Interview Chapters

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Chapter 02: Residency Experience Cultivates Interest in Pediatric Cancer

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

Interest in Cancer: Dr. Knudson sketches the development of his interest in cancer. He notes that during medical school, he did not learn about cancer because there was no real treatment for cancer at the time. His interest came through his residency in pediatrics at New York Hospital, where he completed a month-long rotation in the children's cancer unit at Memorial Hospital. Dr. Knudson explains the impact this experience had on him.
Chapter 03: A Geneticist Pediatrician Joins the Army; Return to Cal Tech

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

Military Experience: Dr. Knudson talks about his enlistment in the army during the Korean War. He was supposed to spend a year in Korea and a year in the U.S. Instead, he spent two years in Fort Riley, Kansas because the army was not sure what to do with a geneticist pediatrician in Korea.

Education: Dr. Knudson then discusses his return to the California Institute of Technology in 1953 to study. He briefly talks about the influence of Watson and Crick's work on the field of genetics earlier that year. After he finished at Cal Tech, Dr. Knudson was put in charge of a small pediatrics unit at City of Hope Medical Center, which fit his previous experiences well.
Chapter 04: A Slow-Moving Start at Stonybrook Opportunity at MD Anderson

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

Interest in Cancer: Dr. Knudson continues outlining his path towards discovering the two-hit model. He explains that during his time at City of Hope Medical Center, he became more interested in cancer and hereditary predisposition and was asked to write a book on genetics and disease. Dr. Knudson notes that although this work helped him to put the cancer problem in perspective, it was too early for him to discover the two-hit model.

Administrative Experience:

Next, Dr. Knudson recalls his frustrations about his slow-moving experience starting a genetics unit at Stonybrook in New York. After three years at Stonybrook, Dr. Knudson accepted an invitation to come to MD Anderson to start a genetics unit.
Chapter 05: Discovering the Two-Hit Model Through Studying Retinoblastoma

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

R. Lee Clark's Influence: Dr. Knudson reflects on the environment of MD Anderson under R. Lee Clark's presidency, saying that "Lee didn't understand [the word] 'can't.'" Dr. Knudson explains that Clark asked him to write a review article for a journal, which forced him to think about what kind of gene is important in cancer. He notes that research on cancer was mostly done on adult cancer, but children's cancer is important for answering that question.

Overview of Two-Hit Model: Dr. Knudson then describes how he discovered the two-hit model. Muller published a paper claiming that several steps are necessary to make cancer. Though the literature after Muller's paper attempted to figure out those steps, Dr. Knudson wanted to know what the smallest number of events could be. He explains that his experience in pediatrics led him to look at retinoblastoma, a cancer with a hereditary form, to figure out the problem. Through statistical studies, Dr. Knudson concluded that the smallest number of events is two.
Chapter 06: Two-Hit Model Allows for Genetic Testing of Blood

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

Contributions: Dr. Knudson discusses how the two-hit model influenced research by opening the possibility of testing for the gene in patients' blood. He explains that this is useful for adults who had childhood cancer who want to know the likelihood of passing on the cancer to their children. Dr. Knudson mentions that the two-hit model additionally called attention and interest to other hereditary cancers.

Research Reflections: Dr. Knudson then reflects on the research process that led to the two-hit model, saying that he was lucky that retinoblastoma gave a quick answer to the problem.
Chapter 07: Work with Dr. Louise Strong

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

Mentoring Experience: Dr. Knudson did not have much experience with trainees, because most of his work was theoretical. He discusses one meaningful experience with a young woman who asked to work in his lab. At that time, he had just arrived at MD Anderson and had not started to study retinoblastoma. Dr. Knudson says that after he wrote his paper on the two-hit model, he called the woman and invited her to work with him. The woman's name was Louise Strong.

Portrait of Dr. Strong: Dr. Knudson then tells an amusing anecdote about Dr. Strong. He describes the work that they completed together, reviewing the literature on tumors and publishing papers together. Dr. Knudson concludes by saying that he offered Dr. Strong an assistant professor position, which she accepted.
Chapter 08: Curiosity and Asking Innovative Questions is "The Way He's Wired"

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

Personal Character: When asked about how he developed his innovative style to problem solving, Dr. Knudson responds by saying that it is not a conscious decision. He states that a lot of people have an attraction to the unknown and are curious. The interviewer reveals that Dr. Strong remembered Dr. Knudson asking innovative questions from a diverse background and asks if he is aware of that characteristic. Dr. Knudson says that it is just the way he is.
Chapter 09: Advice for Young Researchers and Mentoring

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

Advice for Young Scientists: Dr. Knudson says that young scientists need curiosity, intelligence, and training to be successful.

Critical Perspectives: He then critiques the state of funding for scientists. He discusses the drop in funding from the NIH and points out that back in the 1960s, a handful of grants were approved that probably wouldn't work, but would be monumental if they did work. Now, he says, those projects are never funded. Dr. Knudson believes that too many grants are doing predictable research and not enough are surprising.

Perspectives on Research: Dr. Knudson then reiterates that to be successful, a scientist needs curiosity. He notes that he has never known a person conducting scientific research for a long time who regretted it. He additionally states that although physician scientists may benefit from seeing direct benefits from their work, some research may not be immediately beneficial to anyone, such as Einstein's work. Dr. Knudson declares that the greatest thing that humans can do is have new ideas. He says that people may come and go, but knowledge keeps building.

On Mentoring: Dr. Knudson outlines what students should expect from a mentor, saying that a mentor should minimally be able to identify whether a project is worthwhile. He notes that this impacts where a student should go, because some problems may not be able to be studied everywhere.
Chapter 10: The Start of the Graduate School of Biomedical Sciences at MD Anderson

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

Administrative Experience: Dr. Knudson outlines how he became dean of the Graduate School of Biomedical Sciences. He says that R. Lee Clark asked him to start a genetics program. As soon as he arrived, the plans changed because the medical school was created and would include a genetics program. He states that Clark believed the answer was the graduate school. Dr. Knudson explains that Clark persuaded him to become the dean. He notes the difference between MD Anderson and Stonybrook, where everything moved slowly.
Chapter 11: The Graduate School: An "Amazing Experiment" in Sub-Institutional Collaboration

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

Education at MD Anderson: Dr. Knudson explains that the graduate school affected students by increased the faculty, which increased the student body as well. It also provided opportunities outside of the field of cancer. Dr. Knudson says that the dean of the medical school went along with this new graduate school. The School of Public Health additionally got involved in the collaboration. Dr. Knudson states that the graduate school was an "amazing experiment" because they went beyond what graduate schools typically do.

Effects of the Graduate School: Dr. Knudson admits that he has not kept track of the graduate school much over the years. When asked about the interdisciplinarity within the school and how it can prepare students, Dr. Knudson says that it is good for students to get a broad basis of understanding because new fields are appearing all of the time. He believes that understanding the human brain and what it can do is the future.
Chapter 12: Perspectives on the Field of Cancer Biology and Neuroscience

Albert G. Knudson, Jr. MD, PhD and Tacey A. Rosolowski PhD

On Cancer Biology: Dr. Knudson reflects on the field of cancer biology. He says that knowing the genetic changes that can occur in cancer is important because different cancers have different cures. He presents radiation and chemotherapy as an example. Dr. Knudson additionally points out that leukemia did not use to have a treatment, but now, there are long-living survivors of leukemia. He explains how adult cancer is more challenging to cure than children's cancer.

On Neuroscience: Dr. Knudson talks about his interest in neuroscience when asked about which field he would chose if he was a young scientist today. He then explains that cancer and degenerative diseases will always exist because of the nature of the cells in the human body.
Chapter 01: A Family in Japan during World War II

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki talks about her childhood in Japan, focusing in particular on her experiences in Hiroshima after the Americans dropped the atomic bomb.

She begins by sketching her family background, noting that her father (a banker) and her mother (a member of a samurai family) married across class boundaries. She talks about her mother’s many talents and notes the lessons her mother taught her. She explains her mother’s insistence that her three daughters focus on gaining technical expertise (stemming from her mother’s experience having to provide for the family during WWII). She also talks about her father’s difficult family background and the perseverance that he needed to become successful in business.

