Chapter 07: The Challenges of Creating a Multi-Disciplinary Section of Gastro-Intestinal Medical Oncology
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Description
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 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.
Identifier
LevinB_01_20130207_C07
Publication Date
2-7-2013
City
Houston, Texas
Interview Session
Bernard Levin, MD, Oral History Interview, February 07, 2013
Topics Covered
The Interview Subject's Story - The AdministratorProfessional Path The Administrator The Researcher MD Anderson History MD Anderson Culture Obstacles, Challenges Obstacles, Challenges Controversy Industry Partnerships
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Bernard Levin, MD:
I started being approached about coming to Houston probably in about ’79, maybe ’78 even. And John Stroehlein had asked me about that, because I had been part of the National Large Bowel Cancer Project, which at that time was run by Tony Mastromarino, who is a PhD, who was a very good administrator. And he had a dual role. He was both a faculty member, or an administrator, at MD Anderson and also had the Large Bowel Cancer Project. Murray Copeland, who was a retired surgeon, and Rulon Rawson, who was a retired endocrinologist, also figured prominently. And at that time, I was interviewed by R. Lee Clark, who was still at the height of his powers, and Bob Hickey, who was his executive vice president. And we debated various scenarios. There was a man whose name I forget now, who would have been recruited over John Stroehlein. He was a military officer in San Antonio and was getting out of the military and was possibly interested in coming to MD Anderson. John would have been his junior, and I would have been along at about John’s level. But those plans fell apart. I decided it wasn’t appropriate. Subsequently, Irwin Krakoff was appointed as the chair of what was called Medical Oncology in ’82 and invited me down to consider becoming Section Chief of Gastroenterology. My goal—by then John Stroehlein had moved to Baylor or Methodist. In coming there, my goal was to establish a multidisciplinary section of gastrointestinal oncology and digestive diseases.
Tacey Ann Rosolowski, PhD:
Now, wasn’t it the case that you created the section?
Bernard Levin, MD:
Yes, right. And my idea was to have gastroenterologists working alongside medical oncologists so that you would see the same illnesses and would be part of a multidisciplinary group that would eventually involve surgeons, radiologists and pathologists, and of course, nurses and social workers.
Tacey Ann Rosolowski, PhD:
How responsive was the MD Anderson community at that time to that kind of idea?
Bernard Levin, MD:
Krakoff [Irwin] was very responsive, and he was the reason I came. Others were interested, too. And I believe they were responsive. The physical circumstances were particularly challenging. It was called Station 14—you can see that was sort of a military designation. Station 14 was the GI clinic, which abutted on one of the rear entrances MD Anderson, or was close to it. And the air intake into part of the clinic was from the outside where waiting vans would discharge their exhaust fumes into the clinic. Patients were seen in rooms, but the doctor’s quarters were in the hallway. They had these standing benches where they would dictate, write orders, in a corridor. There was no actual office. And the endoscopy facilities were okay, were not awful, but they were small and cramped. In general, the facilities were not stellar. There was talk soon after I got there of building a new clinic facility. This eventually became something that my friend and colleague, David Hohn, who subsequently became president of Roswell Park, was deeply involved in. And we eventually moved into new offices and new clinic facilities. The offices came first and then the facilities later. And Waun Ki Hong, who’s still Chair of Medical Oncology, and I shared an office area having arrived at MD Anderson at around the same time in September ’84. Some of the old guard was not that happy with the fact that we received new facilities and particularly new offices. We were sort of a source of great envy. But I won’t forget easily that when I was thinking of coming, several individuals called me and were extraordinarily encouraging. Jordan Gutterman, who has remained on the faculty, I remember was particularly welcoming on the phone, and there were others. Dr. Hersh, [Evan] who was an immunologist, also was very welcoming to me. There were others who viewed my interest in intra-arterial therapy as threatening, because they felt that they had carved that area out at MD Anderson and weren’t particularly interested in a newcomer becoming involved. In fact, so much so that the RO1 that I referred to earlier was transferable to MD Anderson, but amongst certain members of the IRB, there was a belief that it was fairly complete, that this worked, so that doing a randomized controlled trial of intra-arterial therapy would not pass through the IRB, so it was blocked. So I lost the RO1 because certain members of the IRB, who I won’t name, decided that it was doomed.
Tacey Ann Rosolowski, PhD:
When I was talking to Gabriel Hortobagyi, we had quite a long conversation about the attitudes towards randomized clinical trials at MD Anderson around this time. And he also said that there was a philosophy at MD Anderson, which was kind of anti-randomized trial. Was this attitude towards your grant part of that, do you think? Or was it the competitive dimension that you were bringing something that they felt didn’t need to be studied further? Or was there a larger issue about randomized trials?
