Chapter 12: Expanding the Scope of Cancer Prevention
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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.
Identifier
LevinB_01_20130207_C12
Publication Date
2-7-2013
City
Houston, Texas
Interview Session
Bernard Levin, MD, Oral History Interview, February 07, 2013
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the InstitutionThe Administrator Building/Transforming the Institution Multi-disciplinary Approaches Philanthropy, Fundraising, Donations, Volunteers The History of Health Care, Patient Care Patients Obstacles, Challenges MD Anderson Impact Portraits The Clinician Information for Patients and the Public On Care
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
Tacey Ann Rosolowski, PhD:
Now did it also happen that as the financial support to prevention increased it grained greater respect and credence within the institution?
Bernard Levin, MD:
Absolutely. And of course, the building of the cancer prevention building was a tangible example of the commitment. That was extraordinary.
Tacey Ann Rosolowski, PhD:
Tell me about that.
Bernard Levin, MD:
I have to recall the events that led up to it but I think—I don’t remember a specific moment—but there was clearly a recognition that additional space was needed for a number of departments and clinics. Funds were raised to build a structure that would house Gynecology and the offices of Cancer Prevention and its departments as well as the Cancer Prevention Center. I do not recall the chronology of that and the financing of that well at all. But it was probably a two-year effort that culminated in that final construction and housing.
Tacey Ann Rosolowski, PhD:
And it opened in 2005.
Bernard Levin, MD:
Yes—I thought it opened earlier, but okay. And it was clearly a huge step forward, because what it enabled was good office space for the academic department. It didn’t provide lab space, unfortunately. That was its one deficit. But that was not permitted under the code under which the building was built. That also allowed for the very capacious Cancer Prevention Center and laboratories for behavioral research within the center, not wet labs, but labs that enabled one to study smoking even, because of highly filtered air being circulated—also, an exercise facility within the Cancer Prevention Center, nutrition assessment. So it was, in a sense, a tremendous leap forward. And those we built into the design of the center.
Tacey Ann Rosolowski, PhD:
So you were part of that whole planning process?
Bernard Levin, MD:
Yes, I and other faculty, of course. All the faculty were involved. It was a collaborative effort.
Tacey Ann Rosolowski, PhD:
You said when you embarked on this, there was a learning curve. You had to really kind of learn what this new area of prevention was all about. First, we have Epidemiology, then the Department of Behavioral Sciences. I mean, I’ve got the list of all of what’s encompassed here. Then the Department of Clinical Cancer Prevention opened within the cancer prevention center. Then we also have the Behavioral Research and Treatment Center, and the Center for Research on Minority Health and the Department of Health Disparities Research.
Bernard Levin, MD:
Right. All those have been opened. So let me tell you about some of those. Behavioral Research and Treatment Center was an offshoot of the Department of Behavioral Science, focused heavily on management of psych-social issues related to tobacco.
Tacey Ann Rosolowski, PhD:
Let me ask you just a quick second here. Was the idea in the development of some of these areas that the first initiative was to treat MD Anderson patients from this perspective? Or were these different departments kind of looking outward and trying to bring in people from outside for studies? Or maybe I’m giving you an either/or that’s not valid.
Bernard Levin, MD:
No, it’s a valid question, and it makes me think about how this all developed. It was clear that there were insufficient MD Anderson patients to be of interest to a prevention center—alone to be of interest to a prevention center. We needed to expand to a broader population, particularly if we were interested in doing research on well people for screening. MD Anderson, by definition, saw mostly people with suspected or established cancer. Those weren’t going to be the people. But there were high-risk individuals within that group who would be appropriate for additional screening. There was also the question of payment for all of these—how was this all going to be paid for? And given restrictions on Texas reimbursement, many poor people weren’t able to be accommodated, so it had to be people with some form of insurance mostly who could come. The idea of screening out in the community was broached by me and others through Baylor and Ben Taub at LBJ. We tried to set up the design of a colon cancer screening program through those two centers, not involving MD Anderson but involving those centers. And I had discussions with the Houston Department of Health and various leadership individuals. But it didn’t come to anything, but there was interest in a broader screening program. What became important in terms of the Behavioral Research and Treatment Center was the treatment of MD Anderson patients for tobacco addiction. And that became a very strong focus under the leadership of someone Ellen recruited, Paul Cinciripini.
Tacey Ann Rosolowski, PhD:
And I’m sorry, his last name again?
Bernard Levin, MD:
Cinciripini. C-I-N-C-I-R-I-P-I-N-I.
Tacey Ann Rosolowski, PhD:
Thank you. Sounds like somebody needs to make a song to remember that one.
Bernard Levin, MD:
So that’s the Behavioral Research and Treatment Center. Part of it really was the fact that it became clear from studies that Paul and his colleagues did—and they were very interested in pharmacological studies in tobacco—varenicline was one of the drugs they studied intensively, Chantix, it’s called—that many of the people who were addicted to tobacco at MD Anderson as patients had significant psychiatric comorbidities. So this was more than—this was just the tip of the iceberg.