Next, Dr. Komaki sketches the family’s story after the atomic bomb was dropped on Hiroshima on 6 August 1945. Her family was living in Osaka, her father having been transferred there for work, but he returned to Hiroshima in the days after the bomb was dropped to search for family members. Dr. Komaki shares what she learned about the devastation in Hiroshima, as well as the health impact on her father and other family members.
Chapter 02: Experiences in the Aftermath of the Atomic Bomb Become an Inspiration

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki talks about her own early memories, first of life in Osaka and then in Hiroshima during the post-war period. She also discusses the effect it had on her, inspiring her interest in medicine, in research, and eventually in her focus on radiation treatments.

She begins with very early childhood memories of “being always hungry.” She talks about her mother’s struggles to feed the family and a family separation, when she was sent to live with her mother’s sister to ease the family burden.

Next, she talks about her schooling and the role of the Atomic Bomb Casualty Commission [renamed, Radiation Effects Research Foundation], set up early after the war to monitor the effects of radiation on Japanese citizens.

Dr. Komaki then talks about her friendship with fellow pupil, Sadako Sasaki, who would die from radiation-effect leukemia and who would inspire her own commitment to become a physician. [This story has been captured in several publications; Miss Sadako’s story has been told in the book, Sadako and the Thousand Paper Cranes.]
Chapter 03: A Park for Sadako and Thoughts on Radiation Research

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

Dr. Komaki begins this chapter by talking about how she became curious about how radiation had different effects on Sadako, who was young when the bomb was dropped and died young, versus the effect on her grandmother, who was much older and who did not die prematurely. She then tells the story of her commitment to make sure that her friend, Sadako was not forgotten. She explains that as president of her class at Noborichu Junior High School, she worked with her classmates first to raise money to create a monument, and then working with several key adults to organize space in a public park to erect a statue in an area that would be named “Peace Memorial Park.” She recalls that almost 1000 people attended the opening reception. She also notes that every year around 6 August, the anniversary of the dropping of the bomb, teachers around the world arrange for activities so this event is not forgotten.

Dr. Komaki talks about visits she has made in the last years to schools in Houston to talk about WWII and atomic weapons. In the final moments of this chapter, she shares her own message against creating nuclear weapons and the importance of communities educating the next generation about their power and danger.
Chapter 04: Japanese Attitudes about Radiation and the Bomb; First Experiences Working in Medicine and with Radiation Effects

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

Dr. Komaki begins this chapter with observations about how teachers in her schools avoided negative comments about the United States’ decision to drop the bomb. She notes that, in fact, they said that since the Japanese “started the war” with the attack on Pearl Harbor, “Japan deserved the bomb.”

Next, she talks about her interest in how different people responded differently to radiation exposure, leading to her commitment to be a researcher. She also notes that her mother encouraged her to go to medical school: Hiroshima University School of Medicine, MD in medicine conferred in 1969. She notes that during medical school, she volunteered at the Atomic Bomb Casualty Commission. She did checkups, attended staff conferences, and heard about chromosomal abnormalities and second-generation effects of radiation. Dr. Komaki also met several mentors.

Next, Dr. Komaki talks about medical school and her growing interest in hematology and leukemia patients. She also discusses the medical students’ strike, in which she took part: the students objected to the educational hierarchy and medical culture in Japan. Dr. Komaki shared these objections, which motivated her to come to the United States for her internship, residency, and fellowships.
Chapter 05: Medical Education in Japan and Internship and Residency in the United States

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

Dr. Komaki begins this chapter by adding to the Chapter 04 discussion of the features of medical education in Japan that led to the student strikes and her own decision to pursue an internship and residency in the United States. She explains that through her volunteer work at the Atomic Bomb Casualty Commission, she met and married her first husband and also made a connection with Walter Russell, MD, who helped her secure an internship at the Medical College (1972). (Her husband also secured a fellowship, but later returned to Japan to practice and the couple divorced.) She intended to focus on hematology and leukemia.

Dr. Komaki talks about the differences between medical education in the US and Japan.
Chapter 06: Encountering a New View of Radiation and the Decision to Shift to Radiation Oncology

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

Dr. Komaki begins this chapter by summarizing Japanese attitudes about radiation and the lack of interest in Japan in researching the therapeutic potential of targeted radiation. She explains that she began to question this perspective when she encountered entirely different views during her internship and residency in the United States.

Dr. Komaki then talks about key events during her fellowship in hematology at the Veteran’s Administration Hospital in Milwaukee that motivated her to shift to radiation oncology. She also talks about work with patients and also the impact of seeing Anthony Guaninger, MD on rounds and hearing him speak about cancer. She talks about meeting Dr. James Cox [oral history interview], who came to Milwaukee as Chief of Radiation Oncology at the Medical College of Wisconsin (and who would become her second husband). She became the first resident in Radiation Oncology in the department he was building.

Dr. Komaki then talks about making the intellectual shift from hematology to radiation oncology and the types of questions she was interested in exploring.
Chapter 07: A Residency and Research on Fractionation to Preserve Normal Tissue

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki talks about her residency in Radiation Oncology, an experience that gave exposed her to the noted radiation oncologists being recruited to the new program. As the sole resident, she had unusual opportunities to present cases, which offered her learning opportunities. She also began to conduct research.

Dr. Komaki begins the discussion of her research career by talking about the first research study she conducted while still in medical school. She notes that she was (and is) fascinated by basic research (and has some regrets that she focused on clinical research) and explains what led her to focus on clinical work.

Next Dr. Komaki discusses her research during her residency program: fractionation of radiation dosages to preserve normal tissues. She discusses historical shifts in approaches to dosing and explains the concept of sub-lethal damage to tissue.
Chapter 08: Mentors, Unusual Challenges, and Striving to Establish Credibility

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

Dr. Komaki begins this chapter with discussions of James Cox, MD and others who influenced her career at that time. She then talks about an unusual situation of responsibility when she was a resident—explaining treatments to surgeons as the only available radiation oncologist. She explains that she became very good at working with surgeons and developing true multi-disciplinary treatment plans because of her close study of surgical procedures and their complications, as well as the details of treatments in her own field.

Dr. Komaki touches on how being a foreign national and a woman led certain people to doubt her ability. This leads to a discussion first of how Dr. Komaki made a plan to develop her credibility. Dr. Komaki gives examples of how her credentials have been ignored or diminished over the course of her career.
Chapter 09: A Difficult Exit from MD Anderson

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki shares the story of how she came to retire from MD Anderson. She begins by explaining that Dr. Cox felt that attitudes toward him changed when he stepped down as Chair of Radiation Oncology and as Division Head. She reports that people began asking her why was not retiring and goes on to tell a series of stories about how she was treated in the Division under the new division head. She describes changes in division culture under the new division head. She then narrates a series of events that demonstrate that the department wished to push her out of her position. She describes her late husband’s reaction to her treatment in the division and her own feelings now that her husband has passed away and she has left the institution.
Chapter 10: A Fellowship at MD Anderson to Work with Gilbert Fletcher

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki talks about her fellowship at MD Anderson in Radiation Oncology [1/1977-1/1978]. She provides a portrait of Dr. Gilbert Fletcher: she attended his planning clinic every morning and discusses how these worked. She explains that Dr. Fletcher determined all aspects of treatment. She also tells a story about questioning his approach, which resulted in him changing a treatment plan. She explains that her mentors in the department taught her to think critically about cases rather than “follow the recipes.” She shares her impressions of the faculty and staff in Radiation Oncology at that time and talks about a neutron treatment facility that MD Anderson used at College Station.

Next, Dr. Komaki talks about Eleanor Montague and tells a story about inviting her to lecture in Radiation Oncology at Columbia Presbyterian in 1987 to encourage a less conservative approach to radiation treatment. She explains why the surgeons there were resistant, noting that positive results from studies conducted at MD Anderson were often discounted.
Chapter 11: As a Young Faculty Member: the Medical College of Wisconsin and Columbia Presbyterian

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki talks about two faculty positions she held prior to coming to MD Anderson. She first talks about her return to the Medical College of Wisconsin, Milwaukee. She talks about her shift to a focus on gynecologic cancers and applying what she learned about case management during her fellowship at MD Anderson. She also describes the challenges she confronted when advocating for this type of approach to the department chair and how she found a strategy to encourage buy-in from resistant clinicians.

