Seymour Levitt, MD, DSc, FASTRO

By Luther Brady, MD, FASTRO, and David Hussey, MD, FASTRO

In 2002, ASTRO established the History Committee for the purpose of documenting and recording the history of radiation oncology in the United States. This interview took place at the 44th Annual Meeting of the American Society for Therapeutic Radiology and Oncology in New Orleans on October 7, 2002.

Question: I am David Hussey, and I'm a member of the ASTRO History Committee. Over the past several years our committee has been interviewing members of the Society who have made significant contributions both to ASTRO and to the specialty. Today is October 7. We're in New Orleans at the Annual Meeting of ASTRO, and we're interviewing Dr. Seymour Levitt, who is currently at the University of Minnesota. The other interviewer besides myself is Dr. Luther Brady. Now with that, we can start the interview and, Sey, I wonder if you could give us some background, starting, I guess, actually, from you were born and going through where you trained and how you ended up where you are. Okay? 

Dr. Levitt: Well, I was actually born in Chicago, but I was moved to Denver when I was a year-and-a-half old. I actually was raised in Denver and went to elementary school, high school, college and medical school in Colorado. And from that time when I finished medical school, I took an internship at the Philadelphia General Hospital and from there spent two years in the Army, came back to take an internal medicine residency at the University in California in San Francisco; I then changed to radiology. I then spent an additional three years in radiology and most of it in radiation oncology. At that time the head of the radiation therapy section or division of the department of radiology at the University of California was Dr. Franz Buschke, who was quite an important, eminent actually, an outstanding radiation oncologist. He was the head of the department, and a young man by the name of Jerome Vaeth was one of the junior staff people who was there who had trained with Dr. del Regato. Those people had a great influence on me, and I decided that I wanted to learn more about radiation oncology and moved to Ann Arbor after I finished my residency and spent a year with Dr. Isadore Lampe at the University of Michigan. I then spent the year following that at the University of Rochester with Dr. Rubin. And from there I went to the University of Oklahoma. I was there three years and moved to the Medical College of Virginia, was there four years and finally to my present home, the University of Minnesota, and I've been there now for 32 years and I was chairman of the department there for 29 years.

Question: You alluded a moment ago to the fact that you made your decision to do radiation oncology when you were at the University of California in San Francisco. What really influenced you in making that decision? 

Dr. Levitt: Well, I must admit that I went into radiology because I, after spending a certain amount of time in internal medicine, realized that was not something that I wanted to do with the rest of my life for various reasons. And so I went into radiology, just thinking it was something I thought I would like to do. And when I was in that residency, I did come into contact with Dr. Buschke. That was very much of an eye-opener because, really, radiation oncology in that period of time, that had been sort of an unknown specialty to most of us. We had very little, if any, contact with it while we were medical students or even in internship, so we knew very little about it. He opened a whole new view of radiation oncology. Dr. Buschke, Franz Buschke, was an extremely unusual individual. He was a complete physician. When we were training, the patient had to be seen and examined, and the slides had to be looked. If there was a cystoscopy or any interventional procedure, one of the radiation oncology residents or staff had to be there. So he was, in addition to being an outstanding radiation oncologist, he was also an outstanding pathologist and he was a complete physician.

Question: I was impressed, I think, with two of the names you mentioned. Both Dr. 

Buschke and Dr. Lampe, I think, have trained a lot of radiation oncologists who went on to become chairs of departments. And I've always wondered why that was so. I mean, was it the fact that they were complete physicians? Did they have charisma that would … you know, good role models? 

Dr. Levitt: No, I think they were both very good role models, but they were quitedifferent personalities. Buschke was ... he was ... comes from the earth. He was very open, very warm, had a wonderful sense of humor and more on the European style. Lampe was—I have said this before—I think ...

Question: He seems very taciturn... 

Dr. Levitt: He was taciturn, usually smoking on a pipe. He was very, very bright and hewas an excellent clinician. He was the best clinician that I have ever had contact with. I mean, he really knew...his examinations of the patients were superb.

Question: He totally set up the patients ... all the patients himself. 

Dr. Levitt: Every patient every day was checked by either himself ... even though as the resident we check ... or I came there as a senior—not a senior resident, but as a post-residency position, an instructor if you will—either he or senior staffers had to check every field every day. That's what he did.

Question: But also, too, it seems to me, knowing Dr. Lampe, that he had an inordinate sense of the necessity in keeping good records and reviewing those records on an ongoing, continuing basis to have impact on changing treatment programs in a beneficial way for the patient. It seems to me that that comes through in my discussions with you but also with the others who were there who ultimately became chair, like Bob Parker, both at the University of Washington and at UCLA in Los Angeles, Phil Rubin at Rochester and Malcolm Bagshaw at Stanford. Is that a reasonable assessment of this kind of commitment to data? 

