Submitted: 1 December 2014
Six interview sessions: 7 February 2013, 8 February 2013, 31 May 2013, 8 July 2013, 27 August 2013, 28 August 2013
Total approximate duration: 10 hours
Interviewer: Tacey A. Rosolowski, Ph.D.
For supplementary materials:
Please contact, the Historical Resources Center, Research Medical Library:
Javier Garza, MSIS, email@example.com
About the Interview Subject:
Bernard Levin, M.D. (b. Johannesburg, South Africa, April 1, 1942) was recruited to the MD Anderson faculty in 1984 as a Professor of Medicine tasked to establish a new Section of Gastrointestinal Oncology. His research focused on identifying markers that enable early detection of colorectal cancer and the management of polyposis, as well as surgical adjuvant therapies and chemo-preventative treatments.
Dr. Levin served as Chair of the Department of Gastrointestinal Medical Oncology and Digestive Diseases until 1994 when he was appointed Vice President for Cancer Prevention and Population Sciences, a position held until he retired in 2007. As Vice President, he had an increasingly public role in raising awareness about prevention. In 1996, he was a guest speaker at the White House under the Clinton administration, discussing “New Efforts to Promote Colon Cancer Prevention”: he testified before Congress on screening initiatives in 2000. Dr. Levin now holds the title of Professor Emeritus.
Major Topics Covered
Personal and educational background; evolution of political conscience
Research: Celebrex –colon cancer study; portable infusion pump; intra-arterial therapy pump; early detection; biomarkers, colon cancer; chemoprevention;
Views on translational research, research collaboration and multi-disciplinary care/research
Research: collaborative international projects
Section of Gastro-intestinal Medical Oncology; expanding;
The Division of Cancer Prevention: establishing and evolution of; controversies over; culture of
Cancer prevention: public policy roles; expanding public awareness of; funding initiatives
Ethics; views on conflict of interest; evolution in the future
Service to national organizations: Early Detection Research Network; GI Tumor Study Group; National Colorectal Cancer Committee
Regarding the Transcript and Audio Files
In accordance with oral history best practices, this transcript was intentionally created to preserve the conversational language of the interview sessions. (Language has not been edited to conform to written prose).
The interview subject was given the opportunity to review the transcript. Any requested editorial changes are indicated in brackets [ ], and the audio file has not correspondingly altered.
Redactions to the transcript and audio files may have been made in response to the interview subject’s request or to eliminate personal health information in compliance with HIPAA.
Interview Session One: 7 February 2013
Family and Politics in South Africa
Chapter 01 / Personal Background
Medical Training in South Africa
Chapter 02 / Educational Path
Coming to the United States for Further Training
Chapter 03 / Professional Path
A Political Conscience
Chapter 04 / Character and Personal Philosophy
An Interest in Malignancy
Chapter 05 / Professional Path
An Interest in Clinical Trials, Design of Research, and Government Oversight
Chapter 06 / The Researcher
The Challenges of Creating a Multi-Disciplinary Section of Gastro-Intestinal Medical Oncology
Chapter 07 / The Administrator
Mentoring and Research
Chapter 08 / Personal Background
Challenges to the Division of Cancer Prevention
Chapter 09 / Building the Institution
The New Division of Cancer Prevention (and Questions about Whether It Should Exist)
Chapter 10 / An Institutional Unit
The New Division of Cancer Prevention: Defining Its Scope
Chapter 11 / Building the Institution
Expanding the Scope of Cancer Prevention
Chapter 12 / Building the Institution
Cancer Prevention: Expanding into New Departments and Programs
Chapter 13 / Building the Institution
Expanding the Division of Cancer Prevention, Funding Sources, and Public Awareness
Chapter 14 / Building the Institution
The Culture of the Division and Its Impact
Chapter 15 / An Institutional Unit
Interview Session Two: 8 February 2013
Leading a New Division and Lessons Learned
Chapter 16 / An Institutional Unit
The MD Anderson Presidents
Chapter 17 / Key MD Anderson Figures
Strategies to Build Public Awareness of Colorectal Cancer
Chapter 19 / The Administrator
Leading the Section of Gastrointestinal Oncology
Chapter 20 / An Institutional Unit
Service to National and International Organization and a Small Cancer Center
Chapter 21 / Professional Service beyond MD Anderson
The Division of Cancer Prevention, Awards, and an Active Retirement
Chapter 22 / View on Career and Accomplishments
Interview Session Three: 31 May 2013
Developing Training Opportunities in Gastroenterology
Chapter 23 / Building the Institution
Early Research; Research Blocked at MD Anderson
Chapter 24 / The Researcher
The Celebrex – Colon Cancer Study
Chapter 25 / The Researcher
Interview Session Four: 8 July 2013
Chemoprevention and the Celebrex Study: Some Background
Chapter 26 / The Researcher
A Study of Colorectal Cancer in Egypt
Chapter 27 / The Researcher
The Portable Infusion Pump: Some Background on Intra-arterial Therapy
Chapter 28 / The Researcher
Interview Session Five: 27 August 2013
Work on Ulcerative Colitis and A Growing Interest in High-Risk Patients
Chapter 29 / The Researcher
The Intra-Arterial Therapy Pump
Chapter 30 / The Researcher
Combination Treatments and the Value of Collaboration
Chapter 31 / The Researcher
Occult Blood Testing and Public Awareness of Colorectal Cancer
Chapter 32 / The Researcher
Congressional Testimony about Colorectal Cancer Screening, The Economics of Testing, and Public Awareness
Segment 33 / The Administrator
Advocating for Chemoprevention, Lifestyle Changes and Cancer Prevention
Chapter 34 / The Administrator
The GI Tumor Study Group and the Early Detection Research Network
Chapter 35 / The Administrator
Interview Session Six: 28 August 2013
An Interest in Biomarkers Spurs the Creation of the Early Detection Research Network and Its Services
Chapter 36 / The Researcher
The Future of Cancer Prevention
Chapter 38 / Overview
Interview Identifier (listen/read)
Chapter 01 (Personal Background)
Family and Politics in South Africa (listen/read)
In this segment, Dr. Levin sketches his family life and the significance of South Africa’s apartheid system in his formative years. His parents owned a store and greatly valued education, encouraging both him and his brother, who went on to a distinguished career in nephrology and served as role model and mentor over the years. Dr. Levin notes that he “discovered he had a caring soul” in high school, considering both veterinary medicine and human medicine as professions. He also made up his mind very early that he would leave South Africa because of the political situation and apartheid. Dr. Levin notes that he went to a de-segregated medical school, but even there saw the effects of apartheid. He describes the effects, socially, and explains that any attempts to break barriers between the races was dangerous. Dr. Levin served as president of the student organization at his medical school and also as secretary of the Medical Students of South Africa, making statements against apartheid in both organizations. However, he had a “dire view” of the future that convinced him he would leave the country at some point.