Next, Dr. Komaki notes that she married James Cox, MD [oral history interview] on 27 January 1987, explaining that she arranged her career to be independent of him, rather than attempting to benefit from marriage to someone at a higher administrative level. She talks about their move to New York City and the new Radiation Oncology department at Columbia Presbyterian, where she served as Clinical Chief and Program Director of the Residency Program (’85-’88), focusing on gynecologic malignancies, breast cancer, and lung cancer.

Dr. Komaki next sketches how this was a “very difficult time” because the conservatism at Columbia Presbyterian did not offer an environment where she could conduct the type of research that would allow her to set up prospective trials. She notes that Dr. Cox was promised support to develop the new department, but these came to nothing.
Chapter 12: Returning to MD Anderson and a Focus on Lung Cancer

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki begins to discuss her faculty career when she returned to MD Anderson in 1988 to become Section Chief of Thoracic Oncology, as there was no position in gynecologic oncology.

An initial project she took on with collaborator….? Was to focus on the use of radiation oncology for prevention. She describes how she became aware of the problem of lung cancer in Texas and the informational presentations she gave in many Texas communities to talk about speak against smoking and discuss post-operative radiation treatments for lung cancer. She describes the events and what she believes they accomplished over the course of 2-3 years. She notes that she saw a decrease in the numbers of Texans coming to her service with advanced lung cancer.

Dr. Komaki also talks about her involvement in a research group focusing on early detection and sketches other lung cancer studies she participated in examining combination treatments.
Chapter 13: Studies of Concurrent Radiation and Chemotherapy in Lung Cancer

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki talks about a series of studies she conducted with James Cox, MD between 1988 and 1999 to compare the effects of sequential versus (the more effective) concurrent treatment of small cell lung cancer with radiation at various frequencies and chemotherapy. She explains the various treatments studied and the significance of the results. She explains that the most effective concurrent treatment plan created side effects and these discouraged clinicians in private practice from accepting and prescribing this course of treatment, despite its improved outcomes for treating the cancer. She goes into detail describing the different dosages studied.
Chapter 14: Bringing Proton Therapy to MD Anderson

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki describes the first steps in the process of bringing a proton therapy center to MD Anderson. She first underscores that she supported such a center because it was her dream to have the best methods available to avoid radiation toxicities in normal tissue. She lists some of the secondary effects of conventional radiation treatment.

She talks about the financial context in the late eighties and how Dr. James Cox, MD [oral history interview] was able to move on this project when he became Head of the Division of Radiation Oncology, securing fifty percent of the support from MD Anderson and the University of Texas system and the remainder from private funding. (The Proton Therapy Center opened in 2006.)

Next, Dr. Komaki talks about the controversy over the value of proton therapy. She also describes efforts she and Dr. Cox made to find the best proton system available, eventually setting on Hitachi.

Dr. Komaki then explains how she was able to intervene when contract negotiations with Hitachi broke down, using her fluent Japanese and her cultural knowledge to convince the CEO of Hitachi not to back out of the deal.

She next sketches the slow increase in patients after the Proton Therapy Center opened in 2006, some problems confronted, and the difficulties of getting insurance reimbursement for proton therapies.
Chapter 15: Research to Compare Proton Therapy with Standard Radiation Treatment

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki discusses the clinical trials designed to study the value of proton therapy in comparison to standard radiation treatments. She notes that it was the goal that every patient treated at the Proton Therapy Center be involved in a clinical trial. She explains her reasoning: that there was no other way to establish standard of treatment with this relatively new therapy. She also explains that the lack of insurance reimbursement for treatment (with the bill to the patient being between 200 and 700 thousand dollars) was an obstacle to running trials.

Dr. Komaki also recalls that both surgeons and medical oncologists had objections to proton therapy, and she explains her responses to them. She then explains that the results of clinical trials over the last thirteen years has helped convince clinicians to accept proton therapy.

Dr. Komaki then talks about the results of a randomized phase 2 trial comparing proton therapy with IMRT. She notes that patients treated after 11 September 2011 did significantly better and explains that this date marks the period when MD Anderson became compliant with National Cancer Center Network [NCCN] guidelines for dosage and volume for normal tissue. She comments briefly on the reorganization of regional radiation oncology groups and sketches a comparative study they are not collaborating on to determine overall survival rates. Dr. Komaki then notes that patients are requesting proton therapy as their tolerance of chemotherapy is better than with standard radiation therapy. She explains that she sees the difference in patients.

Dr. Komaki then talks more about the increasing acceptance of proton therapy among medical oncologists, attributable to the fact that the treatment planning teams now include a radiation oncologist who can interpret and explain the proposed radiation treatment plans.

Next, she talks about attempts to promote proton therapy, including an initiative to allow pediatric patients to be treated for free. She also explains that MD Anderson purchased the fifty percent share of the Center controlled by private investors and has plans to build a second center behind the first. This center will be equipped with special imaging to address problems of tumor motion during therapy. Finally, she explains some her concerns about carbon ion radiotherapy (and all special particle treatment), a treatment that is gaining in acceptance internationally, and which will also be studied at the new center.
Chapter 16: Women at MD Anderson and in Radiation Oncology

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki shares some of her own experiences as a woman in radiation oncology and observes some behavior of other women.

First, she confirms that she participated in the Women Faculty Organization led by Elizabeth Travis, PhD [oral history interview] and others. Next, she tells a story about a woman fellow in the Department of Radiation Oncology who was pregnant and who refused to come near the imaging equipment, convinced any contact would endanger her pregnancy. She talks about the importance of women being correctly informed about such risks and the messages they send to (male) colleagues when they act on incorrect information.

[The recorder is paused]

Dr. Komaki then talks about receiving the Madame Curie Award (2005) from the American Association of Women Radiologists and her work to convince women to join and enter leadership pipelines. She also talks about a regular lunch meeting held via that organization that gives women a chance to discuss issues. She explains that she emphasizes to women that they must think of themselves as oncologists, not just technicians.

Dr. Komaki then discusses the challenges women from Japan and other countries face, given male-dominated hierarchies in their countries of origin.

In response to a question about what would make a difference for women, Dr. Komaki responds that new leaders need to appreciate the contributions of senior women and not be intimidated by them. She reflects on her own situation as a senior woman in a division and department with shifting leadership. She notes that she has seen incoming leaders of other divisions and departments at MD Anderson remove senior women.
Chapter 17: An Impact on Japanese Radiation Oncology

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki talks about her recent trip to Japan to receive the International Honorary Award of Japanese Society of Therapeutic Radiation Oncology (JASTRO), given to recognize the role she (and her husband, Dr. James Cox [oral history interview]) played in shifting Japanese attitudes about radiation oncology. She explains that because she had been living in the U.S. but understood Japanese culture and attitudes, she could speak up against tradition, and emphasize that radiation oncologist must think of themselves as much more than technicians and become an integral part of a multi-disciplinary team. She then talks about Japan’s contributions to developing proton therapy and other technologies. She explains that surgery is still considered a primary treatment.
Chapter 18: A Future in Personalized Treatment

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

Dr. Komaki begins this chapter by asserting the importance of MD Anderson’s focus on personalized treatments for cancer, then sets radiation therapy in this context: radiation treatments should be determined by much more than anatomical features of the person and tumor. Advanced need to be made to determine exact histology, specific mutations, and dimensions of the patient’s situation. She goes on to talk about her own work establishing criteria for treating tumors with prophylactic cranial irradiation.
Chapter 19: Thoughts on MD Anderson in a Period of Change

Ritsuko Komaki MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Komaki talks about third President John Mendelsohn [oral history interview] and his successor Ronald DePinho [oral history interview] and discusses changes at the institution during the transition between them and since Dr. DePinho’s resignation on 8 March 2018. She begins with a very positive portrait of Dr. Mendelsohn and the feeling of teamwork he was able to create among employees to take the institution to its number one position.