Dr. Levitt: He had superb records for follow up on patients. Even in the days beforecomputers, he was extremely well organized; he had a very organized, very orderly department. He did have excellent follow-up on patients and it was a very eye-opening experience also, in a sense different from Buschke, but in a sense just another aspect of excellent radiation oncology and which wasn't really available much outside of a number of very few institutions.

Question: He used to keep things on IBM punch cards. 

Dr. Levitt: He had punch cards.

Question: And upgraded them on a constant, ongoing, continuing basis. I remember all the little probes that you could put through to find the various groups of patients. 

Dr. Levitt: Yes, you could punch another hole in the card, absolutely, for all those patients.

Question: It was impressive, you know, because we think now that computers are the answer to everything that we need to do, but even though primitive at that point in time, it was clearly the beginning of a computer age which, goes back...I dare not say how long ago, but certainly ... 

Dr. Levitt: It's a few years ago.

Question: A few years ago. 

Question: And his anticipation of the importance of this kind of record keeping. 

Dr. Levitt: Well, he was ... yeah, he was really a scientist in a sense. He was a goodclinician, but he was a mathematician and a scientist. You know, he did go to Berkeley and had a doctorate of philosophy from Berkeley in nuclear physics. So he was a very unique individual, as was Buschke in his own way. In different ways they were very unique and they were very influential, and as you said, there were a number of people trained by Dr. Buschke, including Ted Phillips, myself and the whole school in San Francisco. But Lampe had a very important influence on the field and on people going into radiation oncology, including the people you mentioned, Phil Rubin, Bob Parker, Malcolm Bagshaw and myself, because I certainly would not deny that he had a tremendous influence.

Question: Tell me a bit about your experience in Rochester 

Dr. Levitt: ... Dr. Rubin and I think it was an experience also because it was somewhat different in the sense that they were doing more research, radiation research, and there were at that time one of the people that was working in the field, not as part of Dr. Rubin's department but outside the department, a man by the name of George Casarett who was an outstanding radiation pathologist and a wonderful, wonderful individual—warm, very wonderful human being. During the time I was there, Jack Meiers was there who was also doing research.

Question: Was that a separate department? 

Dr. Levitt: I think it was a division of the department of radiology. But it was pretty independent in a sense.

Question: I remember that two-volume book. 

Dr. Levitt: Yeah, well ... that was actually probably still his best work in radiation pathology. Although there's been a more recent book, it's not quite the same because the more recent book had the input of essentially radiation pathologists. The Rubin/Casarett book had the input of both the clinician and the pathologist, which was very important.

Question: If you move on to your next academic appointment, which was at the University of Oklahoma, how would you judge that in terms of its impact on your ultimate contributions in radiation oncology? You were there only a short period of time. 

Dr. Levitt: I was there three years. I had the opportunity really to do some clinical research based on some research that had been done before. It was really a unique situation in the sense that there really hadn't been a strong radiation therapy program there. While I was there we set up a training program and we had some residents in radiation oncology—not just general radiology residents. So I think that was important. I became more involved in writing and although I had written publications before, but in research, in clinical research. I think that one of the important papers that came out at the time was the first paper that looked at the effect of hypertension in arteriosclerosis on survival in cervical cancer patients, which actually was the first paper on that. Also, I became interested in vascular changes and the impact on survival. Of course, Gray had already written a lot about, so far as experimental data was concerned, but I think that this was an initial paper that looked at how these arteriosclerotic changes and/or hypertension would affect response to treatment for cervical cancer patients.

Question: When you went to the Medical College of Virginia in Richmond, it seems, if I remember correctly, you had the unique opportunity to work with a urologist, Dr. David Hume. Was it Dr. David Hume? 

Dr. Levitt: David Hume was a surgeon.

Question: Surgeon. 

Dr. Levitt: Yes, he was a surgeon and he was doing a lot of kidney transplants, and actually that was a center for kidney transplants at the time that I was there and even before then. And so they had a long history of that and I did have the opportunity to work with him. I also worked with a surgical oncologist, Walter Lawrence, and that was a good experience for me. And also I had more administrative responsibilities when I was there, so I felt I gained some skills.

Question: You also had a unique opportunity to work with Richard King. 

Question: The Richard King, yes.
 
 Question: Were you chair in there? 

Dr. Levitt: No. It was a division. It still was a division. Actually, Oklahoma was a division. This was a division and Virginia. And it was a, you know, I think all of the experiences you have as you move or encounter new colleagues and new situations, I think, are learning experiences if you accept them as such.