Chapter 02 (Educational Path)
Medical Training in South Africa (listen/read)
Dr. Levin explains that medical training takes six years in South Africa. He describes the curriculum that was geared to building clinical competence. He also talks about his brother, Nathan Levin, who was a pioneer of dialysis. Dr. Levin’s brother took him to witness dialysis procedures and also brought him to his laboratory, where he was measuring renal function and manganese metabolism. Dr. Levin explains that he was frustrated, at the time, because he was drawn to thinking along linear and precise scientific lines, but clinical medicine was very imprecise. Under the tutelage of some mentors, he began to refine his clinical skills, using his senses and intuition to discover patient conditions and then putting that information into a coherent and logical frame of reference that could be used to make therapeutic decisions. During his medical training and residency, Dr. Levin worked in county hospitals and saw African patients with “textbook illnesses.”
Dr. Levin describes how, as a medical student, he founded a free clinic in Johannesburg that catered to served mulatto patients underserved by the medical community under South Africa’s apartheid system. He also sought out other experiences with the underserved, working at an Anglican Mission in Zululand and at the Charles Johnson Memorial Hospital, where he has additional exposure to African patients who had never had any medical care.
Dr. Levin speaks more about the apartheid system and its inhumanity; the South African practice of moving entire villages but not providing any services; the conditions of Africans who had never received any medical care; the struggle of clinics that had no blood products trying to treat stab wounds.
Chapter 03 (Professional Path)
Coming to the United States for Further Training (listen/read)
Here Dr. Levin describes the process of coming to the United States in 1966 for further training. Dr. Levin’s b brother, Nathan Levin, was already at Rush Saint Luke’s in Chicago, Illinois and he brought Dr. Levin’s name to the attention of a member of the administration to sponsor him as a resident. Dr. Levin emphasizes that came to the U.S. as an immigrant, not on a student visa. He describes many of the difficulties connected with that process. Dr. Levin first did a residency at Rush-Presbyterian-St. Luke’s Medical Center, then did another at Northwestern, where he worked at the Passavant Memorial Hospital on Chicago’s Gold Coast. Dr. Levin describes the differences between those wealthy patients and those he has served in South Africa and notes that he made efforts to see the real medical problems of Chicago through work in clinics.
Chapter 04 (Character and Personal Philosophy)
A Political Conscience (listen/read)
Dr. Levin discusses the political climate of the late sixties and seventies in the U.S. and how this effected his thinking. He recalls the activities of the Black Panther movement, human rights activists, and the role of such formative people as Dr. Quentin Young, from Chicago, who advocated for medical care as a free right for everyone. Dr. Levin also recalls that he was subject to the draft for the Vietnam War because of his immigrant visa status, and describes how he was “battered by the process” of seeing his status shift from 1A on one day to 4A the next. He speaks briefly about the Vietnam War and says that he recently traveled to Vietnam and visited the museum documenting the War’s devastating effects.
Chapter 05 (Professional Path)
An Interest in Malignancy (listen/read)
Dr. Levin explains that his focus on gastroenterology, and specifically his interest in ulcerative colitis, led to his interest in cancer as the disease was associated with colitis. In this segment he reviews a number of people who influenced his direction. Dr. Levin wrote a large grant to study the relationship of the two diseases. With this grant (administered by John E. Ultmann, another mentor), his interest in malignancy began. At the time, there was a void in this area. Ultmann advised him to “Learn everything you can about colon cancer and you can make a mark in this field.” Dr. Levin notes that was recruited to MD Anderson in ’84 to head the new section of Gastrointestinal Oncology. Dr. Levin was recruited to the Section of Gastroenterology (as Assistant Professor, then Professor) at the University of Chicago School of Medicine in 1972. He saw a lot of GI cancer and his involvement in oncology evolved. In his role as Director of the Gastrointestinal Oncology Clinic, he traveled to other clinics such as the Mayo Clinic, Memorial Sloan Kettering, and Roswell Park to see how they put together multidisciplinary services.
Chapter 06 (The Researcher)
An Interest in Clinical Trials, Design of Research, and Government Oversight (listen/read)
In this segment, Dr. Levin explains how his interest in clinical trials evolved, as well as his understanding of the issues involved in running such trials. He describes a trial run with a drug provided by a philanthropist who had imported the drug from Russia. He received a call from the NCI, who informed him they were taking over the trial. He quickly learned that clinical oncology trials have to be carefully monitored for safety. He briefly describes trials and collaborations he undertook to study liver cancer. In this segment, Dr. Levin talks about the design of clinical trials.
Chapter 07 (The Administrator)
The Challenges of Creating a Multi-Disciplinary Section of Gastro-Intestinal Medical Oncology (listen/read)
Dr. Levin recalls that he first began thinking seriously about coming to Houston in 1982, though he had been approached by John Stroehlein [Oral History Interview] as early as 1979. When Irving Krakoff was appointed head of Medical Oncology, Dr. Levin was invited to consider the position as Section Chief of Gastro-Intestinal Medical Oncology. His aim would be to develop a multi-disciplinary service in which gastroenterologists would work alongside medical oncologists as well as a broad range of specialties. Dr. Levin next describes some of the challenges of creating the multidisciplinary environment, including the physical limitations of Station 14 (the GI Clinic). In addition, some faculty viewed Dr. Levin’s work with intra-arterial therapy as threatening to their specialties. Dr. Levin next talks about the institutional controversy over conducting clinical trials.
Dr. Levin next explains that he was “ambitious for Gastro-Intestinal Oncology.” He reflects back on the institutional factors that limited his work at the University of Chicago, noting that at MD Anderson he saw a chance to expand Gastrointestinal and Medical Oncology. He discusses how his goals dovetailed with those of Dr. Charles LeMaistre [Oral History Interview]. Dr. Levin was originally hired with the mission of managing and treating gastrointestinal malignancies, but he believed it would be better to prevent them altogether. Dr. Levin then lists the individuals with whom he began to collaborate on this project. He ends this session with some comments about early discussions of establishing a cancer prevention program at MD Anderson, including a colorectal cancer screening project run in collaboration with Smith Kline.