Next, she reflects on Dr. DePinho, noting that she respected him, but that his focus on basic since didn’t ripple through the institution to generate a common feeling. She also explains that the focus on generating funds for the Moon Shots program created a mechanical, inhuman feel to the institution that had an impact on patient care. Next, Dr. Komaki explains that the transition team that assumed leadership after Dr. DePinho’s resignation began to fire and “target” anyone who had been supported by Dr. DePinho. She says she counts herself in this category. After a few comments about Dr. Peter Pisters, MD, fifth president of MD Anderson, a close friend of hers and Dr. James Cox’s [oral history interview], she explains that people were afraid during to speak up in support of people being fired during the interim period. She touches on her own experience, which she attributes to being targeted for removal. She laments the lack of respect for the faculty and leaders who were able to take the institution to its number one position and the fact that the incoming faculty do not know and respect the institution-builders who have come before. She cites some evidence that the Department of Radiation Oncology is losing ground.

Dr. Komaki then speaks about how “blessed” she has been by seeing patients and her commitment to teaching residents the patient care mission. She talks about the lectureship she and Dr. Cox established in November 2017 and the individual who will be giving the lecture this year.
Chapter 01: Northern California in the Sixties and Tracking into the Sciences

Margaret L. Kripke PhD and Lesley W. Brunet

Personal and educational background
Chapter 02: New Work on Photoimmunology; Reflections on Mentors and Inspirations

Margaret L. Kripke PhD and Lesley W. Brunet

Research: Photoimmunology
Chapter 03: Coming to MD Anderson to Build a New Department

Margaret L. Kripke PhD and Lesley W. Brunet

Photoimmunology
Chapter 04: Taking on Gender Inequity at MD Anderson; Establishing the Organization for Women

Margaret L. Kripke PhD and Lesley W. Brunet

Founding, purpose, institutional support of Women Faculty Organization
Chapter 01: Photo-Immunology: Creating a New Field out of an Observation

Margaret L. Kripke PhD and Tacey A. Rosolowski PhD

Dr. Kripke begins this segment with some comments about joining MD Anderson in 1983, noting differences between the hospital environment and the research contexts she was accustomed to. She notes that professionals came to MD Anderson for many reasons, but stay because of the mission to cure cancer, a mission that "permeates the activities of the institution." She then traces how her own research on photoimmunology evolved, beginning with an observation she made in her dissertation (on immune surveillance) that "it would important to investigate the immunology of animals exposed to ultraviolet light." She had the opportunity for exactly this study from 1972" 1975, when she went to the Department of Pathology at the University of Utah's College of Medicine in Salt Lake City to look at the role of immuno-suppressive drugs in animals, including those exposed to UV light. It was "tailor-made for her interests and background." She describes the effects of UV light on the skin and the cancers induced, noting that no one else was doing similar work at the time and that her findings went against common assumptions about the progress of cancer. She presented her results at the Society for Photobiology, and "the results were so black and white, it was hard to argue with them,"and other scientists were very interested. She describes the early days of understanding that the skin is an "immunological organ."
Chapter 02: Administrative and Leadership Experience

Margaret L. Kripke PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Kripke descirbes her work at the National Cancer Institute in Frederick, Maryland (1975 -1983), including her administrative experience. She set up a laboratory from scratch and eventually became head of the Immunobiology Physical and Chemical Carcinogenesis Section in the Cancer Biology Program at the NCI-Frederick Cancer Research Facility. To streamline the discussion about the development of her research path during this time, Dr. Kripke provides the manuscript of a lecture she gave on the progress of her research. She notes that the period at the NCI broadened her outlook on biology, as it was devoted exclusively to doing science and exposed her to scientists from diverse fields. She also speaks about the administrative skills she acquired (how to manage people; how to run a scientific meeting), in addition to raising her own professional profile in the field. This period, she notes, stimulated her interest in the issues of leadership -this would continue with her increasingly significant administrative roles at MD Anderson.
Chapter 03: Coming to MD Anderson: First Woman Chair; Setting Up a Laboratory, Leading a Department; Clinical Applications of Research

Margaret L. Kripke PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Kripke covers her arrival at MD Anderson (Hospital and Tumor Institute) in 1983 to establish a new Department of Immunology. She addresses gender issues very forthrightly: she is very proud of the fact that she was 39 when she came to MD Anderson as a department chair; the first woman chair of a department and the first women who was a tenured full professor in a research department. She recalls speaking with Dr. Charles LeMaistre about her two concerns: being a Ph.D. in a clinical, medical environment and being a woman in an environment that was much more male-oriented than NCI-Frederick. She tells anecdotes to flesh out the latter view. She offers examples of the practical challenges she faced while setting up a scientific research laboratory in an environment that is designed for clinical activity (noting that “starting a laboratory is like starting a small business”). She makes additional comments on the persistence of challenges to women, though she notes that the Vice President of Research, Frederick Becker, was a “true champion of women in the institution,” who made sure she had opportunities to progress. (She notes that new basic science departments were being created in the 80s, and in fact the Department of Immunology was “a little late in coming” to MD Anderson.) She talks about being pleasantly surprised that she enjoyed teaching and then outlines the goals she had as Chair of the Department. (She also talks about building a program that would integrate immunology into other cancer approaches housed in Research Building 1 on the South Campus.)
Chapter 04: Research Advances and the Excitement of Scientific Discovery

Margaret L. Kripke PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Kripke expands on her research career. She talks about her collaborations with doctors who translated her research into clinical applications. She gives an example of research with liposomes ("fat capsules") to deliver an enzyme to repair DNA damage caused by ultraviolet light: these liposomes worked and also prevented further damage (though have not been translated into therapy for humans). She emphasizes that photoimmunology continues to tease apart the mechanisms that connect UV light to skin cancers. In response to a question about the mental dimensions of the research process, Dr. Kripke explains that interpreting data is like solving a crossword puzzle, but the "exciting part is designing the right experiment,"and "the feeling that you know something or know how to do something that no one else knows. The rest is just doing the work." She describes some of these moments she has experienced in her research career. She acknowledges her many collaborations with her husband, Dr. Isaiah Joshua Fidler ("all of our papers together were the result of an argument") and characterizes the role he has had on her career as an advisor about the processes and politics of science. She says that her daughter (Katherine Kripke) "grew up speaking metastasis and immunology." She also notes that she read Dr. Fidler's papers, that they improved each other's scientific output. (She notes that her own administrative roles have created awkward situations for both of them.)
Chapter 05: Moving into Administration: a Path from Department Chair to Executive Vice President for Academic Affairs

Margaret L. Kripke PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Kripke talks about her shift from research to administration and her "learning curve"as she grappled with leadership. She talks about her (exclusively) mentors in leadership and also her participation in a program for women in academic medicine, ELAM, the Executive Leadership in Medicine Program in 1996-1997. (She was the only appointee from Texas that year.) She describes being interested in "the science of administration." She details the lessons she learned during this "phenomenally exciting time"that allowed her to reflect on where she wanted to go with her career. She explains her decision to leave her research career, resulting in her 1998 appointment as Vice President for Academic Programs (promoted to Senior Vice President in 1999 and to Executive Vice President in 2001). She outlines the principles on which she bases leadership and discusses institutional and cultural changes that evolved after 1996, when Dr. Mendelsohn became president, including a new openness compared to the secrecy of previous administrations. She describes how she tried to implement one of her goals as VP for Academic Programs --to "level the playing field"for researchers. She talks about her working relationship with Dr. Andrew von Eschenbach, whom Dr. Mendelsohn appointed to Senior VP of Academic Programs. She describes the scope of her role as Executive Vice President, emphasizing that she had to become familiar with the clinical side of research, "a completely different culture."
Chapter 06: Roles in Building Research and Advocating for Faculty

Margaret L. Kripke PhD and Tacey A. Rosolowski PhD

Dr. Kripke begins this segment by further detailing her role as Vice President and Executive Vice President of Academic Affairs. She notes that when Dr. Mendelsohn took over as the institution's president, he combated the "spirit of retrenchment"at MD Anderson, creating an unexpected period of "explosive growth." She then underscores that the limiting factor for research at the institution is "facilities, even more than money"and describes how she worked with Dr. Mendelsohn to further specific research areas: immunology, genetics, and other programs. As part of this discussion, she talks about ongoing challenge of refining how researchers' careers are organized and managed within the institution, noting in particular the challenges associated with career paths for physician-scientists. Reflecting on her own achievements in the VP role, she notes particular pride in "leveling the playing field"for researchers, the assignment of space and resources to researchers based on merit, and the complete rewriting of the grievance policy for faculty.
Chapter 07: MD Anderson Presidents