Question: But the paper that you and Dr. Hume published, which was in Acta Radiologica I think, summarizing the whole experience relative to the immunosuppressive benefits that accrued as a consequence of the radiation of the kidney transplant, still stands and now some resurgence of interest actually in that area, even though it may follow for a long time. But the critical key paper that really, in my opinion, warrants being read again by people talking about benign disease, or not so benign disease at this particular point in time. I know that Dr. King was really more interested in nuclear medicine. 

Dr. Levitt: Yes.

Question: And so, therefore, the relationship really was primarily more of that kind of a relationship between radiation oncology on one hand, even though he was a radiation oncologist, but had a greater interest in nuclear medicine. Did that offer any opportunities for integrated kinds of activities between nuclear medicine and radiation oncology? 

Dr. Levitt: No. Well, not really, no. But I think what ... it's nice to have the stimulus because I think one of the things that may have had a major impact—probably did have a major impact on me—was the fact that at both the University of Oklahoma and at the Medical College of Virginia essentially I had to establish a program of radiation oncology, which was quite different than what most of the other department people interested in oncology were used to.

Question: In what way? 

Dr. Levitt: In the sense that it set up a situation where they had to realize that the radiation oncologist, radiation was as a consultant, was going to make his or her own decisions and decide which patients were going to be treated and which were not going to be treated and how to determine the dosage and the way the patients were being treated.

Question: So you are talking about in relation to other cancer care physicians and not necessarily the diagnostic radiologist. 

Dr. Levitt: And this created a number of conflicts, as you can well imagine, because that was not the way radiation therapy was considered in those days in most institutions.

Question: How is that? 

Dr. Levitt: In most institutions it was considered service and not a medical specialty.

Question: Where you got a prescription from a surgeon. 

Dr. Levitt: That's right.

Question: As you came to these various institutions, was that philosophy present and then you had to change it? 

Dr. Levitt: That was the situation that was present, and I had to change it, which was not always greeted warmly. [Laughter] But it was okay because I was quite enthusiastic. I still am enthusiastic about radiation oncology, and I felt that it was an important thing to do and I felt that it was ... I mean, there were situations that I could talk about that would, for example, one urologist had a patient who'd been treated three or four times before and was having a problem, and the urologist wanted the family to think that the patient has been treated,and said to me, "Why don't you treat the patient again." and I said, "I can't treat this patient. He had all this treatment before. It's a very bad situation." "Well, why don't you just take him in the room and turn on the light."

Question: Sham irradiation. 

Dr. Levitt: Sham irradiation. And I said, "Well, why don't you take him up to the operating room and put a scratch on his abdomen and tell him that you've done an operation," which, of course, created a ... [laughter] … it was a situation. But it's okay. I think it's important to maintain your integrity. I think it's really critical.

Question: I think all of us actually who grew up in that period had the same kind of experience in trying to establish the validity of the specialty as a physician who was going to be managing patients. I mean, I think both Dr. Hussey and I can quote similar kinds of situations that you've just quoted there. When you left Virginia to go to Minnesota, it wasn't necessarily stepping into a bright, brilliant program. 

Dr. Levitt: No. [Laughter]

Question: It was in some sense not unlike stepping into Oklahoma or into the Medical College of Virginia because you really had to build the entire department again from where the physicist was doing the radiation therapy to where the physician made the decisions. 

Dr. Levitt: Well, the history of the University of Minnesota was very interesting becauseup until 1956, the person in charge of the radiation therapy group was Dr. Stenstrom, who was a physicist. There was always a physician there to do the medical things that were necessary, but the decision as to dosage and things like that were quite dependent on Dr. Stenstrom, which was sort of an interesting situation because the University of Minnesota in the 1950s and early 1960s was one of the most outstanding radiology departments in the world. Leo Rigler was the head of that department. But their approach to radiation oncology was unbelievable in that there was not a physician doing that. It was a physicist.

Question: There was sort of the attitude that radiation oncology was a service rendered by the diagnostic radiologist to continue the referral of the patients for diagnostic procedures. 

Dr. Levitt: Well, I'm not so sure it was that so much as they just didn't consider it, really, a separate specialty in a sense. They thought that you didn't need a lot of skills to be a radiotherapist.

Question: Was that unique to Minnesota or were there other institutions where that occurred. 

Dr. Levitt: I don't think that happened anywhere else. I'm not aware of any other placesthat had that situation going on.

Question: And it wasn't a situation that they just couldn't find a radiation therapist to come? 

Dr. Levitt: I'm not sure they even looked. When Dr. Stenstrom retired, then they brought in Donn Mosser who is a physician, as head of the division. From that time on there were physicians who were in charge of the program.

Question: Well that's fascinating. A fascinating story. 