Chapter 08 (Personal Background)
Mentoring and Research (listen/read)
Dr. Levin briefly speaks about the role of a mentor and how his brother, Nathan, served as a mentor for him. He then tells a story about receiving a call from Burt Vogelstein at Johns Hopkins University regarding work on cytogenetics.
Chapter 09 (Building the Institution)
Challenges to the Division of Cancer Prevention (listen/read)
Dr. Levin begins this segment with a brief history of Dr. Charles LeMaistre’s [Oral History Interview] interest in cancer prevention. He notes that MD Anderson’s external review committee produced a white paper stating that prevention is important and should be part of a cancer center. Immediately, Dr. Levin and others began to anticipate political opposition among clinicians to any such initiative. He describes investigating what was involved and also the process by which he was identified as an interim head of the new division as three external candidates were considered for the role. Each of them turned down the position, leaving the role open for Dr. Levin. He then describes how his perspective began to shift and he saw prevention as a very significant undertaking.
Chapter 10 (An Institutional Unit)
The New Division of Cancer Prevention (and Questions about Whether It Should Exist) (listen/read)
Dr. Levin first lists the departments included in the new Division of Cancer Prevention and the key individuals first involved. During the first two to four years, there was a great deal of interest in the institution in chemoprevention. Dr. Levin notes that, in this context, he saw the Division’s role as a platform and resource, not as taking “ownership” over prevention at MD Anderson. Political issues continued to surface, as individuals continued to question whether the Division should even exist. Dr. Levin explains acknowledges his lack of specific training in prevention and his strategy of recruiting to supplement those gaps. He also evaluates his hiring and firing decisions, considering how well his recruitments set the Division on a strong path.
Chapter 11 (Building the Institution)
The New Division of Cancer Prevention: Defining Its Scope (listen/read)
Dr. Levin explains some debates about the areas to be included in “prevention.” He then talks about recruiting Dr. Ellen Gritz [Oral History Interview] as the head of the new Department of Behavioral Science (in ‘95/’96). Dr. Levin explains that he had high-level administrative support for all his projects. He talks about the establishing of the Program in Translational Research, the Clinical Prevention Center. The Division received an even greater boost after the arrival of John Mendelsohn in ’96. Dr. Mendelsohn became a champion of prevention; he also changed the reporting structure and revised Dr. Levin’s role to Division Head, rather than Vice President. Dr. Levin explains that Dr. Mendelsohn used his fundraising abilities to build support among the Board of Visitors
Chapter 12 (Building the Institution)
Expanding the Scope of Cancer Prevention (listen/read)
Dr. Levin explains that the impetus for the new cancer prevention building arose when more space was needed for the Departments and clinics. The new building has afforded good office space and spacious labs for behavioral research. Dr. Levin also explains that because MD Anderson sees high risk patients, the institution cannot itself generate enough subjects to feed all of the different types of studies conducted on prevention. He then turns to funding issues and talks about how Texas limits on reimbursements for screening procedures has in turn limited the patients who can participate in studies. He notes the institutions that have failed at attempts to set up cancer screening programs.
Dr. Levin explains an initiative spearheaded by Paul M. Cinciripini, Ph.D. in the Behavioral Research and Treatment: Dr. Cinciripini was a pioneer in making a referral to a tobacco addiction specialist automatic for any MD Anderson patient who smokes. This is all paid for by MD Anderson.
Dr. Levin then talks about work done by Ellen Gritz on HIV AIDS and by Lovell Jones in the Center for Research and Minority Health, and David Wetter in the Department of Health Disparities Research.
Dr. Levin describes the lifestyle factors that have an powerful impact on individuals’ health and susceptibility to developing cancer: no access to parks, exercise, good food. He also mentions the power of advertising to promote unhealthy behaviors, noting that the risk for cancer is a combination of behavioral and epidemiological factors.
Next, Dr. Levin outlines the three aims of prevention with respect to smoking. Smoking prevention is a primary aim, followed by the secondary aim of the early detection of cancer and predispositions to determine individuals at risk. The third aim is to minimize harm in those who already have cancer, largely via irradiation of the head and neck. [The recorder is paused for 5 minutes as Dr. Levin takes a phone call.]
Dr. Levin explains that medical oncologists are often too busy addressing cancer to do adequate survivorship follow-up and so the Division of Cancer Prevention took on that role.
Chapter 13 (Building the Institution)
Cancer Prevention: Expanding into New Departments and Programs (listen/read)
Dr. Levin begins this segment by explaining how he built the case to include population sciences, health disparities research, and minority health in cancer prevention, despite controversy. He notes that Dr. Andrew von Eschenbach was a great supporter. He then discussed the Cancer Prevention Education Fellowship, noting the administrators involved, funding sources, and the numbers of fellows in the early years. He also talks about the Tobacco Treatment Program and the program in Professional Education for Early Detection, noting the missions of these initiatives and the individuals involved.
Chapter 14 (Building the Institution)
Expanding the Division of Cancer Prevention, Funding Sources, and Public Awareness (listen/read)
Dr. Levin explains how both state funds and philanthropy (via the Development Office) support faculty and initiatives in the Division, then talks about the important of raising public awareness for prevention. He explains some of the history of colorectal cancer screening, notes his own work in the area, and Katie Kouric’s role as a much-needed a public champion. Dr. Levin then talks about John Mendelsohn’s development activities, explaining that Prevention sent teams of people with Dr. Mendelsohn to speak to potential donors about key elements of prevention.
Dr. Levin notes that the Division has relied heavily on philanthropy to move projects ahead. For example, donated funds allowed the Division to purchase a computer to run population analyses.
Dr. Levin ends this segment with observations about why he was unable to start a Department of Health Services Research and comments on the search for his successor.
Chapter 15 (An Institutional Unit)
The Culture of the Division and Its Impact (listen/read)
Dr. Levin explains that during his tenure as Vice President and Head, the Division of Cancer Prevention was a loosely defined entity, but one characterized by a spirit of discovery and a commitment to application of knowledge. He then talks about what is left to be done.
