Chapter 31: Combination Treatments and the Value of Collaboration
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Description
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 Chapter 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.
Identifier
LevinB_05_20130827_C31
Publication Date
8-27-2013
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - The Researcher The Researcher Overview Definitions, Explanations, Translations Professional Practice Understanding Cancer, the History of Science, Cancer Research The History of Health Care, Patient Care Discovery and Success Technology and R&D Healing, Hope, and the Promise of Research MD Anderson Snapshot The Administrator MD Anderson Culture Building/Transforming the Institution Multi-disciplinary Approaches Critical Perspectives on MD Anderson Education
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:
Would you like to address that issue now of the sort of combination approaches that you’ve looked at over the years?
Bernard Levin, MD:
Yeah. Well, by then I had begun to achieve what I think were the goals that Dr. Krakoff, who was then Chair of Medicine, and I had agreed on. It was to build a department comprised of gastroenterologists who could attend to the needs of patients at MD Anderson, basic scientists who were going to be studying various forms of GI malignancy, and medical oncologists who would be involved in studies of drug treatment using investigational drugs. And the hope was to have an interactive interdisciplinary group of individuals who communicated with each other and therefore were more effective than if they were in separate silos.
Tacey Ann Rosolowski, PhD:
Can I ask? You said “by this time.” What is the time period?
Bernard Levin, MD:
This was probably 1986, 1987.
Tacey Ann Rosolowski, PhD:
Okay.
Bernard Levin, MD:
And I was fortunate enough to recruit Jim Abbruzzese, who’s now the Chair of GI oncology at MD Anderson, who’s a notable clinical researcher who also then was also doing some lab research, and he and I, and working also with Jaffer Ajani, who was interested particularly in esophageal and gastric cancer, and also Bruce Bowman, who was a medical oncologist, had opportunity to study a number of different drugs and combinations of drugs in Phase 1 and Phase 2 studies, very early studies as well as later studies, and combinations of drugs we used, some of those I was participatory to, some of them I wasn’t. Some I entered patients on to and participated actively, and others I really didn’t have much role and therefore didn’t participate. But a number of different studies were done, some of them with other investigators outside of the department, on pancreas and colon cancer. Those are the two main ones. Dr. Ajani primarily confined his interest to stomach and esophageal cancer, and he’s still at MD Anderson and still doing this work very well. Some of the work also involved radiation therapy, and at the time, the particular radiation therapist who we worked with was Dr. Tyvin Rich [phonetic]. Now, some of the work that I was involved in also involved collaborative studies with the GI Tumor Study Group, which was a branch of the National Cancer Institute, and we entered some patients on their studies as well. So the milieu was quite fruitful for doing research to try and find better ways of managing people with advanced or essentially cancers of the GI tract which were no longer curable by surgery.
Tacey Ann Rosolowski, PhD:
I mean, as you’re describing that, even the use of the word “milieu,” it sounds like it was really key to create a culture and an environment in which collaboration was very, very highly valued and in which there was a lot of conversation across what would normally see as interdisciplinary divides. Is that really the case?
Bernard Levin, MD:
Well, that was my hope, and it worked to some extent and may not have as well as I had intended. Certainly I tried to be the bridge and the glue. That didn’t always work, and there were personality differences and dissents that certainly didn’t make that an always easy task, and there were certainly many challenges that I confronted, because each of the groups had their own specific agendas, so to speak. The gastroenterologists were part of a larger team in GI oncology, but they also related to individuals who were at the UT system, University of Texas Health Science Center in Houston, with its own gastroenterology faculty. And the relationship was that there was a training program, as I’d mentioned previously, where fellows rotated between UT Houston and MD Anderson. So gastroenterologists had a larger context for their activities. They were interested primarily in endoscopic research,. The medical oncologists were also in the team, but they also related to a much larger group of medical oncologists. Of course, that was the main business of the Division of Cancer Medicine. And the basic scientists also had to relate to a larger group of basic scientists in other departments. So I viewed this department as a nucleus for interdisciplinary research, but, as you know, that is only successful to the extent that people want to collaborate and view it as something that has value for them, and that wasn’t always successful.
Tacey Ann Rosolowski, PhD:
Were there some strategies that you attempted to overcome those, you know, kind of conflicts, if you will, of the desire to collaborate within this department and the need to kind of have stronger connections outside?
Bernard Levin, MD:
, In retrospect, I tried very hard to enhance the value of such collaborations and that something that in annual evaluations I praised and tried to make a real goal for the department, but I have to admit that it was most successful for the medical oncologists and the basic scientists. It did not work as well as I thought it would for the gastroenterologists, probably because of the very skewed nature of the patients seen at MD Anderson at that time. The GI problems did not lend themselves easily to the kind of studies for which these gastroenterologists were equipped. They were clinical gastroenterologists, not well trained in research. It was about the same time that we had substantial numbers of patients with HIV/AIDS—
Tacey Ann Rosolowski, PhD:
Oh, I see.
Bernard Levin, MD:
—and the GI problems were overwhelming and, again, were not something that could easily be studied. So there was, in a sense, a bias against doing much in the way of research. It was mostly just keeping up a brave front to diagnose and manage people with quite serious gastrointestinal problems.
Tacey Ann Rosolowski, PhD:
Kind of bracketing that, which seems to be, you know, kind of a unique historical situation, in retrospect, is there anything that you think about in your own strategies as a leader of that department that you could have done differently or, you know, a fresh initiative you could have taken to help build collaboration?
Bernard Levin, MD:
Well, one of them was the failed attempt to build a training program with the other centers in the medical center. That might have allowed for a rotation of attending physicians, such that the people who were at MD Anderson were not going to get burned-out by the severity of seemingly incurable and advanced disease. It might have allowed for a fresher and more perhaps exchange of information and ideas and personalities. That would have been one possible outcome of that failed attempt. I think also recognizing the need for a more senior gastroenterologist rather than the more junior ones whom I recruited who were not as perhaps accomplished as they might have been and still needed further training. So those are two things that I possibly could have done better. Then basic scientists, I think, were sort of the luck of the draw. I recruited essentially three individuals, and to some extent two out of the three were reasonably successful, but were not necessarily that interactive. So part of it, I think, depends on understanding personalities and goals better, and hindsight, of course, gives you that.
Tacey Ann Rosolowski, PhD:
Yes. (laughs) How true. Well, I kind of, with that more administrative question, took you on a digression from the story of the intra-arterial theory or, rather, the combination therapy. I was wondering if there was more you wanted to say about that.
Bernard Levin, MD:
I think that there were lots of attempts to develop innovative approaches, but there was nothing like an understanding of the targeted nature of treatments today that we had available, so all the treatments were almost by, without exception, relatively poorly focused, not because we didn’t want to focus them, but by their very nature, they were toxins and, for the most part, the only reason that they worked is that they killed cancer cells a little bit more than they killed the normal cells. So the treatment of advanced disease was relatively futile. The treatment of localized disease with combinations of radiation and chemotherapy actually was much more successful because there there was a localized target, for example, rectal cancer, and the use of radiation chemotherapy was definitely of benefit because it was a local modality interjected with a systemic treatment, 5fu, which had some effectiveness against colon cancer cells. So there were lessons to be learned about how to utilize a local combination like radiation plus chemotherapy as opposed to systemic chemotherapy using drugs that had relatively little specificity.
Recommended Citation
Levin, Bernard MD and Rosolowski, Tacey A. PhD, "Chapter 31: Combination Treatments and the Value of Collaboration" (2013). Interview Chapters. 1367.
https://openworks.mdanderson.org/mchv_interviewchapters/1367
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