Question: When you got to Minnesota, what really were the facilities like? The equipment? Space? 

Dr. Levitt: I had to carve out the department. My requirements for moving to Minnesota were that a separate department would be set up. Dr. Buschke was constantly saying that radiation oncology needs to be a separate department. It has to be because we are so different from the radiology department, they had to be separate. And I think that was something that many, many people felt, including yourself. But one of the reasons that I moved to Minnesota was the fact that they were willing to set up a separate department of therapeutic radiology, radiation oncology. When I came there, there was one physicist and there was one graduate student who happened to be Faiz Kahn. There was not Dr. Muriyama who had been there, Dr. Muriyama and Dr. Sheri Yule were the clinicians that were there when I came. Muriyama was doing research, but other than that, there was no real radiation biology research going on. The equipment was a cobalt unit, a linear accelerator and a simulator, which had been purchased from Toshiba for a package deal. So we did have a linear accelerator, which was a 13 MeV linear accelerator, and we had a simulator and we had sort of an archaic computer system. And the physical facilities were really pretty bad. I mean, they were, you know, we were using a basement across from the morgue.

Question: That was in somewhere around 1965, was it? 1966? 

Dr. Levitt: No, 1970.

Question: 1970. 

Dr. Levitt: 1970.

Question: I remember you coming by Iowa, though, and I thought you were on your way from MCV to Minnesota while I was there. I went to M.D. Anderson in 1968, so you must have been coming back from ... 

Dr. Levitt: I was probably on my way on a visit somewhere because I moved, actually looked at, it was 1969 that I was looking at Minnesota. It's possible that's when I was looking there and agreed in 1972 to go and actually landed.

Question: In 1970, Minnesota actually must have been one of the early ones that actually split the department.
 
 Question: The first department that I knew of was at Thomas Jefferson University with Simon Kramer and the second one was my department at Hahnemann University, and you were right at third or fourth. 

Dr. Levitt: There were three or four of us at that time, so ours was one of the first, not the first but one of the first.

Question: But the truth is that over time there has been a major movement toward independent academic departments in radiation oncology to where, at my last count, 90-95 out of 125 medical schools have independent academic departments in radiation oncology. 

Dr. Levitt: Before coming on, we heard today that Hopkins is getting a separate department and I think Washington University in St. Louis now is.

Question: It became a separate department in June of 2001. 

Dr. Levitt: There’s a movement that's in that direction. We sat there until about 1980 when they built a whole new department for us, which is quite spacious, but we were in cramped quarters for quite a while. But I think we were very fortunate. I had Faiz Kahn who became our chief of physics and I recruited Chang Song who had been with me in Virginia. And I became interested, actually as I had mentioned earlier, I was interested in vascular effects of radiation and he had been doing work in that area, so he came along and then joined me in Minnesota.

Question: When you went there, they did not have a training program in radiation oncology. 

Dr. Levitt: No, they did not then.

Question: You went in 1970. How long after that did you initiate the training program in radiation oncology? 

Dr. Levitt: Almost immediately. And I think we, for the first two or three years, we continued to have residents rotating through general radiology. I was fortunate to be able to talk some of them into becoming radiation oncologists.

Question: That's seems to have been a time of change. That was just about the time that people stopped doing general radiology training and doing straight radiation therapy. 

Dr. Levitt: That's exactly...

Question: The decision made by the Residency Review Committee in radiology at that point and the American Board of Radiology to initiate the transition to separate programs of training in radiation oncology would be about 1972 to 1973. The American Board of Radiology called a meeting in Dallas, Texas, of 35 preeminent radiation oncologists with the clear understanding to begin development of an independent program in radiation oncology with written examinations and oral examinations and to encourage the Residency Review Committee to develop the criteria by which those programs could be judged. So I think the last part of the general radiology program, where they trained in all the aspects of radiology, diagnosis and therapy, had its ending beginning about 1972. Of course, then there was the transition before it was fully implemented. And I want to ask you that, obviously, when you go to a new department and you have to take care of all the various aspects of creating a good, solid, functioning department with a good staff, training programs, research programs and so on. So it's obvious that you did that at the University of Minnesota and so once you have done that, you can then begin to have an impact on what goes on nationally. So tell us perhaps something about the kinds of things that happened in terms of your national efforts in radiation oncology but also in oncology in general. 

Dr. Levitt: Well, I was involved in ASTRO in particular. I was involved in the RSNA. I was involved with the American Radium Society in particular and also became involved with the local American Cancer Society in the Minnesota division. In the early years, ASTRO was a club, as you well know. It was the American Club of Therapeutic Radiology and essentially there were meetings primarily in association with either the Radium Society and the RSNA.