Dr. Levin discusses the impact of the Division and what has contributed to its success.
Dr. Levin responds to the observation that many believe that physicians and institutions do not support prevention because it will put cancer institutions out of business, ending with the comment, “That’s my dream.”
Dr. Levin explains that “cancers survive because they are smarter than we are,” but the many tools included in prevention can help make the disease controllable and turn it into a chronic rather than a deadly disease.
Dr. Levin makes final comments on the notion that cancer can be ‘curable.’
Interview Session Two: 8 February 2013 (listen/read)
Interview Identifier (listen/read)
Chapter 16 (An Institutional Unit)
Leading a New Division and Lessons Learned (listen/read)
In this segment, Dr. Levin talks about some Division of Cancer Prevention initiatives and makes observations on leading a new and evolving division. He first describes the contributions that Dr. Alvin Tarlov, who specializes in the social determinants of health and helped the Division of Cancer Prevention think through the rationale for a Department of Health Disparities Research. He then talks about examples of Division research translating into interventions for patient care and health. Dr. Levin assesses what was achieved between ’92 and 2007, a period of great growth into virtually a new area and how role of a comprehensive cancer center evolved.
Dr. Levin discusses what he learned about leadership during his years as head of the Division of Cancer Prevention, then comments on the vast resources available throughout the Texas Medical Center and other institutions that have furthered work on cancer prevention.
Dr. Levin next characterizes himself as an ambitious leader, noting that he needed to come up top speed on the subject of cancer prevention and relied heavily on peer experts. He also praises the support that the Legislature and the institution’s administration gave the Division of Cancer Prevention. Dr. Levin then talks about the specific challenge of simultaneously mastering a field and developing a new institutional division from scratch, a situation he describes as “novel, if not unique.”
Chapter 17 (Key MD Anderson Figures)
The MD Anderson Presidents (listen/read)
Dr. Levin begins this segment by reflecting on R. Lee Clark’s “prophetic leadership” of MD Anderson, noting that his time in Paris gave him a world view that gave rise to the Global Education Program. Dr. Levin notes that he met Dr. Clark and became friends with him. (Dr. Levin notes Dr. Clark’s charm as well as his poor taste in restaurants.) Dr. Levin then characterizes Dr. Charles LeMaistre [Oral History Interview], with his broad view of education and historic participation in the first Surgeon General’s report on cancer. He then describes his vision for MD Anderson, his occasional lack of crisp decisiveness, and his difficult involvement with Enron. He then compares the leadership styles of Dr. LeMaistre and Dr. Frederick Becker [Oral History Interview].
Dr. Levin next talks about Dr. John Mendelsohn, who became a strong ally of cancer prevention within the first year of his presidency. He talks about questioning mind and global vision of cancer that Dr. Mendelsohn brought to the institution, as well as a new management style patterned after business. He reviews what Dr. Mendelsohn and his wife, Anne, were able to accomplish through their strong connections within the community and around the country and world. Dr. Levin then reflects briefly on Dr. DePinho, saying that it is too early to draw any conclusions about the lasting impact he will leave on the institution; he notes he will reserve judgment about the Moon Shots Program, as well.
Chapter 18 (Overview)
Conflict of Interest, MD Anderson Leadership, and Protection for the Institution and Patients (listen/read)
Dr. Levin reflects on conflicts of interest (which have plagued three of the four MD Anderson presidents), taking first the perspective of a patient and then the viewpoint of the faculty. Patients, Dr. Levin says, must know there is not financial motive behind their treatment, though that does not necessarily mean that innovative and productive individuals have no connections to the pharmaceutical industry. He then observes that the average faculty member or employee must also be protected so his/her choices of research/clinical approach or equipment are only governed by pure motives. Transparency is fundamental to these matters, and academic leaders will increasingly have connections to biotech companies, but there must be mechanisms, such as blind trusts, for insuring that these links do not govern day to day decisions. He notes that he would not want to see the presidents sitting on decision-making boards of biotech companies and that there must be a mechanism for top administrators moving into different roles within MD Anderson, should their external responsibilities reach a certain point. Dr. Levin closes this segment with some observations about nepotism.
Chapter 19 (The Administrator)
Strategies to Build Public Awareness of Colorectal Cancer (listen/read)
In this segment, Dr. Levin talks about his role as a public representative of MD Anderson, the Division of Cancer Prevention, and colorectal cancer awareness. He mentions that MD Anderson provided him with training for television appearances and also notes that the Department of Public Affairs “embraced cancer prevention,” which was seen as a strong promotion point for the institution. He also mentions his appearance on the Today Show with Katie Kouric and other cancer prevention specialists to increase awareness of colorectal cancer. He says that after that appearance, MD Anderson saw an increase in requests for information about colorectal cancer screening. He also mentions that when Katie Kouric publicly announced her own colonoscopy, there was a measurable increase nationwide in requests for this screening procedure known as “the Kouric Effect.” He mentions the ways in which Public Affairs creatively used these public appearances at Board of Visitor meetings and other situations to advance the cause of cancer preventions.
Dr. Levin talks about what he learned about leadership from his appearances on television and at other public events. He also talks about his admiration for Katie Kouric and her ability to overcome hardship and make a national difference for cancer prevention.
Chapter 20 (An Institutional Unit)
Leading the Section of Gastrointestinal Oncology (listen/read)
[Because of a recorder malfunction, some material is lost.] Dr. Levin speaks about his role in establishing the Section of Gastrointestinal Oncology. He speaks about the his dream of creating a multi-disciplinary service by recruiting younger gastroenterologists interested in medical oncology, then explains some of the practical limitations that impeded movement to that goal at the time. He felt that sharing and communicating about patient care across disciplines would move the field forward. He mentions the linkages he built between MD Anderson and the UT Health Sciences Center to expose fellows to the full array of oncologic problems.
Summary of lost material:
Dr. Levin looks at the period when the Section transitioned to a new status as a Department, evaluating what he might have done differently in his role as outgoing head. He describes MD Anderson was reorganized, with departments splitting into a variety of medical specialties; with gastroenterology becoming part of the Division of Medicine, as that split from Medical Oncology. Dr. Levin saw this as a natural evolution that “emboldened” individuals to develop valuable skills and interests. He evaluates his own contributions to this shifting structure: he “straddled the fence,” in his words, developing skills in oncology and patient treatment as well as the laboratory and he understood the language and motivations of many different communities in the institution. He explains that his “one unfulfilled dream” was that he was not able to establish a Houston-wide fellowship training program that would enable fellows to work at many different institutions in the city.