Tacey Ann Rosolowski, PhD:
There was just an article in the New York Times today about the fact that smoking is being eliminated in psychiatric hospitals. They were talking about the fact that psychiatric patients smoke at a much higher rate the rest of the population and die often of smoking-related diseases.
Bernard Levin, MD:
That’s what they found. They also really, I think, were pioneers in making referrals to a tobacco addiction specialist automatic if a patient came to the hospital and expressed an interest in being referred. It didn’t require the attending physician’s permission. All of this was essentially paid for by MD Anderson. So it was tremendously enlightened, in my opinion, that we could garner support for this tobacco effort from the institutional coffers. As far as—and just to finish that thought—Ellen had also become interested in the relationship between HIV/AIDS and tobacco and did some very important work in that area. As far as the Center for Research in Minority Health, the head of that was Dr. Lovell Jones, who had been at the institution for a long time. He had been trained as a gynecological endocrinologist. He’s not a physician, he’s a PhD, and had been recruited to work in Gynecology. When it became clear that his areas of interest were much more related to health disparities, he became, I think, awkward for people to fit into a slot, because although he had some continued interest in gynecological endocrinology, he really was much more a population scientist and was becoming involved in studies in minority health. So he moved around a little. And Lovell had grown up in a very tough environment and was undoubtedly suspicious of authority and had been the victim of racial prejudice in his early years and probably continuing into—
Tacey Ann Rosolowski, PhD:
Okay, we’ll try this again. (The recorder is paused.) All right, let me just get this back on. Okay, noise problem dealt with, here we go.
Bernard Levin, MD:
So Lovell had undoubtedly been the victim of prejudice in many ways and had a strong antiauthoritarian feeling. I was asked by John to see if I could enlist him into the faculty, and it was not truly successful. I think Lovell believed that he knew the best path forward. He had received significant accolades from leaders in health disparities. He had received grants of various kinds over the years. And he was quite content to run his own show. But it was felt that that was an inefficient way to run a program. He couldn’t be a freestanding individual program. He had to be part of a department. Eventually, the logical outcome was that we formed a Department of Health Disparity Research for the reasons that are obvious—that there are huge disparities in health care, particularly preventive care in this country and in the city of Houston and the state of Texas. We conducted a formal search for the chair and selected David Wetter, who is the current chair. Dr. Lovell Jones was a candidate but wasn’t chosen to be the candidate of the committee. That certainly led to some hard feelings, which have persisted to this day. On the other hand, Lovell is a well-known figure in health disparities research. He’s received many accolades and honors. He, most latterly, has a joint program with the University of Houston. I think that’s how it has settled out.
Tacey Ann Rosolowski, PhD:
Now I’m interested in how the Department of Health Disparities and the very subject matter it deals with—how that is supported by an institution that relies on reimbursement through insurance. We’ve talked already about one area with the referrals with MD Anderson patients who are automatically referred for addiction support if they smoke. Here we have a huge number of patients whose needs are going to be addressed and probably have no health insurance or minimal health insurance. How does that all work within the MD Anderson culture and practically in terms of finances?
Bernard Levin, MD:
The name of the department actually provides that answer. It is health disparities research. And several of us felt that while the topic was being addressed in some respects by others, it needed a strong focus within the institution. And it was, as far as I know, the first department of its kind in the country at a cancer center. David Wetter had been a recruit of Ellen Gritz. He is a very successful researcher with a stellar academic record. And he was a tobacco researcher and was interested in studying in disparate populations, so that naturally led to his becoming a candidate.
Tacey Ann Rosolowski, PhD:
And that was in 2006 that he came, which is when the department was established.
Bernard Levin, MD:
Yes, I suppose. It felt like it was further back, but if you say so then that’s correct. It all seems so long ago, but yes. I thought we had a longer time together than that. And David had a very clear vision of what he wanted to do. He had undoubtedly some differences of opinion with Lovell, who was more senior in rank in terms of time and tenure at the institution. That marriage didn’t necessarily work out as smoothly as I would have liked or as anyone else would have liked. But David brought his own strengths to bear. He had a passionate commitment to this field, very clear thinking, brought on some excellent young researchers. And it’s remained a small department ever since but doing very good work. His researchers are well supported, because David is a superb mentor. But research was the focus, and therefore, they didn’t run into substantial issues of clinical reimbursement, because it was studying the phenomenon of what constitutes disparities, what leads to them, what factors can be modified in the environment.
Tacey Ann Rosolowski, PhD:
What were some of the things they looked at?
