Chapter 27: A Study of Colorectal Cancer in Egypt
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In this Chapter 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.
Identifier
LevinB_04_20130708_C27
Publication Date
7-8-2013
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - The Researcher The Researcher Overview Definitions, Explanations, Translations Professional Practice Discovery and Success The Professional at Work Collaborations Understanding Cancer, the History of Science, Cancer Research The History of Health Care, Patient Care Beyond the Institution Cultural/Social Influences Global Issues –Cancer, Health, Medicine On Research and Researchers
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:
We should maybe take on a new topic and get it out of the way, and then we can go back to some of the old topics. The new topic which I haven’t talked to you about was colorectal cancer in Egypt in young people. And the background for all of this is that I became aware of some—an interesting finding or observation by Dr. Palmer Beasley, B-E-A-S-L-E-Y, who was the dean at the University of Texas School of Public Health. He was very famous for his work on hepatitis B vaccines in Taiwan. He really is one of the pioneers in showing that the hepatitis B vaccination would reduce the risk of the development of cancer—liver cancer. So he was invited to Egypt, and while there he was told about young people with colorectal cancer, which he as an epidemiologist knew to be very unusual. And when he came back to Houston, he told me and a young Egyptian epidemiologist who was then a fellow on the faculty in the Department of Epidemiology at MD Anderson whose name is Amr, A-M-R, Soliman, S-O-L-I-M-A-N, who was a trained physician and had a degree in public health. He was from Egypt. He and I became quite interested in this finding. And I went to Egypt briefly in the early nineties to confirm that this entity actually existed, because I too was not a believer at the time. And then to my great surprise, I was confronted with the finding that there were indeed cases of young people with quite advanced colorectal cancer, mostly left-sided—that is, towards the rectum. And unfortunately, these people, because of the rarity of the condition, were diagnosed late in the course and had a great deal of suffering as a result.
Tacey Ann Rosolowski, PhD:
Let me just interrupt you for a second, Dr. Levin. I wanted to ask you why is it that colorectal cancer is so rare in young people?
Bernard Levin, MD:
Well, it’s a good question, because the answer is we really don’t know. One assumes that apart from the inherited forms, which are much more common in young people and can occur as early as age ten or earlier where they’ve inherited numerous polyps. Presumably the mucosa of—the lining of the colon over years is subject to various insults, one could call them, as a reflection of diet or interactions with a bacteria or other unknown agents, perhaps even infectious agents, which we don’t know about. Viruses have been speculated. This is a long-term process and cannot occur quickly. So we know that as one ages, the lining becomes more predisposed to abnormalities in gene regulation. What causes these abnormalities, we don’t know. But presumably over time there is an accumulation of these abnormalities. And then polyps or adenomas form, and then over time some of these adenomas can become malignant. But there are many more adenomas that occur in normal people that don’t become malignant. They stay small, or they don’t become genetically modified. So this is a long-term process, and presumably the evolution of this takes many years. That’s why it doesn’t occur in young people unless there is some sort of accelerant like an inherited condition.
Tacey Ann Rosolowski, PhD:
So I suppose that studying these young people might shed some light on exactly what’s involved in this process too?
Bernard Levin, MD:
Exactly. Well, that was our thinking. So we became quite interested and started cataloging these people and doing some epidemiological studies. In fact, there were a number of papers—I think about ten papers published, which you can find in my CV with various authors, but particularly Soliman. But we also involved other investigators. There was interest on the part of Stanley Hamilton, who is still at MD Anderson. He is a very famous gastrointestinal pathologist, and he did some of the molecular studies. We also involved other pathologists at MD Anderson like Dr. Rashid and also epidemiologists and statisticians at MD Anderson—Melissa Bondy and Chris Amos. And studying methylation, we involved Jean-Pierre Issa, who was then at MD Anderson. So there were a number of different approaches taken. So we would try to come up with some ideas of why this could have occurred. And there was some question about exposure to DDT and some exposure to other toxins in the water that these people were ingesting. Some sort of theories about inheritance, perhaps it was consanguinity, meaning intermarriage of relatives, thereby causing more gene abnormalities. In fact, we didn’t really come up with any definitive explanations. What was interesting is that it was also found in other studies that there was some increased incidence of pancreatic cancer in the Nile Delta, and reasons for that weren’t clear. So it seemed to me that there was a high risk of development of cancer in these populations for reasons that were never properly elucidated. So these studies were all began in the late 1990s and probably had their peak around 2000 to 2003. The impetus for trying to find why these cancers occurred in young people, of course, was trying to find if there was something that we could also apply to other populations. And subsequently it became clear that colorectal cancer was becoming more common in young people around the world. Similar findings were reported in the Far East. And even in the United States there is some evidence that there is an increased incident of colorectal cancer in people below the age of fifty, which was traditionally the age where it was thought that it begins to occur more frequently. So I think that’s about probably all you want to know about Egypt.