Bernard Levin, MD:
I think it was both. I think I ran into the obstacles because the IRB chair represented the old guard, who believed that, A, they had the proprietary right to conduct intra-arterial therapy, and B, that the issue was proven beyond the shadow of a doubt, and therefore, randomized controlled trial wasn’t appropriate. Some of this emanated from one of the leaders in hematology, who was against randomized controlled trials for various reasons. So there was kind of a thread of an academic discipline or training that had been established at MD Anderson that, I’m happy to say, subsequently disappeared. And Gabriel and many others had a strong influence on that.
Tacey Ann Rosolowski, PhD:
Can you name that individual?
Bernard Levin, MD:
Well, [Emil] J Freireich. He had a strong view about this.
Tacey Ann Rosolowski, PhD:
It did seem—Dr. [Gabriel] Hortobagyi kind of sketched a little bit of that history of how that attitude shifted. But his impression certainly was that it held back investigations that really needed to happen.
Bernard Levin, MD:
Right. Well, I think Krakoff’s coming and Waun Ki Hong’s coming all helped to shift that. I omitted to mention that there was one other very remarkable man at MD Anderson, who I can’t recall exactly when I interacted with him, but it was largely over the telephone, because when I actually first met him he was getting treatment for his testicular cancer. That was Jeff Gottlieb, who, I think, was encouraging to me in my first recruitment. He either died or had become mortally infirm by the time of my second recruitment. But Jeff was extremely positive about MD Anderson. He had a great sense of the future of oncology. He was actually, I think, a visionary man. It was very sad that the world lost him.
Tacey Ann Rosolowski, PhD:
Why did you, at that moment, choose to leave Chicago and choose to come to MD Anderson?
Bernard Levin, MD:
I was ambitious for gastrointestinal oncology. And I could see that, while the University of Chicago was and is a remarkable place of which I have undying admiration, this was likely to become too big and too parochial for them in a balanced world. The area of gastrointestinal oncology would overbalance either gastroenterology, because that’s not the main focus, or oncology, because that’s not the main focus, because it had a very strong background there in lung cancer, lymphomas, leukemias. Those were its great strengths. And there wasn’t a great deal of interest in gastrointestinal malignancy. I was also doing some research at the time—this is another sort of tangent—on cytogenetics of colon cancer. And I had received a grant through the Melamid Foundation. Mrs. Melamid is still alive, I believe. She is the daughter of an iinfluential family. Because I had been a physician to the Chicago Symphony—that’s not on my CV. But I was with them for a long time, actually, when they went on tour. So I had met a young man, Peter Jonas—he’s now Sir Peter Jonas—and had helped take care of him with John Ultmann and others. He had Hodgkin’s disease and was cured by treatment, both in Chicago and in London at Royal Marsden. And Peter’s aunt, Elizabeth Malamid, knew of my interest in cytogenetics and encouraged me to apply for a grant to her Foundation, established in her husband’s name. The competition was tough. It was actually from Memorial Sloan-Kettering. The applicant——president of Sloan-Kettering also submitted a grant request. But apparently, he didn’t take it as seriously as I took it, because he thought it was in the bag for him. Luckily, I received it. So I began studying cytogenetics of colon cancer in a very primitive way in retrospect. And I had a colleague, Amelia Reichman, who was an Argentinean, whom I had recruited. She was a physician, but she was interested in cytogenetics. And she learned the technology of cytogenetics. I tried to get some help at U. of Chicago with this. But again, it didn’t fit the mold. The most famous cytogeneticist there is Janet Rowley, who I hope will win a Nobel Prize one day. She’s eighty-seven now. She has made enormous contributions to the field of hematology, of leukemia. She’s a giant in the field. It wasn’t in her main area of interest. So I didn’t really—I couldn’t join anything that was in existence. We saw some other interesting findings in these cells that were probably abnormal pieces of DNA. Again, at the time the knowledge wasn’t sufficient to do much with them. So I didn’t see a real future for this work in Chicago, although we published a few papers on it. So I thought possibly moving to another institution might enable me to continue and have this work develop further. It didn’t, unfortunately. It sort of came to a full stop. But I saw at MD Anderson a chance to expand gastroenterology and GI oncology. I think Krakoff and I had a similar approach to things, and he accepted that. I was familiar with the institution. I was impressed by its vigor. I thought R. Lee Clark—I thought Dr. LeMaistre by then was an impressive figure.
Tacey Ann Rosolowski, PhD:
He, of course, also supported the great interest in cancer prevention at the institution. So in some of your conversations with Dr. LeMaistre, what sense did you get of his vision and how there was overlap between what you saw and what he did?
Bernard Levin, MD:
I can’t reasonably state that there was overlap. I think that when I came there the mission was relatively clear to manage and treat gastrointestinal malignancies. I became, at an early stage, imbued with the idea that it would be better to prevent these than treat them late. So early on, I began to interact with a group of individuals interested in colon cancer screening, including my friend and colleague, Sid Winawer at Memorial Sloan-Kettering, who is still very active and prominent in the field. And I was invited by him to some seminars that were being given by the makers of a test for blood in the stool, occult blood test. I became aware of methodology to find cancers early. At some point, I began my own study of this in Houston and set up a program to do occult blood testing in peripheral clinics.