[Note, recorder malfunction at end of segment at explanation of what this training program would provide.]
Chapter 21 (Professional Service beyond MD Anderson)
Service to National and International Organization and a Small Cancer Center (listen/read)
In this segment, Dr. Levin describes his service on various national and international organizations. He begins by describing the structure, mission, and funding of the World Gastroenterology Organization and briefly explains the value of bringing together professionals who can compare notes on how training and patient care are approached in regions around the world with very different resources. He describes how funding for this organization began to dry up, at which point he was invited to Chair the first Foundation that would continue the work of the WGO, specifically funding training programs around the world. He doesn’t feel he was effective as a fundraiser and glad to hand the job over to Haman Quigley from Cork after four years. He explains that the organization has online materials, thirteen training centers around the world and “Teach the Trainers” session held regularly to train gastroenterologists around the world.
Dr. Levin then talks about his role as president of the Society of Gastrointestinal Carcinogenesis, describing the focus of the organization and the reality that a lack of resources limits its activities. Next, he briefly describes his role on the American Cancer Society Task Force as well as his service, in 2008, as interim Director of the Vermont Cancer Center.
[NOTE: there is a period of silence here while Dr. Levin takes a call and the recorder remains running.]
Chapter 22 (View on Career and Accomplishments)
The Division of Cancer Prevention, Awards, and an Active Retirement (listen/read)
In this segment, Dr. Levin first talks about the importance of receiving the Charles LeMaistre Outstanding Achievement Award and the American Society of Clinical Oncology Award for Cancer Prevention. He then talks about the Betty B. Marcus Chair that was created for him.
[The recorder failed during Dr. Levin’s reflections on receiving honors/awards.]
Dr. Levin next explains how pleased that the paradigm for cancer prevention at MD Anderson has been established, with new people pushing the field ahead. He wishes that he could have had more of an impact on inefficiencies and overutilization of clinical resources at MD Anderson. He observes that new blood in leadership is important, and that it is a mistake for leaders to stay in any position for more than ten years.
Dr. Levin then lists the professional organizations he continues to participate with and notes his role in colorectal screening activities in New York City by way of the C-5 Coalition (he is on the steering committee). He serves on advisory boards for companies that screen for colorectal cancer and as still assistant editor of the Journal of the National Cancer Institute. He enjoys the cultural activities in New York City and the beauty of the region.
Dr. Levin says how grateful he is to MD Anderson for his opportunities, his colleagues, and the institution’s leaders.
Interview Session Three: 31 May 2013 (listen/read)
Interview Identifier (listen/read)
Chapter 23 (Building the Institution)
Developing Training Opportunities in Gastroenterology (listen/read)
In a continuation of the discussion of the fellowship in the Department of Gastroenterology (see Chapter 21) Dr. Levin first talks about the existing fellowship program run in collaboration with the Medical School and the fact that there needed to be more input from MD Anderson faculty. Dr. Levin brought in more faculty to broaden the scope of the program, however it could not be sufficiently developed because of lack of good will from people in other programs. He notes that there were discussions about setting up a fellowship program with the University of Texas Medical Branch in Galveston, but this was never developed. Dr. Levin next notes that he was head of the combined Gastroenterology and Medical Oncology program and he describes how the two faculties have different foci and roles. A training program for gastroenterology people will involve principles of early detection, prevention, and the management of the disease.
Dr. Levin notes that in 1994, when he became Vice President of Cancer Prevention, he substantially expanded the fellowship program with NIH support given to Dr. Robert Chamberlain. Dr. Levin explains that this was a nationally competitive program in which fellows were very deliberately mentored by chosen faculty. He discusses the content of the training, and observes that fellows went on to become very successful academics. He also mentions that he received funds from a patient, to train international students.
Chapter 24 (The Researcher)
Early Research; Research Blocked at MD Anderson (listen/read)
Dr. Levin explains that his research path began when he received a grant (during his post-doctoral fellowship at the University of Chicago) to study the effect of drugs on liver cells (but stopped working on this area). He describes his next research arethe effects of fatty acids on the walls of yeast cells. He explains the research question he was working on and the challenges. He also looked at the effect of fatty acids on the respiratory components of mitochondrial enzymes in normal cells. Dr. Levin notes that he was unable to complete this work as a post-doctoral fellow, and it was completed by another of Dr. Goetz’s fellows.
Dr. Levin next takes up his interest in cancer, with a specific focus on genetic changes in colon cancer cells. He explains his work on large adenomas and that support from the Melamid Foundation enabled him to equip a small lab. Though he published on this work, he was unable to draw many conclusions. In addition, when he was offered a position at MD Anderson, he was unable to move this work.
Dr. Levin next talks about his interest in the treatment of metastatic colon cancer using an infusion pump invented by Dr. Bill Ensigner. Dr. Levin explains that he wanted to bring this work to MD Anderson. He had received a multi-institution RO1 and wanted to conduct a randomized trial, but investigators at MD Anderson blocked it because of internal controversies about such studies. Dr. Levin explains the environment of debate and also considered what might have been done to work to a positive outcome.
Chapter 25 (The Researcher)
The Celebrex – Colon Cancer Study (listen/read)
Dr. Levin next discusses a famous study in which he took part: the study of celecoxib (Celebrex) on polyps and ademonas of the colon. He explains how the study originated when an Israeli colleague approached him in the late 90s to be part of a large-scale, international trail based on original work conducted by MD Anderson scientist, Dr. Ray Dubois. Dr. Levin explains Dr. Dubois’ discovery that aspirin inhibited the overexpression of cyclooxygenase 1 (which can lead to a proliferation of cells). The study in which Dr. Levin took part had over 1500 patients: he organized the studies and quality control. Dr. Levin explains that the study was going very well until a sister study by the NIH linked celecoxib to an increased risk of myocardial infarction. Though celecoxib was shown to reduce adenoma formation by thirty to forty percent, both studies were immediately halted. At the end of this segment, Dr. Levin discusses special uses of celecoxib.
