tumors.

In summary, Joan Bull is one of the best-known and most highly honored academic scientists associated with the use of an integrative or CAM technique in the US. She is the author of nearly 100 Pub-Med articles on the topic of hyperthermia and is internationally recognized as an expert on these topics. There could be many advantages to being treated by her within the Texas Medical Center, particularly since excellent conventional care of every sort is available at her own and neighboring institutions.

Note: My visit to Joan Bull is part of a systematic survey I am conducting of CAM or integrative cancer clinics in the US and abroad. These visits then form the basis for the "Where to Go?" series of reports available at my website:

1. See Dr. Bull's website. Available at: Accessed May 27, 2008.
2. Investigational Device Exemption (IDE). Available at: Accessed May 27, 2008.


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