Tacey Ann Rosolowski, PhD:
Why was it in peripheral clinics?
Bernard Levin, MD:
Because MD Anderson didn’t actually have a cohort of people who were interested in being screened. It wasn’t something that was—and this was done around the city of Houston at pharmacies in conjunction with Smith Kline, who made the occult blood test. Again, a little foreknowledge would have helped a lot. But we literally overwhelmed the institution with these cards that arrived in great big batches. These cards were stool tests. Just huge numbers arrived. We had to involve numerous volunteers. People from the Department of Pathology went crazy, because it had to be done officially through them.
Tacey Ann Rosolowski, PhD:
How many are we talking about?
Bernard Levin, MD:
Hundreds. I don’t know, thousands maybe. But serial stool tests. And I had a wonderful research nurse, Constance Johnson, who I’m pleased to say has gone through various careers and is now a faculty member with her own PhD in Health Information Sciences at Duke and with whom I’m still in touch, because we’ve just finished our last ever paper together, six years post-mature. So we literally—there was a saga of this stuff arriving at MD Anderson. There were rooms full of people putting this colorimetric agent—and it led to an important publication but it was—we had no idea what would actually happen.
Tacey Ann Rosolowski, PhD:
So how did that work? I mean, you went to these peripheral clinics. How did you get your participants?
Bernard Levin, MD:
You know, I’d have to think back. I’d have to look at the paper now. But Smith Kline helped set this up. And they already had done a trial in Houston. They had patients identified or physicians identified at centers who would enroll people in these efforts to screen for colon cancer.
Tacey Ann Rosolowski, PhD:
And what was Smith Kline providing to this?
Bernard Levin, MD:
They were providing funding. They were providing the cards. They were providing publicity.
Tacey Ann Rosolowski, PhD:
So they developed the screening technology.
Bernard Levin, MD:
They developed the screening technology. It was crude. It’s call guaiac. It’s a colorimetric test for the presence of hidden blood in the stool. It releases something called peroxidase, which splits the guaiac into a colored substance. It turns blue. You can imagine how rough that is.
Tacey Ann Rosolowski, PhD:
But it was something.
Bernard Levin, MD:
It was something. And subsequent studies—very well-randomized controlled trials done over a decade and a half have shown that it reduces cancer mortality in incidence. Not done by me, but by colleagues in Minnesota and Neewcastle,England—I mean, yes, Newcastle, and in Sweden.
Tacey Ann Rosolowski, PhD:
I just wanted to observe, because you had said you wanted to finish this at 11:30. Do we need to?
Bernard Levin, MD:
Yes, we have perhaps another five minutes. I have to run some errands. So this was part of the early exposure to prevention screening. It involved someone who was very important in my subsequent decision, and that’s the late Roger Winn. He was a very interesting man, a physician, a medical oncologist, who knew Krakoff very well and was recruited by him. He came from private practice in St. Barnabas Hospital in New Jersey to head I think what was a general oncology clinic. I’m not entirely sure. But Roger also became interested in prevention.
Tacey Ann Rosolowski, PhD:
And what was his role at MD Anderson?
Bernard Levin, MD:
He was—I think he was in general medical oncology. Subsequently, he became involved in clinical trials. He left MD Anderson rather abruptly. Unfortunately, he died of esophageal cancer very tragically. So Roger had a broad view of cancer. In fact, I will never forget a telephone discussion. He said, “There is talk of developing a cancer prevention program. Would you be interested in this?”
Tacey Ann Rosolowski, PhD:
And when did you have this conversation?
Bernard Levin, MD:
Probably in 1981 or ’82—excuse me, 1991 or 1992, probably 1991. Honestly, I knew very little then about what was involved. I vaguely could conceive of what the issues were. But there were lots of political land mines that I could not have foreseen that lay ahead.
Tacey Ann Rosolowski, PhD:
This is sounding like a cliff hanger to me.
Bernard Levin, MD:
I’ll leave it there. And Roger was wise and had a much broader knowledge than I did.
Tacey Ann Rosolowski, PhD:
Shall we leave it there? That’s a good cliff hanger. So I am turning off the recorder at—I’m trying to see my watch here in the glare—11:39. Thank you very much for your session this morning. (End of Audio One)
Recommended Citation
Levin, Bernard MD and Rosolowski, Tacey A. PhD, "Chapter 07: The Challenges of Creating a Multi-Disciplinary Section of Gastro-Intestinal Medical Oncology" (2013). Interview Chapters. 1343.
https://openworks.mdanderson.org/mchv_interviewchapters/1343
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