Question: Did you attend the club meetings before ASTRO started? 

Dr. Levitt: Yes. In Chicago.

Question: In Chicago at the Palmer House or Joe's Steak House? 

Dr. Levitt: Well, I wasn't at that meeting. I think Luther was at Joe's Steak House. But I didn't get to Joe's Steak House. We got the Palmer House where we used to joke that the waiters would come around and pour soup on you while you were waiting for the main meal, so yes, I was involved with all of the meetings after that, at least during the initial years. When Luther was president I was chairman of the arrangements committee, and I was fortunate enough to be elected to the presidency in the year of 1978.

Question: You've been president of ASTRO, president of the American Radium Society, president of the Radiological Society of North America and a trustee of the American Board of Radiology. I don't think you ever were on the Residency Review Committee. Not so far as I remember. 

Dr. Levitt: No, I was never on the Residency Review Committee.

Question: But you moved on to have what I think was an important impact in the American Joint Committee for End Results Reporting. In the early stages of the clinical staging. 

Dr. Levitt: Yeah, I was on the American Joint Committee twice. Once I think it came out of the American College of Radiology, and incidentally, I was a trustee on the American Board of Radiology and chancellor of the American College of Radiology. Then later on from the American Cancer Society, I was their representative to the American Joint Committee, so I spent a number of years there. In staging systems it's important to have the input of radiation oncology, which I think that I was able to do to a certain extent. I hope it was an important contribution to radiation oncology.

Question: Oh, I don't think there's any question that your contributions to the American Joint Committee were critically important as a strong and effective voice for radiation oncology in the staging system evolution process, which still goes on, of course. 

Dr. Levitt: I must have spent maybe 10 or 12 years on the American Joint Committee at two separate times so that was part of what I did. And then I was on the National Board of the American Cancer Society for a period of time. I was president of the Minnesota division of the American Cancer Society.

Question: You were also on the Medical Scientific Executive Committee with the American Cancer Society. 

Dr. Levitt: Yes, I was.

Question: And at a very critical and key time you and Victor Marcial had a significant impact on changing some of the points of view of the American Cancer Society, particularly with regards to lumpectomy and radiation therapy and the management of cancer of the breast. 

Dr. Levitt: I think Victor really may have been. I think Victor was certainly every bit, if not more so, influential than I was on that, and it was a very tough, very difficult battle.

Question: With the surgeons. 

Dr. Levitt: With the surgeons. It was quite a problem. I've been somewhat disappointed in the American Cancer Society because I think they still do not have a real appreciation of the importance of radiation oncology. I don't think they really have the awareness of the importance of radiation oncologists in the entire cancer treatment field.

Question: At the time that you and Victor were so critically important in this discussion about changing the recommendations of the American Cancer Society, the recommendation was that the only standard treatment for breast cancer was radical mastectomy. Either radical mastectomy or modified radical mastectomy or extended radical mastectomy, which Dr. Urban at Memorial was a great proponent for doing. And Victor, working on the Breast Cancer Task Force, and you, on the Medical Scientific Executive Committee, were able to change that committee from 26 representatives, six of whom were lay people and 20 of whom were surgeons. So no wonder the recommendation, but with your efforts in that regard—yours and Victor's—suddenly, and it really was sudden, was the recognition that they had to have pathologists and diagnostic radiologists and medical oncologists and radiation oncologists along with the surgeons. So the number of surgeons dropped to 12 and there were eight new voices that were put on the Breast Cancer Task Force. That was a very key time for us, I think, in radiation oncology. But, you know, as you go on having these experiences at the University of Minnesota and building a strong foundation for an excellent department and being active at a national level, tell us a bit about your actions or activities internationally because they've been equally distinguished, I think. 

Dr. Levitt: Well, during the time that I was president of ASTRO we had contact with an international group and formed the International Society of Radiation Oncology. And you and Luther were involved. I was involved, Phil Rubin, Maurice Tubiana from France, Jerzy Einhorn from Sweden among many, many others. There were a lot of people. And eventually we were able to separate the radiation oncology from the radiology congress, working through the International Society of Radiology.

Question: When did ISRO actually start? 