Margaret L. Kripke PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Kripke talks about Dr. Charles LeMaistre and Dr. John Mendelsohn. She notes that Dr. LeMaistre's greatest contribution may be the creation of the Department of Cancer Prevention, then goes on to discuss the leadership style of Dr. Mendelsohn, with whom she worked closely. She describes him as a consensus builder, and notes his success in fostering translational research (he is a physician-scientist) at MD Anderson, to the degree that there are more physician-scientists who want to come to the institution than they can afford to hire. She then speaks about her optimism that Dr. Ronald DePinho will be able to guide MD Anderson through another "quantum leap." She credits the Board of Regents for selecting the presidents that MD Anderson needs as a particular moment, even if the choice at first seem surprising.
Chapter 08: Evaluating the Status of Women and Creating Programs for Women Faculty

Margaret L. Kripke PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Kripke narrates her role in advancing the status of women at the institution, beginning with her role in writing a report on the status of women and minorities. (She credits the administration with allowing the committee full access to all records to prepare this report.) She details the gender inequities at MD Anderson and lists the other women with whom she partnered to help start, first, the Organization for Women (1989) that included faculty and administrative staff, and then the Women Faculty Organization (1990) to address issues unique to women faculty. She also tells a significant anecdote about how she realized that she herself had the institutional power to do something about gender inequity. She notes that it is important for high-ranking women to advocate for gender equity in order for the initiatives to have credibility (rather than seeming self-serving). She talks about the process of assessing what women faculty needed and lists the changes they were able to effect (parental leave time, annual salary reviews, etc.). She explains that prior to her retirement she created the position of Associate Vice President for Women Faculty (leading to the creation of the Office of Women Faculty Programs) to insure that there would be a high-ranking individual to highlight women's issues at the institution. She underscores that even when there are more women being hired, it's necessary to aggressively address gender inequities in order for women to be given equal chances for career advancement, for their achievements to be recognized as equal to men's, etc. She then reflects on how her work as an activist for women influenced her own leadership and offers thoughts on her own leadership style: a consensus builder with a sense of how to pick the right battles. Dr. Kripke explains that she gave up traveling so she could achieve the same kind of excellence in her administrative work as she had in her research. She notes her open-door policy and believes that faculty appreciated her accessibility.
Chapter 09: The President's Panel and Post Retirement Activities

Margaret L. Kripke PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Kripke discusses the "great and unexpected honor"of serving for two terms on the President's Cancer Panel (2003 and 2006, appointed by George Bush). This experience, she says, taught her that cancer research does not necessarily serve patients, a discovery (after a career in research labs) that turned her into an advocate for changing the balance of how research is funded. She believes that the Panel's report on cancer survivorship ('03 term) helped to bring attention to the need for follow up plans when patients leave the hospital, as well as the necessity of providing them with complete medical records. She would like to see the Panel address issues of cancer prevention, noting that the most important report she contributed to was on the effects of the environment on cancer ('06 term) and how little we know about the cancer causing properties of agents in our food and environment and how agents banned in other countries are still in use in the U.S. She notes that "the government doesn't want to deal with it"and this kind of study has lagged behind everything else. The Panel took a lot of criticism for its "strongly worded report"(including from the American Cancer Society). She explains why the Cancer Panel elected to focus on environmental factors, given that only 6% of cancers are attributable to the environment. Dr. Kripke then turns to her post-retirement activities. She first talks about serving as Special Assistant to Provost Dr. Raymond DuBois to ease him into the culture and institution. She also served as ad interim department chair at the Smithville remote facility when the head stepped down. She also explains how she came to serve on the Mayor's Advisory Council on Health and Environment for the city of Houston (one project on the CEO Roundtable; one developing a resolution on obesity).
Chapter 10: MD Anderson Growth; Key Awards; Views on Women in the Workplace; A Life in Magnolia, Texas

Margaret L. Kripke PhD and Tacey A. Rosolowski PhD

In this final segment of her interview, Dr. Kripke comments on the growth of MD Anderson and on her own career and life after retirement. She begins by noting that many people think that the institution has already become too big. She talks about the loss of personal relationships, but that the mission remains strong. She notes that there were concerns at the executive level about "how big is big enough,"but that the demand for services will increase as the population ages. She explains why satellite operations offer a good solution. Dr. Kripke reflecte on what has given her most satisfaction in her career. Scientifically, she says she was pleased to move forward the Montreal Protocol, which got rid of chlorofluorocarbons (noting with pride that Al Gore mentioned her in his book, An Inconvenient Truth). Administratively, she was proud to bring a sense of fairness, transparency, and a change of leadership style to the role of Vice President of Academic Programs. She also feels she made significant contributions to women in the institution. She hopes that the Office of Women Faculty Programs will continue. Dr. Kripke then speaks about her most meaningful awards, singling out her 1984 receipt of the Lila Gruber Award for Cancer Research from the American Academy of Dermatology, since it is more meaningful to be recognized by those outside one's field than by colleagues. In the last minutes of the interview, Dr. Kripke speaks about the person behind the research and administrative personas. Her "great escape place"is in Magnolia, Texas, where she and Dr. Fidler own property. She built a pool and a greenhouse so she could raise orchids and likes country life, being a "biologist at heart." Reflecting on career expectations of her daughter and stepdaughter, she notes differences between the experiences of career women today and when she was going through her career, acknowledging that things have changed.
Chapter 01: A Dissertation Overview

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Leach describes the subject of his dissertation (entitled “Academic Medical Centers: A Framework for Strategic Repositioning”) prepared in completion of work for his Ph.D., conferred in 2011 by the University of Texas School of Public Health. (He worked on this degree while fully employed at MD Anderson.) Dr. Leach was interested in the factors that support the success of strategic initiatives. He explains that he built his dissertation around three case studies of strategic repositioning: The Baylor College of Medicine’s decision to own and operate a hospital; MD Anderson’s 2008/’09 attempts to improve operational efficiency; and The efforts of the UT Medical Branch at Galveston to expand service to additional locations. He lists the decision makers he interviewed and summarizes his findings.

Next, Dr. Leach clarifies why he pursued degrees beyond his M.B.A. while serving as Executive Vice President of MD Anderson. He sees both his Ph.D. and his M.A. in Christian Education (Southwestern Baptist Theological Seminary, 2001) as personal challenges. He describes the value of the process and discipline of working toward his Ph.D., which gave him an opportunity to serve on a restructuring committee at the Baylor College of Medicine. He gives examples of how the experience provided him with an appreciation for how different leaders view the same situation from different perspectives.<.p>
Chapter 02: Education and Work Experience

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach begins this segment with a brief overview of his modest family beginnings in Port Norris, New Jersey, where his father worked as an oyster fisherman. (He tells an anecdote about owning his own boat at the age of twelve.) He then shifts to the educational and professional path. He begins with his long relationship with The Prudential Insurance Company of America (1963 – 1973) where he began working while earning his Associates Degree from Cumberland County College in New Jersey (conferred 1969). Dr. Leach explains that he didn’t have the money to go to college, so he worked full time at Prudential (with claims) and attended class at night for virtually all of his schooling, including his undergraduate work at Rutgers University (B.S. 1973) and his studies for his M.B.A. at Widener University (1976). Once he received his MBA, he was fast-tracked at Prudential, leading to an opportunity to serve as Vice President of Marketing in Nashville, Tennessee.
Chapter 03: Moving to the Provider Side of Insurance

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach explains that his role as Vice President of Marketing for Prudential in Nashville (1980 – ’85) gave him his first experience with the health-care provider functions of insurance companies. He describes his experience managing all parts of the health-care delivery system. He then explains that his career expanded once again when Prudential purchases Merrill Lynch’s real estate division: he moved to California to become the Chief Financial Officer of the Prudential Real Estate Affiliates. When Prudential asked him to return to Newark, he says his family did not want to move again. At this point, he moved fully into the provider side of health care, developing the professional management of physician’s offices.
Chapter 04: Bringing Fiscal Sophistication to MD Anderson

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

In this segment Dr. Leach explains that by the nineties, he had “turned into a serial entrepreneur” working in high-risk situations. Rethinking his career, he realized he had reached a point where he wanted to “give back” and, very near that time, Michael Myer called to tell him that MD Anderson was looking for a CFO. Dr. Leach then describes the fiscal context when he assumed the role at MD Anderson. He also talks about John Mendelsohn’s vision for the institution and some of the changes made early in his role as CFO (e.g. shifting the institution from fund accounting to GAAP accounting; canceling managed care contracts as a shock tactic so HMOs would renegotiate).