Tacey Ann Rosolowski, PhD:
Well, it was very interesting. Did you feel that there—I mean, despite the fact that you came to know a kind of definitive understanding of why—what the actual causes were, what did you feel you learned from this long experience?
Bernard Levin, MD:
Well, it was—there was a great deal of appreciation for the difficulty of doing research in a developing country. It’s a great credit to Amr Soliman, who subsequently left MD Anderson. He was the person on the ground that collected samples, put them in dry ice for refrigeration purposes, got them to the airport and had them transported to the United States for analysis and negotiated a lot of difficult scenarios in Egypt—driving around in his old beaten up Fiat as I did when I went there. It was an amazing experience to try to sort out all the difficulties that existed when one tried to do research of this kind—clinical research in a developing country where there is no real tradition and where there are huge gaps in infrastructure. Of course, it was totally fascinating to first go to Egypt about 15 years ago and see parts of the country and meet some of the physicians and scientists there who were interested in this. And there are some very fine individuals who were very dedicated who I met—surgeons, epidemiologists and statisticians primarily working at the National Cancer Institute in Cairo. Of course, as one can image, it bore no resemblance whatsoever to our US department—the US National Cancer Institute, which is a huge number of buildings. The NCI in Cairo was a relatively small operation but run by dedicated individuals.
Tacey Ann Rosolowski, PhD:
I’m trying to formulate a question here because I’m just—it really strikes me when I’ve spoken to interview subjects and they describe doing work abroad—you know—in nonwestern countries. I mean, clearly there is enormous value in investigating some of the health issues and sort of the research challenges that come up but there are these big obstacles—you know—maybe lack of infrastructure or resources, and sometimes there are training issues. Do you feel—I mean, this is a blind question to something that we haven’t—sort of not on my original list, but do you feel that it would be of value for people in the US to be more aware of these differences and to encourage those kinds of collaborations? Is there a great deal for American researchers to be gained from doing this work overseas?
Bernard Levin, MD:
Oh, I do. I am very firmly of the opinion that it is incredibly useful for both sides when there is more than one country involved for this kind of international collaboration to occur. The prerequisites have to be very well specified. There has to be—obviously, there has to be some benefit from collaborations for all involved. It’s not just that we take from them or they take from us. The structure has to be well defined. The scope of the interaction, the collaborations, the type of research, and the ethical/political issues have to be addressed completely or transparently. And the financial concerns have to be very clear. As you can image, there is potential for exploitation of people in developing counties, and it’s very critical that those who embark on this have a very clear and open and honest motives and the recipients of this collaboration be well informed as to what the goals and the outcomes are likely to be. But I think it’s definitely consistent of my own personal belief that there has to be greater interest in global health and that—to use a cliché—the world is really flat, and there are many issues that arise in developing countries that are all of great relevance to those in developed countries.
Tacey Ann Rosolowski, PhD:
I just wanted to do—you know—connect the dots on the studies that you did in Egypt. What do you feel the Egyptian side received from the collaboration on this—on this issue with young people’s health?
Bernard Levin, MD:
They certainly were able to appreciate the fact that there was a reason to take notice of the symptoms of younger people who had some bleeding or abdominal symptoms. There has definitely become greater interest from a public health point of view in the fact that colon cancer was a real entity in younger people, and it really helped them to some extent with greater awareness of this amongst physicians because there were programs which others from Egypt participated in that drew attention to this issue. On a scientific level, their scientists and statisticians were able to participate at a fairly high level with very good people, particularly from MD Anderson, and I think they definitely benefited from this. There was some exchange of—more sending to MD Anderson, but some personnel visited from Egypt as a result. And I think there was a greater sense of mutual working together to try and solve this problem. I think there was—there were definitely benefits on both sides.
Tacey Ann Rosolowski, PhD:
Okay, thank you. Dr. Levin, I would like to pause the unit just for a moment, if you don’t mind?
Bernard Levin, MD:
Sure.
Recommended Citation
Levin, Bernard MD and Rosolowski, Tacey A. PhD, "Chapter 27: A Study of Colorectal Cancer in Egypt" (2013). Interview Chapters. 1363.
https://openworks.mdanderson.org/mchv_interviewchapters/1363
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