Palisadian Dr. Donald L. Morton - The Pioneer of the Sentinel Lymph Node Technique

In a city like Los Angeles, where the modern trends have antiquated social grace, Palisadian Dr. Donald L. Morton is a rare gem you are lucky to discover, who retains the embers of refined manners and class. His intimidating tall stature is offset with inviting twinkling eyes reflecting humor, wisdom and compassion. It was clear from the greeting handshake that Dr. Morton was not like many of today’s slick physicians who employ a publicist to obtain medical stardom. His eye contact and focus exposed that Dr. Morton was a rarified great listener and his life experiences gave him a firm grasp on the human condition. In fact, you would be hard pressed to find any of his patients complaining about lack of bedside manner, a condition that plagues the modern generation of physicians. He’s retained the raw purity of what medical care was intended to be which makes him a stand-out in the medical community.

While his office revealed a trace of his accolades and his history with the legendary John Wayne, Dr. Morton’s authentic humility fooled one to believe that he is just an ordinary small town man.  But, there were clues that revealed to the observant just how extraordinary he really is.  His colleagues and employees not only admire him, but retain a steadfast loyalty to Dr. Morton mirroring the deep respect he projects onto them. Loved by his family, adored by friends, well- respected in his local community and a physician who has pioneered ground-breaking contributions to cancer research, Dr. Morton is, indeed, an exceptional man.

On October 15th, 2011 Dr. Donald L. Morton, Chief of the Melanoma Program at the John Wayne Cancer Institute (JWCI) and Director of the Surgical Oncology Fellowship Program, was recognized with the Spirit of Saint John’s Award at the Caritas Ball for his life-saving contributions to cancer research. One of his pioneering innovations, the Sentinel Lymph Node Technique, has not only fostered a new approach to how cancer is detected, analyzed and treated around the world, but has become the standard of care for melanoma and breast cancer.  The American College of Surgeons in 2008, granted him the Jacobson Innovations Award for his discovery of the Sentinel Node Technique.  Twenty years ago, Dr. Morton with Michael Wayne (John Wayne’s oldest son) founded the John Wayne Cancer Institute at Saint John’s Health Center in Santa Monica, CA, where Dr. Morton became medical director and surgeon-in-chief.  It is now a world-renowned cancer center.

Life has not been an easy path for Dr. Morton. In fact, the deck of cards was stacked against him from the get-go. Born in a small town in West Virginia where he was the first one in his family to go to college, Dr. Morton is a fine example of how an underdog and a man raised with strong family values achieved his American dream.  It was his stint working in a small town drug store in Virginia during high school that influenced him to become a doctor, although there was no foreshadowing of just how prestigious of a doctor, this small town boy, was to become.

From the desire of escaping malicious small town gossip, a doctor was born.

Dr. Morton says with a reminiscent smirk, “It was customary for people to gossip about each other. I was struck by the fact that no one had anything bad to say about their doctor. They only had good things to say about their doctor.”

The doctors he worked with became encouraging role models for him. Not knowing what kind of doctor he wanted to become, he got a booklet from the American Medical Association with descriptions of the training and specialties. Off the bat, he wanted to be a surgeon but the length of training was discouraging.

“I’m going to be so old when I finish,” he declared.

Wanting to change the status quo, which would foreshadow his scientific breakthroughs, he informed his high school counselor of his desires to finish school early and graduated in three years, no easy task by any means.

Dr. Morton went to Berea, a small college in Kentucky, which was targeted for the poor boys and girls in the Appalachian mountain district. There was no tuition, but everybody had to work at least ten hours a week at ten cents an hour, to help pay for room and board and books. After a family move to California, he finished the rest of his college training in California, earning a scholarship to Berkeley and actually getting into medical school at the end of his third year in college. He got his bachelor’s from Berkeley at the end of his first year of medical school at University of California – San Francisco, or UCSF.  Ambitious does not quite capsulate Dr. Morton’s drive. His residency at UCSF was interrupted by two years of research at the National Cancer Institute in Bethesda which ultimately solidified his career interest in cancer.

His discovery of sentinel node mapping stemmed from a friendship he developed with Dr. Donald Cram, a professor of Chemistry at UCLA and a man who was eventually awarded the Nobel Prize. Dr. Cram was diagnosed with a melanoma of the calf and as was more or less standard treatment at the time, Dr. Morton did a wide excision of the calf melanoma with a skin graft and performed a complete groin lymph node dissection as 20% of skin melanoma can spread to the lymph nodes in the groin, under the arm, or in the neck depending upon where the primary melanoma is located.  Fortunately, Dr. Cram did not have any spread to his lymph nodes and did not develop swelling of the leg, a frequent complication of removal of groin lymph nodes.

However, for years following this operation, Dr. Cram would have lunch with Dr. Morton every time he’d come in for a follow-up visit.  And, Dr. Cram would always say something along the lines of, “You know, I don’t know why I had to have all of my lymph nodes removed. They were totally normal. There was no reason to remove them.”

As Dr. Morton thought about it, he realized that Dr. Cram was absolutely right. Why should 100 surgical procedures be done when only 20 of these procedures provide any benefit to the patient? Dr. Morton realized that all the radical surgery was doing was removing all the nodes, knowing that 20% of the time there would be disease and 80% there wouldn’t, meaning 80% of patients were undergoing unnecessary surgery. There were clinical trials where half the patients would be randomized to get complete node removal and others undergo no lymph node surgery.  However, no trial proved to have the answer Dr. Morton was seeking because this meant only 20 patients per 100 could benefit from the radical surgery.