Bernard Levin, MD:
I’ll give you some of the things they studied. For example, people living in an urban area who don’t have access to parks, don’t have access to exercise, people who don’t have access to good food because they rely on 7-11’s or McDonald’s or fast food outlets. There is nothing else. They’re scared to go up and down elevators. They don’t go out to play in the park because they’re going to get mugged. What effect does that have on their health? And the impact of advertising, particularly tobacco, on behavior. So essentially it’s a combination of behavioral and epidemiological research aimed at studying disparities.
Tacey Ann Rosolowski, PhD:
Do you know how many other—I mean, did this department’s establishment become kind of a model for others that got the idea?
Bernard Levin, MD:
There are others at other centers. I know there is one, a quite new one, at Memorial Sloan-Kettering which is focused on immigrant health. There are others at some other institutions, I know that. I don’t know specifics anymore.
Tacey Ann Rosolowski, PhD:
I’m curious about funding that kind of research. I mean, we’ve heard for the last decade and a half that the disparity between rich and poor in this country is growing and that it’s very difficult to bring attention to issues of class differences in the US and certainly to problems of poverty. So is there—what’s the prognosis for someone who’s embarking on research like this getting funding?
Bernard Levin, MD:
I think there are foundations, Robert Wood Johnson being a notable example, and the NIH is interested in this topic. NCI is interested in this topic. So I think that as unfortunate as it is as a sociological phenomenon, nevertheless, there is recognition of it and some attempt to describe it, to circumvent it, to minimize it. I think it’s reasonable to expect that this would be able to achieve continued funding.
Tacey Ann Rosolowski, PhD:
I mean, it wasn’t a doom and gloom. I was just curious, because I’ve had conversations with other researchers who have said that certain kinds of research have fallen out of favor. You’ve had to carry the torch until interest comes back again, these kinds of things. I was curious then since this is a public health issue at a time when these sorts of issues maybe are not in the media very much. So I was just curious about funding sources. And also, it’s kind of coming back to me that we have physicians who are almost acting in an activist kind of role or in an advocacy role for public health questions. Kind of like going back to what you were doing in South Africa as people were recognizing that there were problems with the governmental system and trying to take a stand. I’m curious about the evolution of the role of the doctor, from someone who focuses on a single patient to someone who is suddenly bringing attention to more societal questions. Did you see that as part of the mandate of the Cancer Prevention Center or cancer prevention?
Bernard Levin, MD:
Implicit in its mandate is that recognition. And it gets back to the topic you first suggested, primary prevention as the means to try and avoid illness in the general population. And a primary example is vaccination. That’s the best form of primary prevention, because it’s aimed at a broad swath of the public. It presumably is carried out at relatively low cost and a fairly high level of effectiveness. So that’s the best example of primary prevention. I think preventing people from taking tobacco would be an equally powerful example. So there is a clear role for the public health advocate. Secondary prevention is the recognition or early detection of cancer or predisposition in individuals at risk—so screening, that’s the primary example of secondary prevention. And tertiary prevention, which is sometimes used and sometimes thought not to be a real form of prevention, is the minimization of harms in people who already have had cancer, minimize suffering, minimize the impact of the cancer that they may have been treated for or cured from in a defined population.
Tacey Ann Rosolowski, PhD:
Can you give me some examples of what that might be?
Bernard Levin, MD:
For example, someone who has had radiation of the head and neck—(phone ringing) Excuse me, I’m sorry.
Tacey Ann Rosolowski, PhD:
That’s all right. (The recorder is paused.) I’m just getting the recorder back on.
Bernard Levin, MD:
So we were talking about health disparities research.
Tacey Ann Rosolowski, PhD:
Yes, you were talking about how the radiation—
Bernard Levin, MD:
Tertiary prevention. If you had radiation of the head and neck, you have a lot of disability from it, and how do you overcome that? What measures do you take to prevent the various physical and other disfigurements? Or after a gynecological surgery, scarring and pain—things that are related to the effects of medical or surgical management are broadly encompassed by tertiary prevention. And how do you minimize the adverse effects of what might otherwise be successful treatment?
Tacey Ann Rosolowski, PhD:
So prevention came to be understood pretty broadly.
Bernard Levin, MD:
It really did. We tried to broaden the definition to include survivorship and tried to build a case for the fact that survivors, as is well known, are at risk for developing second malignancies. And screening of these individuals in their follow up is often not well done by clinical oncologists, who are busy treating active—people with active cancer. The follow up is often delegated to nurse practitioners or physician assistants in busy practices. So we tried to make the case that survivors would be naturally accommodated in the prevention center. So there was some territorial warfare at MD Anderson. But that’s not important, as long as these people were being taken care of by someone who cared. So there is one more on that list.
Recommended Citation
Levin, Bernard MD and Rosolowski, Tacey A. PhD, "Chapter 12: Expanding the Scope of Cancer Prevention" (2013). Interview Chapters. 1348.
https://openworks.mdanderson.org/mchv_interviewchapters/1348
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