newsmaker: Robert W. Hobson II, MD
media coverage: San Francisco Chronicle, The New York Times, The Los Angeles Times, Associated Press

On the CREST of His Medical Career

by Maryann B. Brinley

Robert W. Hobson II, MD, professor of surgery and physiology and founding director of the Division of Vascular Disease at UMDNJ - New Jersey Medical School (NJMS), is the principal investigator of a $27.5 million, multi-center, National Institutes of Health (NIH) funded, clinical trial widely known by its acronym: CREST.

"Not the toothpaste," Hobson laughs, dismissing the most obvious interpretation of this word which also means "highest stage" or "apex." A decorated Vietnam War veteran and NJMS professor of surgery, Hobson has been a powerful presence on the Newark campus for three decades. Author of hundreds of books and publications, he has also won numerous awards for his teaching. "Medicine continues to be extraordinarily satisfying," he says. And right now, there may be nothing he enjoys discussing more than CREST.

The letters in CREST stand for Carotid Revascularization Endarterectomy vs. Stenting Trial, "the largest trial of stroke prevention ever conducted in North America and based here at UMDNJ," he explains. Nationally recognized as a leader in stroke treatment, he pioneered the carotid stenting procedure and has been performing it on high risk patients since 1996. After the initial announcement of his success, news coverage ranged from The New York Times to the Los Angeles Times, San Francisco Chronicle and many Associated Press stories.

Hobson's passion for surgery was ignited during the war in Vietnam, where he was stationed after graduation from George Washington University School of Medicine and before his residency in general surgery and fellowship in vascular surgery at Walter Reed Army Medical Center. As a member of the 5th Special Forces Group, he worked in Vietnam for a year with Australian surgeons who were part of an Agency for International Development (AID) team. "They were master surgeons," he recalls, "and also very gregarious. We had some great parties."

If the memories sound like a sequence on MASH, the old television series, it's because they could have been.

"Special Forces established A-teams which were covered by medics at camps located about 10 kilometers apart and arrayed along the Cambodian border," he says. Medically responsible for civilian irregulars, not American servicemen, Hobson treated Vietnamese fighters who might not have received prompt care in regular military hospitals. He and another colleague managed the military ward of the Bien Hoa Province Hospital. "One of us would hop by helicopter from place to place. It was very satisfying work." Normally, doctors aren't airborne qualified, but Hobson had graduated from special warfare college in Fort Bragg, North Carolina. "I was very gung-ho for the military," he admits laughingly, and says he "parachuted over there on many occasions."

"What an interesting, different chapter in my life," he adds. Yet, on closer examination, it was a chapter that seems not out of sync with the medical career of a heroic surgical leader in the area of vascular medicine.

"Stroke prevention has become a really important topic for the American people," Hobson explains. Not only is stroke the third most common cause of death in the United States but "what may be more important is that it is the number one cause of disability among the elderly. Sometimes what elderly patients fear even more than death from stroke is the possibility of surviving and becoming a burden to their families. Patients will say to me, 'Doc, I don't want to become disabled, unable to care for myself or institutionalized.'" More than 700,000 Americans have new or recurrent strokes every year and the lifetime cost of stroke exceeds $90,000 per U.S. patient. Preventing stroke, as Hobson sees it, is "very economical for Americans over 70."

CREST began recruiting in December, 2000 and will eventually enroll 2,500 participants. The trial is designed to compare two procedures aimed at preventing strokes caused by plaque in the carotid arteries, located along both sides of the neck. The buildup of life-threatening plaque is known as atherosclerosis, or hardening of the arteries. Participation in the trial is limited to adult men and women who have experienced a small stroke or what is known as a transient ischemic attack (TIA) and who also have moderate to severe carotid blockage.

Sponsored by the National Institute of Neurological Disorders and Stroke (NINDS) at the NIH, the study is examining "the efficacy of the gold standard of treatment, carotid endarterectomy (CEA), an open operation to remove plaque and fatty deposits from the neck. The procedure has been around for 35 years," Hobson says. CEA is performed approximately 150,000 times a year in the U.S. and is more effective than medical management - using medication alone - of carotid stenosis (narrowing or blockage). Hobson's alternative, carotid artery stenting (CAS), is minimally invasive and involves passing a fine catheter with a balloon tip up into the carotid artery through a puncture in the groin. The catheter dilates the artery, unclogs the sticky plaque and restores blood flow. A mesh-like metal device, or stent, is left behind to hold the artery open.

"Vascular surgery is such a dynamic, evolving specialty," Hobson says. "Over the last decade, more than 50 percent of our open operations have become catheter based." In fact, stents and catheters have been used successfully for years to correct abdominal aneurysms, poor circulation in the legs and feet, and coronary problems. Carotids were once considered off limits to stenting, however. "It was always believed that if you started balloon dilating the arteries up near the brain, you would increase the chances of a piece of plaque breaking off during the manipulation and causing a stroke. A 30 to 40 percent risk was thought possible," Hobson explains. Ingenious engineering and new hardware have changed all that. "What we do now is float a small umbrella up into the artery beyond the blockage to trap and capture the debris that might escape." After the procedure, the umbrella is closed and removed.

Trained CREST physicians rely on ultrasound and/or cerebral angiography to screen potential candidates who must first agree to undergo either procedure. "We need their permission to allow the NIH to flip a coin or randomly select who gets what treatment," Hobson explains. "Thirty percent turn us down but this kind of randomized clinical trial removes any bias associated with treatment selection. This is the only way you can genuinely develop the evidence that will demonstrate that these two procedures are equivalent or that one is superior."

With more than 400 subjects now entered in the randomized phase of the trial and more than 1,100 patients in the pre-randomization lead-in phase at 110 NIH-approved centers, CREST expects to keep going for at least two more years. Administered by Alice Sheffet, PhD, and a staff of six at the UMDNJ headquarters, CREST will receive another $5 million this year. The trial also has the financial support of the stent manufacturer, the Guidant Corporation.

In Vietnam, as a 24-year-old physician, Hobson saw the power and privilege of medicine up close and personally, as well as how good leadership could make a difference. "The Vietnamese word for physician is bac si," Hobson says. When he arrived in that country in September, 1965, the young doctor was struck by the way all bac sis observed poc time (the word he recalls was slang for siesta). "If you came into the emergency ward of the Bin Hoa provincial hospital between 1 and 3 PM, you did not get to see a bac si under any circumstances." They were all taking poc time, a practice that soon changed.

Hobson leans back in his chair and smiles as some of these memories surface. Good septic techniques were missing. "Nurses would use one set of instruments for 20 patients and there were no screens on the hospital windows," he adds. Before Hobson's special forces teams and camps were set up, a gunshot wound in a civilian irregular fighter could easily turn into a fatality because if you let that kind of injury "sit around for four or five days, you don't survive."

His courage in Vietnam brought him a Combat Medal Badge, the Bronze Star, the Air Medal, the Medal of Honor (Merit), the Cross of Gallantry, and the Republic of Vietnam Airborne qualification. His courage in exploring a new way of preventing strokes could bring quality of life to millions of potential stroke victims.