Dr. Morton realized the question he should be asking was, “How do we identify the patients that have disease in their lymph nodes and distinguish from those that don’t?” That question led to scientific research in which blue dye was injected into the skin which showed a drainage pathway into one or two nodes in the groin, but only those one or two nodes were stained blue. The other nodes were not stained since they did not receive drainage from that area of skin.  Thus, it was clear that each area of skin drained to 1 or 2 regional basin nodes.  Dr. Morton asked himself, “How do we detect those one or two nodes?”

His team developed techniques where he injected the blue dye in the skin at the site of the melanoma and made an incision in the groin or axilla and dissected very carefully to find the blue lymphatic channel and followed the path to a blue lymph node and at that point they knew that the blue lymph node was connected to the skin and any tumor cell spreading from the primary melanoma would be in the blue nodes.  After performing many cases, they had an astounding accuracy of 98%.

After more trials testing different theories, it became clear that the sentinel node was the first draining node, meaning if the tumor had the ability to spread it would go to that node. The recurrence rate in the lymph node basin was much lower in those patients that had the sentinel node tumor removed than those that were not.

While Dr. Morton had made this tremendous discovery, there certainly was controversy within the medical community and much resistance as is typical of a novel idea. His peers didn’t realize the importance of this finding. However, Dr. Morton continued pushing the boundaries, convinced that the status quo, had to be changed. And after many trials by other investigators confirming his favorable results, this procedure began to be adopted throughout the world not just for melanoma, but for breast, penile and virtually all types of solid tumors that spread through the lymphatics.

Gone are the days of a radical node dissection on each person who has melanoma or breast cancer. Now, an outpatient procedure is performed with a little incision and 80% of the time that’s all you have to do. Ultimately, 80% of melanoma patients and 70% of breast patients have been saved from a radical lymph node surgery that would cost about $30,000 dollars, and most importantly avoids chronic swelling (lymphedema) of the arm or leg. The savings in healthcare costs nationwide are enormous.

Whereas most new treatments increase the cost of healthcare, this discovery has created approximately $3 billion dollars a year in healthcare savings.

When asked how he felt about creating this new frontier, Dr. Morton fidgeted shyly.

“I didn’t realize how significant the procedure would become.  I didn’t know whether it would be adapted by other cancer surgeons, so I organized a clinical trial to involve 17 other melanoma centers throughout the world who fortunately were able to confirm my results. Some people thought it was a crazy idea and my paper describing the technique was turned down by one prestigious journal before it was accepted for publication. It’s an enormous satisfaction to a patient to know that their sentinel node is negative and their survival chances are about 90% and they do not have to undergo radical lymph node surgery.  So, yes, I’m overwhelmed sometimes when I think about what an impact this has had.”

Ironically, Dr. Morton, a man who has spent his life studying melanoma, ended up with a melanoma. If it weren’t for the persistence of his wife to get it checked out, there could have been drastic ramifications. Dr. Morton says, “it didn’t spread. Thank God. The good Lord decided he still had some work for me to do.”

Dr. Morton explained that melanoma is the most widely metastatic cancer. It can go anywhere. It is the most malignant.  A 5mm melanoma will kill 50% of the patients within 5 years.  Dr. Morton stated that melanoma cases are increasing at about 4% a year.

“Sunscreens prevent sunburn. But, whether or not they prevent DNA damage that can lead to melanoma, that is the $64 dollar question,” Dr. Morton said.  Dr. Morton advised that the best thing for the young generation to do is wear clothing that blocks ultraviolet rays. That’s his recommendation to all of his patients.

“Never get sunburned,” he warned. “Sun splurging causes the damage. The higher cases of melanoma occur with people who are inside most of the time and then go to Hawaii and get sunburned. And, tanning beds are terrible.”

More melanoma cases are being diagnosed and treated earlier so the mortality rates are not going up as fast as the incidents.

Dr. Morton continues to make strides with his research.  He is currently looking at ways to better stimulate the immune system to help better control any residual melanoma cells remaining after surgery as an initial treatment.

Dr. Morton says, “I think that’s it is likely, we’ll develop therapeutic antibodies to target melanoma tumors and better methods of immunotherapy and that we’ll use surgery more frequently after early diagnosis. I think our results will improve. If we cure 75-95% of melanoma’s now, we should be able to reduce the recurrences and deaths by 50% within ten years with earlier diagnosis.”

While Dr. Morton says, “Although public awareness of melanoma has increased, prevention is not routinely practiced, particularly in schools, children without sun protection are still playing outside at recess in midday when the sun is at its most intense."

Just as the interview was coming to a close, Dr. Morton extended the interview so he could spend some time sharing his other great passion in life: His family. He has a 13-year-old daughter who goes to St. Matthews in the Palisades and eight grandchildren.  Dr. Morton considers himself very lucky because he is blessed with a very full life that requires different areas of concentration. Between research, teaching, lecturing around the world, and clinical care his diverse career interests are met and his personal life is extremely gratifying going to recitals, baseball, football games and birthday celebrations. Dr. Morton’s primary avocation, however, is his family.  Dr. Morton honorably spoke about his first wife, a nurse, who tragically died in a car accident and about his current wife, a former banker, a blessing with whom he shares an incredible love story, a love story that many strive to attain and never get in their lifetime.

And just as Dr. Morton recognizes his blessings, those people whose lives have been gracefully touched by Dr. Morton, recognize theirs.