Dr. Levitt: It really started in 1982. There was a meeting in France where Maurice Tubiana was the president and that time there was a somewhat separate meeting. The radiation oncologists met in one building and the radiologists met in another building, and that was somewhat separate. It was not until a meeting in Hawaii, which came at a very bad time because I think it would have been very successful, but we really had two separate programs at the time that I was president. But right before the meeting there was a strike of United Airlines and it was impossible for people to come, or very difficult. And so I think it would have been more important than it was. It didn't have a chance to develop, but it was separate, so we've been talking about since 1980. And then, of course, now there are separate congresses. That was the beginning, in a sense, of my involvement with the international community. I also became involved in both Germany and Sweden with Jerzy Einhorn at the Rottingham and their colleagues and in Germany in conjunction with Luther with a young German radiation oncologist. It was a very young society. They were like we were maybe 10 or 12 years before. And I think that we were able to be very helpful to help them grow their specialty and I'm very happy about what we did and I'm really proud of it in the sense that I think German radiation oncology has really developed very nicely and matured very well. I mean they're doing outstanding work and the people that we knew like Rolf Peter Mueller

Question: Rolf Peter Mueller 

Dr. Levitt: Rolf Peter Mueller and Hans Peter Hallman and Ralph Sauer? And a number of other people have all been, we've be able to help them to develop their own society.

Question: Radiation oncology in Germany is a younger specialty than it is here, isthat correct? 

Dr. Levitt: Yes.

Question: How about in the other European countries? 

Dr. Levitt: Well, certainly. Not in France, of course, and in England it’s more developed in a sense, and Sweden also.

Question: They actually preceded us. 

Dr. Levitt: They preceded us, yes. In Germany, the situation was that they were primarily part of radiology as it was here. And then with the war, of course the whole situation, many of the radiologists were either killed in concentration camps or left the country, so the field was really pretty decimated. After the war, they were really starting up again from scratch. But they have developed very nicely.

Question: I think there's no question that the German Society for Radiation Oncology is really patterned after the American Society for Therapeutic Radiology and Oncology. Thirty German radiation oncologists came to the meeting of ASTRO in Orlando. 

Dr. Levitt: I think it was in 1980 wasn’t it?

Question: Right, and they subsequently came to Philadelphia to look at the independent departments in Philadelphia in the medical schools and to look at the radiation oncology study center and the relationship with the American College of Radiology. And from that experience, which included the people you just mentioned a moment ago plus 20-some-odd others, grew the decision that there had to be an independent society for radiation oncology in Germany. And at the first meeting, it was really unclear whether anybody would come. But indeed, actually 2,500 people came. 

Dr. Levitt: Yeah, they did come.

Question: And they did extraordinarily well. It was an idea whose time had come.
 
 Question: Were you at that first meeting?
 
 Question: I was, yes 

Dr. Levitt: Yeah, I was there, too.

Question: Let's go back...
 
 Question: This relationship, if we can before we go on, because I'm interested in how ESTRO developed in relationship to ASTRO.

Dr. Levitt: I can't say that I really was...I mean, I think that it's more recent than that, but they...I mean I essentially...I think Luther probably understands that better than I do, because this was essentially a decision by a number of some people that there need to be a European Society of Radiation Oncology, which compared...you know, was similar to ASTRO, and this is the way it went with that program.

Question: But there has evolved publicly independent societies for radiation oncology in Italy, also in Spain. In Italy the dominant individual that led to that formation was Professor Romanini at the Polyclinic Gemelli. And in Spain, I think the critical person was Filipe Combo who had trained in Spain but then came to work in the United States for several years and saw the benefits that would accrue by having a national society, which ultimately has come to pass and to some degree the same is true in France. 

Dr. Levitt: Or in Germany.

Question: And Scandinavia? 

Dr. Levitt: Well, in Scandinavia the departments were pretty much set up as oncology departments, non-surgical oncology departments. It's a little bit different than what we do here because they do the chemotherapy and the radiation, so they're somewhat different. But basically they're separate from the surgeons and they have a tremendous influence on what happens to the patient.

Question: Is that an advantage for them or a disadvantage? 

Dr. Levitt: Oh, I think it's sort of mixed in a sense, David. I think that because they are involved with patient care. I think that's very positive. I think it has given them less time to be involved in the technical details that we are in this country but they are very good. In Sweden, I think it works out very well. I'm not so sure in some of the other countries how well that works out.

Question: I think the Swedish system wouldn't necessarily translate itself into the American system. 

Dr. Levitt: No. No, I don't think so.

Question: But that, I think, goes back to the genesis of the situation that you alluded to a moment ago. 

Dr. Levitt: Yeah.

Question: Go back to the University of Minnesota. Early on you started a program of ongoing continuing medical education. 

Dr. Levitt: Yes.

Question: So maybe you might tell us a little bit about your reasons for doing that and how it became such an important educational activity at the University of Minnesota. 

Dr. Levitt: Well, it's another sort of...it sort of just happened – one of those sort of things. The University of Minnesota had a radiology program, CME program, for many, many years. And when the department was split, the deal was that we would have maybe every fourth year a program on radiation oncology but then we decided we were going to do it by ourselves. And everybody said that we were going to fail because these things had never last.