Dr. Leach observes that Charles LeMaistre’s downsizing strategy was the right approach for the situation. He also notes that the reports submitted by the consulting firm hired to evaluate MD Anderson’s financial fate under HMOs (negatively) distorted the institution’s importance to health care delivery in Texas. Dr. Leach knew that managed care was not going to be able to “squeeze” MD Anderson.

Dr. Leach goes on to assess the institutional situation when he arrived. The administrative team was in place; he developed a business modeling system to predict how the institution would need to grow. He explains the “Value Proposition,” an equation that quantifies cost savings. As an example, he explains that the equation can show how much money MD Anderson saves patients by giving them a correct initial diagnosis (as opposed to having to correct a diagnosis given by a non-MD Anderson physician).

Dr. Leach discusses his economic forecasting model and talks about his goals as CFO.
Chapter 05: Communicating about Finances in an Academic Setting

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

In this segment Dr. Leach explains that he had to make some adjustments to work in an academic setting after years in the corporate world. He faced challenges communicating difficult financial and accounting information to MD Anderson faculty and did presentations on “weathering the storm.” He talks about coming to respect the academic side of medicine and the need of faculty to understand the measures he was instituting.
Chapter 06: A Role in a Global Institution

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Leach explains that his work at MD Anderson has been meaningful because the institution has an impact on people globally. He mentions the Dr. Ronald DePinho’s Moon Shots Program will take the institution’s mission “to a new level.” He then lists the opportunities that the institution has afforded him.
Chapter 07: Strategic Decisions and Increasing Patient Numbers

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach begins this segment by observing that strategic decisions evolve over a process. He demonstrates his point with examples from 2008-2009, when the administration addressed disturbing reports that MD Anderson was less productive than it should have been. He describes the metrics used to assess productivity and underscores the importance of bringing relevant information to the groups in a position to change matters.

He notes that a key indicator of the institution’s success is the number of new patients seen: this number was slipping in 2008, and this fact was pointed out to the faculty leadership, initiating an eighteen-month difficult process of change that resulted in a broadening of “faculty templates” (the types of patients each faculty member sees). Dr. Leach comments on how academic and corporate contexts respond differently when changes are instituted and notes that MD Anderson no longer has the luxury of such long lag times given an economic climate that demands more responsiveness.
Chapter 08: An Evolving Economic Context –and New Challenges

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach states that MD Anderson is defined by its commitment to translational research, and in 2012 one half of funds for research come from operations, with over 250 million spent on research per year. He then talks about factors that shape the institution’s balance between investments in patient care versus those in research. He notes that in the current economic climate, faculty may be required to find a different balance and spend more time in the clinic.

Dr. Leach then explains why the “triple threat” model of a faculty member (one equally devoted to research, patient care, and education) may no longer exist. The institution, he says, may have to depend more and more on specialists, as the economic context is evolving and the institution must respond to be successful. This will demand different faculty roles.
Chapter 09: The Economic Forecasting Model: A Tool for Growth

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach begins this segment with comments on how MD Anderson grew under the leadership of Dr. John Mendelsohn and how they worked to balance resources in order to develop research.

Dr. Leach then discusses the Economic Forecasting Model he began to use on arriving at MD Anderson to predict the pressures that specific growth initiatives would place on operating margins. He describes the variables, limits, and uses of the model. In the former economic context, predictions were valid for six years. Now it is more uncertain.

Dr. Leach explains that the forecasting model was his brainchild, developed while he was in the insurance industry, and refined to suit MD Anderson and bring intellectual rigor to the budget for the first time. It is a key strategic planning tool.
Chapter 10: Growth Initiatives: Capital Campaigns, Global Oncology

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach begins this segment by explaining that funds from the Capital Campaigns are all factored into the Economic Forecasting Model. He briefly mentions his role in keeping the Board of Visitors aware of what his office is doing to develop the institution. He then moves to the Global Oncology initiative, which was started because of data that indicated that the institution was paid more for patients who came from out of state. He then talks about the international sister institutions and MD Anderson Banner. He explains that the goal is not necessarily to bring these institutions to the level of care offered at MD Anderson, but to raise the level of care as high as it can go. In addition, quality of care at these other institutions is the primary considering; spreading the MD Anderson brand and increasing name recognition is a secondary consideration.
Chapter 11: Financing the Moon Shots Program and Changes to MD Anderson Structure

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach begins with general comments on Dr. Ronald DePinho’s Moon Shots Program –a speculative and expensive initiative, he says, designed to move the bar. He notes his belief that the most exciting developments in cancer will be coming in the next four to five years.

Dr. Leach then explains that, with the complexity of research today, a new framework is needed to think about conflict of interest. He then notes that the Moon Shots will reorganize all of MD Anderson, moving the institution to more efficient structures that free faculty members’ time so they focus on what they do best.
Chapter 12: Bringing Structure to MD Anderson’s Finances; Developing Spiritual Strength

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Leach summarizes his contributions to MD Anderson and the growth his work on higher degrees has offered him. He first stresses that MD Anderson has undergone exponential growth and moved to a more businesslike structure, and he underscores that an institution must be self-sufficient so it is free to reinvent itself.

Dr. Leach then says he has been pleased to have a role guiding the finances and structure for the institution’s accomplishments, which have come through the efforts of fantastic doctors, scientists, and research support.

Dr. Leach then talks about the degrees he earned while serving as Executive Vice President: his Ph.D. in Public Health and his M.A. in Christian Education and what they contributed to his abilities to perform in his role for MD Anderson. The M.A., he explains, helped him develop patience, a quality that takes spiritual strength. He needed patience to deal with complex challenges in strategic positioning.
Chapter 13: A Prescription for Fiscal Health: Be Pro-Active

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach begins with segment by explaining that institutions tend to hold onto the old rather than moving ahead into change. He then talks about activities that will enable MD Anderson behave pro-actively in the current and future economic context. He notes the importance of commercializing technology, of moving science to the bedside, and establishing relationships with other institutions. MD Anderson, he says, does well with managed care companies, as they recognize value, though he is not certain that the federal government will do the same. He says that health care is a current target of the federal government as health care represents 20% of the economy. He expects that the institution will create savings from a more streamlined organizational chart and continued strategic positioning. He discusses his roles with the state government in Austin.
Chapter 14: MD Anderson Presidents, Values, and Teams

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach begins this segment with the observation that John Mendelsohn and Ronald DePinho were the right leaders for their times. Dr. Mendelsohn had the courage to invest, he says, and turned MD Anderson into one of the few exceptions to the managed care rule. Now Ronald DePinho is building on John Mendelsohn’s work. He talks about “moral suasion” and the importance of communicating.

Dr. Leach then talks about MD Anderson’s values and the moral responsibility that the institution has to deliver on their promise.

At the end of this segment Dr. Leach names important members of his staff and says that the secret to success is hiring well so one can benefit from the strength created by building a team.
Chapter 15: Strategic Financial Initiatives: MD Anderson España

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Leach explains that the increasing costs of health care signaled that traditional reimbursements for medical services were going to come under pressure, creating the necessity to look for other revenue streams. The sister institutions created such a possibility as well as satisfying the institutions mission to eradicate cancer globally.

Dr. Leach tells the story of starting his first day on the job in September of 1997, meeting with President Dr. John Mendelsohn and then immediately going cold into a meeting with Spanish representatives to talk about opening a cancer center from scratch in Madrid. Dr. Leach explains why the Madrid location was selected and describes some of the challenges met. He explains the main lesson learned: that MD Anderson is best suited to guiding institutions to create new cancer centers, rather than itself owning and operating new centers.