Interview Session Four: 8 July 2013 (listen/read)
Interview Identifier (listen/read)
Chapter 26 (The Researcher)
Chemoprevention and the Celebrex Study: Some Background (listen/read)
Dr. Levin sketches the work on which his studies of Celebrex and colorectal cancer were based. This study was based on the idea that pharmaceutical agents, when taken regularly, might influence the formation of lesions in the colon. Work by Dr. Gideon Steinbock (at MD Anderson) had provided early evidence that Celebrex could influence inherited cancers, leading to the study of the drug’s influence on un-inherited carcinomas. Dr. Levin lists the studies and participants. He then notes that the discovery that Celebrex caused heart problems put a damper on research into chemo prevention in colon cancer and all cancers, shifting the emphasis to safety above all else when dealing with healthy patients. He notes that in the early 90s, the discussion focused on how to approach preventative measures, concluding that risks to a healthy patient must be very low in order to undertake chemo-preventative measures. He briefly discusses a peer review group from Pfizer and the NCI which added to the sense of caution about chemo-prevention.
Chapter 27 (The Researcher)
A Study of Colorectal Cancer in Egypt (listen/read)
In this segment Dr. Levin discusses a study of colorectal cancer among young people in Egypt. As background, he explains that Dr. Palmer Beasley, Dean of the University of Texas School of Public Health, was conducting studies that would prove that the Hepatitis B vaccine with reduce cancer. When he was invited to Egypt to speak about these findings, he was told about the high incidence of colorectal cancer among individuals under 50 years of age and passed this information on to Dr. Levin, who went to Egypt to confirm the observation. Dr. Levin notes that it is rare to find young people with advanced colorectal cancer. He explains some possible reasons for the rarity and then explains his interest in cataloguing the young Egyptians with the disease and conducting epidemiological studies. He lists the other investigators involved and explains the multiple approaches taken to come up with explanations for the high incidence (eg. exposure to DDT, toxins in water, consanguinity), though no definitive cause was ever determined. Dr. Levin and the other researchers also found an increased incidence of pancreatic cancer in the Nile Delta. His studies began in Egypt in the late 90s, peaking in 2003, by which time it was clear that colorectal cancer was becoming more common around the world –in the Far East and even in the U.S.
Dr. Levin comments on the challenging process of doing research in a developing country and notes that he met very dedicated surgeons and pathologists working in Cairo. He also comments on the value of doing such research overseas, which is consistent with his personal commitment to global health. He notes how important it is to sort out the ethical issues to prevent any possibility for exploitation. Dr. Levin discusses the benefits the Egyptians received from the study. In particular, he notes that the Egyptian scientists and statisticians were able to participate in a very high-level study.
Chapter 28 (The Researcher)
The Portable Infusion Pump: Some Background on Intra-arterial Therapy (listen/read)
Dr. Levin sketches the beginnings of intra-arterial therapy, noting that there was no good systemic therapy for colorectal cancer that had spread to the liver. 5-Fluorouracil had been studied, and researchers at MD Anderson and other institutions were interested in delivery high doses of drugs, such as floxuridine (FUDR) to the liver by placing a catheter in the hepatic artery. Dr. Levin sketches the technical problems with this, noting that this method was a precursor to the design of a portable infusion pump.
[Technical problems with the audio recording are briefly discussed and the interview is terminated, to be resumed in another session.]
Interview Session Five: 27 August 2013 (listen/read)
Interview Identifier (listen/read)
Chapter 29 (The Researcher)
Work on Ulcerative Colitis and A Growing Interest in High-Risk Patients (listen/read)
Dr. Levin begins this segment by recalling that his interest in high-risk patients began with his work with his mentor at the University of Chicago, Dr. Kirsner, who was interested in the relationship between ulcerative colitis and colon cancer. Dr. Levin set up a very fruitful study (between 1977 and 1983), taking random biopsies in four segments of the colon to find displasias. (It turned out that the patient pool included mostly moderate risk individuals.) He explains that the methods of study available were not sophisticated in comparison to today’s technologies. He explains the weaknesses of the study, its findings, what could have been learned with more sophisticated approaches, and the lessons learned from this experience. Dr. Levin also notes that even though this study did not provide “robust conclusions,” it laid the groundwork for later work on the relationship between dysplasia and cancer. He also defines dysplasia as an abnormality in cellular and tissue architecture that can lead to pre-cancerous conditions.
Dr. Levin emphasizes that this work strengthened his interest in high-risk patients and he believed that this kind of study to lead to greater understanding of colorectal cancer, work he continued when he came to MD Anderson, when he began to study Lynch Syndrome (hereditary nonpolyposis colorectal cancer). He explains that this work was enhanced when he was able to recruit Patrick Lynch and Bruce Boman, both experts in high-risk individuals. Dr. Boman started to DIFI cell line with a high expression of epithelial growth factor (used eventually by Dr. John Mendelsohn in studies leading to discovery of monoclonal antibody 225). Dr. Levin describes the support he provided both researchers in his capacity as Department Chair.
Chapter 30 (The Researcher)
The Intra-Arterial Therapy Pump (listen/read)
Dr. Levin explains that there was a void in studying the treatment of advanced GI cancer when he began his career, and he stepped in to fill this need despite (discouraging advice from mentors) and wanted to set up multi-disciplinary teams to treat patients. He then speaks about the problem of managing people with metastatic colon cancer in the liver. The drug available at the time, 5 Flourouracil, had low response rates. A derivate, FUDR, could be delivered via catheter into the liver: Dr. Levin sketches the disadvantages of the drug and the methods, then goes on to explain that William Ensinger developed the concept of the portable infusion pump that could be inserted under the skin of the abdomen, a technique that aroused the interest of Dr. Levin and his colleagues at the University of Chicago. He narrates the story of going to Ann Arbor, Michigan, so see the pump inserted and coming back to Chicago to use the method. Dr. Levin explains that evidence of toxicity made it necessary to conduct a multi-center study of the device. In 1984 he was awarded an RO1 to administer a large study that would pool the data. He explains the negative attitude at MD Anderson toward randomized studies, making it necessary for him to give up the grant. He explains that there is still controversy over the value of delivering drugs directly into the liver.