Question: You mean for education? 

Dr. Levitt: For education.

Question: Continuing medical education? 

Dr. Levitt: Yeah. Well, I don't think there was any such thing, so we set up the program.

Question: And apropos to this is how much of an influence did Gilbert Fletcher and Nora Tapley have in the development and evolution of that program?

Dr. Levitt: Well, I was just going to say earlier. Nora and Gilbert were extremely influential. They were very good friends. I had known Gilbert I think almost as long as I've known you. Again, when I was at the Medical College of Virginia, I invited him to come and he and Nora would come and give talks and we became very good friends. And so when I went to Minnesota and we set up this program, we would plan the meetings together. We would come to the ASTRO meeting and we would sit down and spend time planning. The first program I sort of planned myself. And I had, not only did I have Dr. Fletcher and Nora, but I also had Dr. del Regato at different times of the week. [Laughter] Because, you know, there was, up until their later days as they got older, they became more mellow and more friendly, but Dr. Fletcher was not extremely happy about that. But in any event, from then on they were, for 10 years until Dr. Tapley's unfortunate early death, they were involved in that program, very much in setting up the program, deciding what we're going to do. We would sit down and go over all these things.

Question: And speakers as well. 

Dr. Levitt: Oh, of course.

Question: Who was going to be on the program, and they were always on the program. 

Dr. Levitt: They were always on the program. And I must say that Dr. Fletcher enjoyed it very much. We always were happy to have him. He was a fantastic contributor and up until, actually the time that he became ill, we would schedule the program. After Dr. Tapley died, and I think it was in 1980 that she died, he would come. It was very important to him. And it was important to us. He was a magnificent contributor. If you recall, he became ill at the Radium Society meeting in Montreal and he went home. We were still talking about him coming in May to the Radium Society meeting and to the CME course in Minneapolis. It was very important to him.

Question: He told me once that it was a very important venue because he could present things I guess in a broader perspective or at least in a different perspective than he could at any meeting like here at ASTRO. 

Dr. Levitt: Yeah, and he was a very important part of attracting people to the program. He was very important. Now, Dr. Brady was usually was speaking there all the time. I mean every year.

Question: It was timed well too, just before the boards. It did attract a lot of residents and that gave you a basic audience. 

Dr. Levitt: Yeah, it was good. And we continued it for a while, but I must say that with Dr. Fletcher and Nora Tapley being gone, it sort of took a lot out of it. It was a fun meeting; we had a good time together. We had a lot of friends, and I think it served a very important purpose and was really appreciated by everybody.

Question: And you fed the people well, too. The first acute gout attack I ever had was at your meeting. [Laughter] 

Dr. Levitt: But it was a good meeting and people enjoyed coming—the people, the participants and also the students. We eventually had to abandon it because there were financial crises. I'll be very frank about it; I think the ASTRO Spring Program had an impact on our program.

Question: There were a lot of other programs as well. UCSF and the program from the San Francisco Cancer Symposium. 

Dr. Levitt: Yeah, there were a lot of other programs, too many programs. In any event, that was when we began to lose money. We didn't do it to make money, but we wanted to break even.

Question: It's interesting to see that some of the programs that have existed independently are now beginning to come together as one program like the San Francisco Cancer Conference at UCSF. I gather in the advertisements that come out that they are cooperating now and doing the program in San Francisco. 

Dr. Levitt: Well, that's wise.

Question: So tell me, one last thing I think that's interesting, you alluded to this supposed separation between Dr. del Regato and Dr. Fletcher. I'm not so sure in my mind that it was ever anything more than a trumped up kind of situation, but you know more than I. But it's interesting that when Dr. Fletcher was interviewed on videotape as a legend in radiology, the interviewer was Dr. Juan del Regato. That videotape is incredible, as you can well imagine. 

Dr. Levitt: I think that as time went on, they really mellowed and I think they gained respect for each other very much. But this period, as you well recall, those people really established radiation therapy as a primary specialty in this country and Henry Kaplan was another individual who...

Question: The triumvirate—Kaplan, Fletcher and del Regato. 

Dr. Levitt: But I remember the first ASTRO Gold Medal was established by Robert Parker, and he wanted to give three medals. But some of those three were not very happy about the other ones getting it at the same time. They thought they were getting a third of the medal. But that was before they mellowed in years, they mellowed...

Question: They all came to receive the medal, though. 

Dr. Levitt: They all came to receive the medal.

Question: In spite of their criticisms of it being one-third the medal. 

Question: I sensed that, as you say, Dr. Fletcher and Dr. del Regato, got closer and were friends at the end, at least during my time. 

Dr. Levitt: Yeah, I think that was true.

Question: That's not true with Kaplan. 