The España project gave rise to a new department for consulting services, Global Business Development.
Chapter 16: Strategic Financial Initiatives: The Story of the Proton Therapy Center, Part 1

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

In this segment Dr. Leach explains the rationale for building MD Anderson’s Proton Therapy Center and describes the unusual financial partnerships that enabled it to be funded. He begins by noting that only a few proton centers existed with only one providing patient care –and that one, in Loma Linda, California, only treated prostate cancer. Dr. James Cox [Interview # 32] made the case that proton therapy was a next step in cancer care. He notes that he ran feasibility studies that confirmed that MD Anderson had the patient volume to support a Proton Therapy Center offering treatment for many different cancers. Dr. Leach then describes a first attempt to finance a center in partnership with Tenet Healthcare Corporation and why that failed. He explains the feasibility studies done regarding patient availability and the possibility for reimbursement, and other financial concerns at the time. (23:00) He then talks about the consortium that responded to the call for proposals: The Styles Company (a healthcare development company) and the Sanders Morris Harris Group (investment banking firm), both Houston based. He goes on to explains what these companies brought to the project, who eventually invested, and (25:00) sketches the innovative dimensions of the consortium/partnership between a government supported academic institution (not usually business friendly) and private investment. Next Dr. Leach explains why some technological challenges made it necessary for the Proton Therapy Center to open with only one of its four gantries in operation and outlines the financial implications this had on Hitachi, the company providing that technology. The delay opened the possibility that investors could return their shares to Hitachi, receiving back their money plus a percentage of their investment. The Center ran for a year with only one gantry.
Chapter 17: MD Anderson Banner and Satellite Care Centers

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Leach sketches the partnership established with Banner Healthcare in Gilbert Arizona, leading to the opening of MD Anderson Banner in 2011, the first fully autonomous center carrying the MD Anderson name. Dr. Leach explaining that the motive to expand beyond 1515 Holcombe comes from the MD Anderson mission –to cure cancer in Texas, the U.S. and the world. The center at Banner came about as MD Anderson experimented with a process of adapting MD Anderson care procedures to make them more universal. He notes that MD Anderson seeks out institutions with which there is a “meeting of minds” on how cancer services must be delivered.

Dr. Leach describes MD Anderson’s multi-disciplinary approach to treating patients, giving the example of the wide range of options that teams consider for prostate cancer.

Dr. Leach explains that MD Anderson is open to establishing partnerships with institutions that embrace a multi-disciplinary approach. MD Anderson does not need to seek out partners, as institutions approach MD Anderson. Dr. Leach next talks about the many lessons learned by establishing partnerships. He mentions MD Anderson Orlando, Florida, which he says eventually morphed into a Banner-like situation. He explains some of the financial challenges setting up MD Anderson Espana, an initiative that also became more like Banner. Through these experiments, “We now know what a good partner looks like.” Dr. Leach then discusses the regional care centers, explaining that they were created to offer patients more access to services.

Dr. Leach explains how MD Anderson insures the quality of care at satellite centers, giving an example of MD Anderson physicians in Houston confer via teleconference with colleagues at MD Anderson Espana.
Chapter 18: Tools for Economic Modeling and the Budget at MD Anderson

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Leach explains how economic modeling and budgeting works for the entire institution, using a “current year plus six years” plan. This long view helps his team accommodate building plans, anticipating the financial effects of expansion. He explains several cost-saving measures that have been taken to bring the budget under control. He is also proud to report that administrative costs for the institution have dropped 4% (from 15% to 11%) since 2008 and there are 200 fewer employees in Business Affairs. Dr. Leach describes how financially-focused employees are imbedded throughout the institution, influencing the complexity of bringing these costs under control.
Chapter 19: A New Economic Climate Will Shape MD Anderson’s Fiscal Future

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

In this segment, Dr. Leach explains that the Affordable Care Act will drive systemic economic changes that will have a dramatic impact on MD Anderson’s finances. He anticipates that the sister institutions and regional care centers will help bring in patients and that it will be necessary to continue to seek out cost-saving measures. Dr. Leach also states that the Moon Shots will eventually generate technologies that the institution can commercialize: the Moon Shots have already created interest from donors and philanthropy has increased. He explains that unlike previous financial fluctuations, the current economic situation represents a “sea change” in which the country is now saying “We won’t pay so much for health care.” MD Anderson’s financial health is connected to the nation’s limited resources, and Dr. Leach explains that the institution must continue to be “a good steward” to be successful.

Dr. Leach explains that, with the new financial realities, MD Anderson will become more patient-centered. He then explains that that the MD Anderson mission to cure cancer will carry the institution through. He anticipates that the institution will become a leader in looking at patient outcomes, noting that the world already has confidence in MD Anderson and that “we have what it takes to thrive.”

Dr. Leach acknowledges that academic institutions are slow to change and speaks about anticipated faculty responses to the need to change. He then describes the shift in thinking that everyone at MD Anderson has to embrace in order for the institution to move forward. He explains the paradox of getting individuals to accept that “We’re number one and you want us to change.”
Chapter 20: The Proton Therapy Center, Part 2

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach explains that the 2008 financial meltdown resulted in a financial situation in which MD Anderson was able to purchase shares in the Proton Therapy Center previously held by other investors at a very good price. He lists the parties that came together to form the unique public/private partnership financing the Center and explains what the Center means to MD Anderson.
Chapter 21: Streamlining the System

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach describes the review of administrative processes conducted in 2012, shortly after Dr. DePinho’s took over as president of the institution. He gives background on the review and explains why Dr. DePinho requested that MD Anderson perform it earlier than required. He describes the constitution of the committee in charge of the review and their recommendations: reducing administrative overhead and staffing, reducing redundancy in staffing.

Dr. Leach asserts that, despite the economically challenging times, the institution needs to continually invest in research to preserve what MD Anderson’s leading thinkers and doers in care. Research, he states, is the “driver for who we are.”

Dr. Leach repeats, however, that the institution must learn to operate differently or risk not being as robust as it is currently.
Chapter 22: Communicating the Need to Change

Leon Leach MBA, PhD and Tacey A. Rosolowski PhD

Dr. Leach talks about how he communicates with faculty and staff at MD Anderson about the need to change. He explains that he has been influenced by Harvard leadership specialist, John P. Cotter, who wrote a book called A Sense of Urgency. Dr. Leach explains some basic concepts from the book, then describes how he goes about talking to heads of departments and divisions to create buy in from leading faculty members who will disseminate the message.
Chapter 01: A Good Education and an Early Focus on Being an Academic

Norman Leeds MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Leeds sketches his family background and his educational path up to his decision to focus on neuroradiology. He begins by explaining that his father was a pediatrician who ran his practice from the family home, giving Dr. Leeds the opportunity to observe the demands of clinical practice. For that reason, he explains, as well as the fact that he was drawn to teaching and leadership, he always wanted to be an academic.

Next, Dr. Leeds talks about the education he received at preparatory school and in college at Yale College [University, BA, 1948], and why he wanted a broad education. He then talks about applying to medical school [MD, 1953, New York Medical College, New York, NY] and his work for the U.S. Public Health Service as a Senior Assistant Surgeon in Memphis [1955-1957], then he return to New York City, where he had an opportunity to work in clinics.
Chapter 02 : Choosing Neuroradiology at the Field’s Infancy

Norman Leeds MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Leeds explains why he chose to specialize in neuroradiology when the field was in its infancy. He notes that he was one of the founders of the American Society of Neuroradiology (ASN) in 1960 and that he was the first individual to receive an NIH Fellowship in this new field. He talks about his mentor, Dr. Tavares.

Next he sketches the state of the field and the challenges involved in diagnosing neurological issues. Dr. Leeds notes that he and Dr. Tavares wrote a book on the veins in the brain; he describes brain angiography and talks about the importance of understanding anatomy.

Next, Dr. Leeds notes that three of the original fourteen founders of the ASN are still living. He then briefly sketches his career track and major colleagues from his 1961, when he was hired as an assistant professor in the Department of Radiology at the University of Southern California at Los Angeles until his role as Director of Department of Radiology and Radiation Therapy at Beth Israel Medical Center in New York [1985-1991].
Chapter 03: A Detailed Understanding of Brain Circulation

Norman Leeds MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Leeds talks about his early research contributions to neuroradiology. He began his work with a focus on understanding the circulatory system of the brain in detail and he achieved expertise in brain angiography and brain circulation time, which led to other discoveries. He notes that he was the first to do a magnification angiograph and the first pediatric radiologist. He also notes his work on genetic abnormalities and pattern in neuroradiology.
Chapter 04: An Evolving Field; Dealing with Patients; Leadership Advice

Norman Leeds MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Leeds recalls finding out about an opening for a neuroradiologist at MD Anderson and explains the process he went through to decide to take the position. As his wife, Betty, preferred not to leave New York City, they set up a long-distance marriage.