Chapter 31 (The Researcher)
Combination Treatments and the Value of Collaboration (listen/read)
Here Dr. Levin focuses on the study of combination approaches to gastrointestinal cancers –studies made possible because, by 1986-7, he had realized Dr. Krakoff’s goals of establishing a multi-disciplinary team of basic scientists, medical oncologists and others in the Department of Gastroenterology. Dr. Levin lists some of the people studying combination approaches via phase 1 and 2 programs and explains how he contributed. He also comments on the collaborative studies with the GI Tumor Study Group.
Dr. Levin explains that the milieu was very conducive to collaborative study. He then evaluates the multi-disciplinary environment he was able to create, exploiting the intra and inter-institutional affiliations of faculty members. He explains that he viewed the department as a nucleus for interdisciplinary research and tried to enhance the value of collaboration by making it part of the yearly evaluation process. He explains that collaboration was most successful for medical oncologists and basic scientists, not so successful for gastroenterologists. He explains where biases against collaborative research come from.
Dr. Levin then evaluates how he might have created a more collaborative environment if he had been successful in setting up the training program for gastroenterologists, in recruiting more senior gastroenterologists, and recruiting different basic scientists. He ends this segment with comments on the kinds of studies possible in the past. Researchers studied innovative approaches, but they were nothing like the targeted therapies of today. The treatment of advanced disease was “relatively futile,” but there were lessons to be learned about the value of both local and systemic treatments.
Chapter 32 (The Researcher)
Occult Blood Testing and Public Awareness of Colorectal Cancer (listen/read)
In this segment, Dr. Levin first talks about the large comparison of occult blood tests conducted by MD Anderson in the early eighties. He explains that he was aware of work done in the sixties to show that blood in the stools could be a sign of colon cancer. He was approached by a company to test the effectiveness of an occult blood test which would be distributed by pharmacies and mailed back to MD Anderson. Dr. Levin talks about the researchers involved and notes the collaboration of Public Affairs. (See also Steve Stuyck, Segment 8.) He talks about the outcome of the study, noting that the team never had the ability to follow up with patients. The study looked at the relative effectiveness of different types of tests and the potential interference of diet and medication. The results were published [Levin B, Hess K, Johnson C. Screening for colorectal cancer. A comparison of 3 fecal occult blood tests.
Archives of Internal Medicine. 1997 May 12;157(9):970-6] and Dr. Levin comments on the finding that providing evidence of an abnormality did not guarantee that patients and practitioners would act on the information.
This finding leads to a discussion of the challenges of creating public awareness of colorectal cancer and Dr. Levin sketches his activities in these areas. He talks about an event organized by Hilary Rodham Clinton at the White House in 1996 to raise awareness. He also notes Katie Kouric’s efforts, including her founding of the National Colorectal Cancer Alliance. He explains that the Alliance partnered with the Entertainment Industry Foundation to fund basic research, community outreach and community education and is still active. Dr. Levin’s study of occult blood tests was partially funded through this group. He makes some final comments on this study, which resulted in a model for predictors of risk.
Chapter 33 (The Administrator)
Congressional Testimony about Colorectal Cancer Screening, The Economics of Testing, and Public Awareness (listen/read)
Dr. Levin begins by explaining why he was selected to speak before Congress in support of Medicare coverage of screening for colorectal cancer (6 March 2000). He notes that he was prepped by people at the American Gastroenterological Association and worked with them on the script he read. The testimony had an impact and led to Medicare legislation to fund screening of colonoscopy and occult blood testing, though not of the double contrast barium enema which Dr. Levin believed should also be covered. He notes the change in public attitudes about screening: now about 60% of Americans get screened. He also explains why physicians are more likely to order a colonoscopy than an occult blood test, though the latter is much less expensive. He then discusses colonoscopy costs (relatively and sometimes unnecessarily high) and what is involved in providing a quality product for a reasonable charge. He notes the other tests that could be done to determine whether a patient needs a colonoscopy. Dr. Levin then explains why it might be difficult to increase the 60% number of Americans screened and notes that the most effective way to educate the public about screening is through a primary care physician or nurse.
Chapter 34 (The Administrator)
Advocating for Chemoprevention, Lifestyle Changes and Cancer Prevention (listen/read)
Dr. Levin begins by mentioning his support for the work of Dr. Michael Wargovich, PhD.on the chemopreventative effects of natural compounds related to garlic and derivative products. He explains that Dr. Waravick added a facet to the Department of Gastroenterology. He also notes that in animal models the sulfur compounds of the derivatives protect against colon cancer. He then talks about the Division of Cancer Prevention’s focus on lifestyle issues. The Division provided nutrition advice and assessment: he lists the people involved with studies of selenium and vitamin E derivatives. He touches on the importance of tobacco, another “ingested” compound, and the importance of physical activity. He notes the challenges to setting up studies of activity, as people needed to have cardiac monitors while exercising.
Dr. Levin then comments on diet, including his own ethically-based choice to be a vegetarian. He states his belief that attempts to isolate chemo-protective elements of diet will be fruitless. He cites the study of carotene, which harmed patients, as an example of how misguided it can be to insert nutrients into a diet. He advocates a moderate diet that can even include moderate amounts of meat and processed food.
Chapter 35 (The Administrator)
The GI Tumor Study Group and the Early Detection Research Network (listen/read)
Dr. Levin begins this segment with a discussion of the GI Tumor Study Group, beginning with the individuals who came together to form the group in the mid-seventies, when it became obvious that GI cancers did not receive enough attention. The study group formed under the auspices of the NCI’s Division of Cancer Treatment and Dr. Levin explains how they met to discuss potential studies to receive NCI funding. He sketches how the group ended in the early eighties.
Dr. Levin begins to talk about the Early Detection Research Network, formed in about 1981 under the Division of Cancer Prevention at the NCI to fund innovative ideas for early detection—the beginning of today’s understanding of the underlying genetic mechanisms of cancer. The Network also established the Goodman Research Conferences.