Next, Dr. Leeds also notes that he wanted to give up chairmanship of neuroradiology at Beth Israel Medical Center and believed that focusing on brain tumor radiology offered a good opportunity for him. He notes that he came to MD Anderson as Head of the Section of Neuroradiology.
Chapter 05: A New Opportunity at MD Anderson

Norman Leeds MD and Tacey A. Rosolowski PhD

Dr. Leeds recalls that he attended the first talk about the new CT technology in the U.S. He comments on the administrations reluctance to invest in the new technology because of the prices, rather than focusing on the revenue it might generate.
Chapter 06 : Early Research that Leveraged the MD Anderson Team Approach

Norman Leeds MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Leeds begins to trace the history of the research he conducted at MD Anderson. He begins by talking about his work (1998-2000) on imaging techniques to differentiate brain tumors from trauma and other causes. He discusses three-dimensional imaging and functional imaging and their roles in this process.

Next he talks about a landmark investigation of the use of dynamic contrast enhancement to identify malignant brain tumors. He notes that this technique became a significant factor in brain surgery.

Dr. Leeds next praises the team, multidisciplinary approach that was important to his research advances and which he says makes MD Anderson unique. He talks about the breadth of experience that MD Anderson faculty bring to research teams, the number of cases they have access to.

He briefly speaks about losing his wife to ovarian cancer.
Chapter 07: Research on Brain Necrosis and Work in Neuro-Pediatrics

Norman Leeds MD and Tacey A. Rosolowski PhD

Dr. Leeds begins this chapter with the statement that his “real contribution” was in studying the impact of cancer therapy on brain necrosis and its effects on brain tissue. He gives the example of a twenty-two year old patient who died from treatment induced brain necrosis.

Dr. Leeds then comments on how work of this kind demonstrates the value of specialty hospitals that bring together people, teams, and materials. He then talks about the impact of Dr. Raymond Sawaya, chair of Neuro-Surgery.

Dr. Leeds then talks briefly about the difficulty of treating brain cancers, particularly glioblastoma, the successes that have been achieved.

Next, Dr. Leeds turns to his work in neuro-pediatrics. He summarizes his professional path to neuroradiology then explains that he met Dr. Kenneth Schulman who asked him to come to University of Pennsylvania Children’s Hospital [CHOP]. Dr. Leeds explains how children’s cancers differ from those seen in adults, a subject he has investigated. He notes that he helped create a strong pediatric neurology program at CHOP, one that eventually became a leading program in the nation. He notes that MD Anderson’s pediatric neuro-oncology program became stronger over time.
Chapter 08: More Research on Techniques to Determine Physiology

Norman Leeds MD and Tacey A. Rosolowski PhD

Dr. Leeds explains that after his work on brain necrosis, he returned to studies focused on physiology. He talks about a book he published with Dr. Juan Tavares on identifying dynamic changes with cerebral angiographs. He notes that angiography created the foundation of his knowledge in the field.

He then turns to more recent work on physiological questions, including interpretation of data from stains. He notes the importance of distinguishing tumors from lesions created by stroke.

Next he talks about the fellowship program and his continued interest in passing on his valuable depth of knowledge to others.
Chapter 09: Perspectives on Serving as an Expert in Lawsuits

Norman Leeds MD and Tacey A. Rosolowski PhD

Dr. Leeds begins this chapter by expressing his concerns about the impact that lawsuits brought against physicians can have on research. He discusses two cases in which he was called to provide expert testimony.
Chapter 10: Educating the Next Generation and Concerns about the Future of Healthcare

Norman Leeds MD and Tacey A. Rosolowski PhD

Dr. Leeds explains that now that he comes to MD Anderson only one day a week, he focuses on educating fellows and students. He comments on the high quality of the next generation of physicians and researchers.

Next he explains his concern over the rising cost of medicine and the specter of a single-payer system which, he feels, would not offer quality people the financial incentives to stay in medicine.
Chapter 11 : Some Views on Change and a Big Vision for the Future of the Neuro-Services

Norman Leeds MD and Tacey A. Rosolowski PhD

Dr. Leeds begins this chapter by talking about changes in Neuroradiology when Dr. William Murphy stepped down as chair, succeeded by Dr. Donald Podoloff [oral history interview]. He compares the temperaments and leadership styles of the two men.

Dr. Leeds then talks about a vision he shares with Raymond Sawaya [oral history interview]: to develop a neuro institute that would bring together all the fields working in neuro and would also feature a dining room to bring back some of the congenial feel of the older MD Anderson.

Dr. Leeds expresses the opinion that MD Anderson is too big, and the size creates obstacles to communication and collaboration. He tells a story about successfully getting money for an MR by talking to the CFO over lunch.
Chapter 12: Reflections on a Marriage and Family

Norman Leeds MD and Tacey A. Rosolowski PhD

In this chapter, Dr. Leeds shares recollections of his wife, Betty, a woman for whom he had great love and respect. He also talks about his children and grandchildren, sharing advice he gives them.
Chapter 01: Family and Politics in South Africa

Bernard Levin MD and Tacey A. Rosolowski PhD

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: Medical Training in South Africa

Bernard Levin MD and Tacey A. Rosolowski PhD

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: Coming to the United States for Further Training

Bernard Levin MD and Tacey A. Rosolowski PhD

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: A Political Conscience

Bernard Levin MD and Tacey A. Rosolowski PhD

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: An Interest in Malignancy

Bernard Levin MD and Tacey A. Rosolowski PhD

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: An Interest in Clinical Trials, Design of Research, and Government Oversight

Bernard Levin MD and Tacey A. Rosolowski PhD

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 Challenges of Creating a Multi-Disciplinary Section of Gastro-Intestinal Medical Oncology

Bernard Levin MD and Tacey A. Rosolowski PhD

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.
Chapter 08: Mentoring and Research

Bernard Levin MD and Tacey A. Rosolowski PhD

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: Challenges to the Division of Cancer Prevention

Bernard Levin MD and Tacey A. Rosolowski PhD

Dr. Levin begins this Chapter 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: The New Division of Cancer Prevention (and Questions about Whether It Should Exist)

Bernard Levin MD and Tacey A. Rosolowski PhD

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: The New Division of Cancer Prevention: Defining Its Scope

Bernard Levin MD and Tacey A. Rosolowski PhD

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: Expanding the Scope of Cancer Prevention

Bernard Levin MD and Tacey A. Rosolowski PhD

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: Cancer Prevention: Expanding into New Departments and Programs

Bernard Levin MD and Tacey A. Rosolowski PhD

Dr. Levin begins this Chapter 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 Administrator;s 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: Expanding the Division of Cancer Prevention, Funding Sources, and Public Awareness

Bernard Levin MD and Tacey A. Rosolowski PhD

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 Chapter 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: The Culture of the Division and Its Impact

Bernard Levin MD and Tacey A. Rosolowski PhD

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.’
Chapter 16: Leading a New Division and Lessons Learned

Bernard Levin MD and Tacey A. Rosolowski PhD

In this Chapter, 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: The MD Anderson Presidents

Bernard Levin MD and Tacey A. Rosolowski PhD

Dr. Levin begins this Chapter 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 after his stroke and became friends with him. (Dr. Levin notes Dr. Clark’s charm as well as his poor taste in restaurants.) Dr. Levin also became his physician after Dr. Clark developed colon cancer. 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: Conflict of Interest, MD Anderson Leadership, and Protection for the Institution and Patients

Bernard Levin MD and Tacey A. Rosolowski PhD

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 Chapter with some observations about nepotism.
Chapter 19: Strategies to Build Public Awareness of Colorectal Cancer

Bernard Levin MD and Tacey A. Rosolowski PhD

In this Chapter, 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: Leading the Section of Gastrointestinal Oncology

Bernard Levin MD and Tacey A. Rosolowski PhD

[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 Chapter: At explanation of what this training program would provide.]
Chapter 21: Service to National and International Organization and a Small Cancer Center

Bernard Levin MD and Tacey A. Rosolowski PhD

In this Chapter, 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: The Division of Cancer Prevention, Awards, and an Active Retirement

Bernard Levin MD and Tacey A. Rosolowski PhD

In this Chapter, 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.

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