Interview Session Six: 28 August 2013 (listen/read)
Interview Identifier (listen/read)
Chapter 36 (The Researcher)
An Interest in Biomarkers Spurs the Creation of the Early Detection Research Network and Its Services (listen/read)
Dr. Levin begins this segment by noting that his interest in biomarkers began when he worked on a Johns Hopkins University study of oncogenes in stools. As further background, he notes that in the eighties he worked with a Philadelphia-based company studying the elevated levels of CA 19-9 in patients with pancreatic cancer. Through this work he attempted to establish a group of individuals around the country interested in biomarkers. He explains why interest waned and why interest in CA 19-9 also diminished. He notes that the ability to find genetic markers and identify cellular and biochemical mechanisms of cancer has come of age and that this has revived interest in early detection, prognosis and therapy. He recalls that when the Early Detection Research Network was established, it was viewed skeptically and funding waxed and waned, depending on the leadership of the NCI and its Division of Cancer Prevention. He also notes that, today, all component of the NCI are suffering financially. Nevertheless, there are more investigations into early detection and the EDRN continues to grow intellectually. He also says that the EDRN has created an “elegant infrastructure” of relationships with other organizations. It continues to amass samples and analyze them using statistical techniques developed by NASA’s Jet Propulsion Laboratories.
Dr. Levin then talks about the Gordon Conferences, created through the EDRN, explaining that it is a forum for scientists to gather and share research ideas in a very relaxed forum. He describes his own experience at the Gordon Conference as a graduate student.
Chapter 37 (The Administrator)
Founding the National Colorectal Cancer Roundtable; Service on the Colorectal Cancer Committee; Perspectives on Bias in Research (listen/read)
Dr. Levin begins with segment by describing how, in the late nineties, he talked with Robert Smith of the NCI about the need to create a forum to discuss activities related to screening. These talks resulted in the creation of the National Colorectal Cancer Roundtable in 1998. Dr. Levin and Dr. Smith co-chaired the Roundtable from 1998 to 2005 (when Dr. Levin stepped down). Dr. Levin talks about the organization and activities of the Roundtable, including the creation of the “Blue Star,” a lapel pin to indicate support for screening, and anti-discrimination support for people with hereditary cancer and for minorities.
Next Dr. Levin talks about his work as chair of the American Cancer Society’s Colorectal Cancer Committee from 2000 to 2008, particularly the Committee’s creation of a set of guidelines for managing patients with average risk for colorectal cancer. He explains the “precedent setting” group of organizations represented on the committee as well as the controversial nature of the guidelines published in 2008 after a year and a half of work. (Critics said that procedures outlined on the guidelines were influenced by the specialties of the individuals on the Committee.) The guidelines are still in existence, but are due for revision following a new procedure established by the Institute of Medicine. Dr. Levin explains this procedure, designed to eliminate professional bias from the process. At the end of this segment he explains how attitudes about professional bias in developing guidelines has changed over the past decade.
Chapter 38 (Overview)
The Future of Cancer Prevention (listen/read)
Dr. Levin begins this segment of final comments by stating how privileged he has been to know Lee Clark, Charles LeMaistre, and John Mendelsohn, each of whom brought important leadership to MD Anderson.
Dr. Levin then states that the future of cancer prevention is very promising. He offers the view that the treatment of cancer is very difficult and expensive, and so preventing cancer through lifestyle, nutrition and the avoidance of tobacco and alcohol is very important.
This interview with Bernard Levin, M.D. (b. Johannesburg, South Africa, April 1, 1942) takes place over six session in 2013 (approximately 10 hours total). Dr. Levin was recruited to MD Anderson in 1984 to join the faculty as a Professor of Medicine and to establish a new Section of Gastrointestinal Oncology. He served as Chair of the Department of Gastrointestinal Medical Oncology and Digestive Diseases until 1994 when he was appointed Vice President for Cancer Prevention and Population Sciences. From 1994 to 2007, when he retired, Dr. Levin also held the Betty B. Marcus Chair in Cancer Prevention. He now holds the title of Professor Emeritus and lives in New York City. The first three sessions take place in New York; the remainder takes place via telephone. Tacey A. Rosolowski, Ph.D. is the interviewer.
Dr. Levin was awarded his M.B., B.Ch. (the equivalent of the M.D.) from the University of Witwatersrand Medical School, Johannesburg, South Africa in 1964. In 1965 he undertook his internships in both surgery and medicine at Johannesburg General Hospital, University of Witwatersrand. He then emigrated to the United States, where he continued with a medical internship at Northwestern University Medical Center in Chicago, Illinois (’66). He did his Residency in Internal Medicine at the Rush-Presbyterian-St. Luke's Medical Center in Chicago (‘66 to ’68). Dr. Levin then held a USPHS Special Research Fellowship (National Institute of
General Medical Sciences) in the Department of Pathology at the University of Chicago (‘68-’71). From 1970-1971 he was a Clinical Fellow in Gastroenterology at the University of Chicago
Medical Center, then undertook an NIH Training Fellowship in Gastroenterology at that institution from ’71-’72. Dr. Levin then joined the faculty of the University of Chicago (‘72-’84). He was progressively Assistant Professor and then Associate Professor (with tenure) in the Section of Gastroenterology, Department of Medicine, and simultaneously held an appointment as Director of the Gastrointestinal Oncology Clinic. Prior to taking on the role as Vice President of the Division of Cancer Prevention, Dr. Levin’s research focused on identifying markers that enable early detection of colorectal cancer and the management of polyposis, as well as surgical adjuvant therapies and chemo-preventative treatments. As Vice President, he had an increasingly public role in raising awareness about prevention. In 1996, he was a guest speaker at the White House under the Clinton administration, discussing “New Efforts to Promote Colon Cancer Prevention”: he testified before Congress on screening initiatives in 2000. Dr. Levin has been widely honored, receiving the 2004 American Cancer Society Award from the American Society of Clinical Oncology (ASCO). That same year he received the American Society of Preventive Oncology Distinguished Achievement Award. In 2007, MD Anderson honored him with the Charles A. LeMaistre, MD Outstanding Achievement Award in Cancer.
In this interview Dr. Levin speaks about the early evolution of his interest in translational research, a commitment that enabled him to create multi-disciplinary connections as he assumed increasingly prominent administrative roles. He discusses many dimensions of leadership as he explains how MD Anderson created an entirely new dimension of the cancer center –the Division of Cancer Prevention—and what this new initiative has meant to the institution. He talks about his work setting up study groups that would stimulate work on gastrointestinal cancers and early screening –two voids in the field when entered. He also discusses his work stimulating public awareness of colorectal cancer. Ethical issues are also a recurring theme in this interview: Dr. Levin discusses the development of his political conscience in South Africa, as he observed the social and medical impact of apartheid. He offers views on social justice issues after coming to the United States in the sixties, and also comments on conflict of interest and nepotism that affect medical institutions.