Dr. Levitt: Well, he died I think before that happened.

Question: He died too soon, I think. 

Dr. Levitt: I think that Kaplan’s death had a real impact on them, helping them realize that they really were not fighting with each other.

Question: Competitive with one another. 

Dr. Levitt: They were competitive, yeah.

Question: Tell me a bit about the kinds of projects that you're doing in the Rottingham Karolinska Institute in Stockholm. 

Dr. Levitt: Yeah, well as you know, I stepped down as chair after 29 years at the University of Minnesota; actually that was during the year that I was president of the RSNA. First of all, I felt that it was time. Secondly, I felt that being president of the RSNA would require more time away and so I stepped down and then I took a sabbatical essentially. And I planned to go to the Karolinska where I'd been in 1992 on sabbatical. And then I went to the Karolinska and worked this time in prostate cancer and that project is still ongoing, but I've in the interim become involved with some of the other things they wanted me to do there. .

Question: Tell me a little bit about the prostate cancer program that you are investigating in Sweden. 

Dr. Levitt: Well, essentially what we're doing is looking at a series of patients that were treated between the early 1970s and the 1990s, and there were a series of patients, actually from 1978 to 1991. There are a series of patients who were treated with watchful waiting. We're looking at those patients and other patients treated during that period either with radiation or surgery to determine whether there are any identifying factors that would predict which patients could be treated with careful observation. We have been looking at the ploidy of the cells because most of these people were diagnosed and treated before the PSA period, and so we're looking at the ploidy and we're looking at a number of other factors to determine if we can predict...

Question: Do you have any preliminary impressions? 

Dr. Levitt: Well, actually, no. When I go back this time, I'm going to analyze. You can well imagine there are 600-odd some patients and going through records is a big task, to go through 600 records for that period. And of course, not being that fluent in Swedish, I have to have somebody go through the records, but we're moving along. But we already have the records on the 155 patients who were treated with watchful waiting and we're going to try to complete that.

Question: And there are a reasonable number still alive? 

Dr. Levitt: Well, there are a reasonable number still alive, yeah. But the point is whether we can predict based on the DNA and some other factors whether there are patients that are successfully watched or not.

Question: Is anybody being observed now with prostate cancer? 

Dr. Levitt: You know they just published a series out of Sweden. They had a randomized study between surgery and observation, and the conclusion was in the overall final survival. There's no difference other than recurrences in the prostate if patients are operated in the pelvis, so that's part of the thing that I'm doing.

Question: Shifting back to your interpretation of the training programs in radiation oncology, obviously much different now from what it was before when it was a part of general radiology training. I mean, that's changed. But what do you think are the most important component parts in a training program in radiation oncology in the third millennium? Now? 

Dr. Levitt: Well, I think one of the things that we may be losing now is the clinical abilities of our trainees. I think that radiation oncology is so absorbed, entranced by technology these days that these young people are not really getting the clinical experience, the clinical feel that they need, and I think that's important. It’s really critical that they have that.

Question: Now when you say the clinical training, clinical training in radiation oncology or clinical training in medicine in general? 

Dr. Levitt: Well, I think in medicine in general but in radiation oncology specifically. I don't know how many of these youngsters know how to use a mirror to look down a throat. Okay?

Question: You're right.
 
 Question: I don't know how many of them can calculate a dose. 

Dr. Levitt: Well, that's another thing. [Laughter] That's absolutely correct.

Question: I asked to put it on the board exam, asking residents to calculate a dose and not a single one could calculate a dose either with SAD or SSD technique. 

Dr. Levitt: Yeah, no. And if the physicists aren't around, they're lost.

Question: And yet they will sit hours at the computer drawing tumor margins, which I think is one of the things you alluded to that they don't have training in diagnostic radiology in looking at MRIs and/or CTs. 

Dr. Levitt: Well, I think that's a real concern because I think that they really need to get a better feel for the patient.

Question: But the point I think is you go back and look at the Residency Review, too many requirements now. That the individual needs 36 months in clinical training—and correct me, David, if I'm wrong—and then they need 12 months, which really would incur rotations in medical oncology, experience in pathology and perhaps some research experience. And it used to be in many of the programs they also would rotate through diagnostic radiology or nuclear medicine or both. 

Dr. Levitt: They still can.

Question: They still can, I know they can, but how often does that happen? 

Dr. Levitt: Not very often.

Question: And I think that's what you're alluding to is that here they are using the high technology in diagnostic imaging to draw tumor volumes, etc., when they really don't understand the difficulties actually that are inherent in doing that. I remember you and Dr. Bartelink having a very interesting discussion in Sydney, Australia, about this issue. 

Dr. Levitt: Yeah. The thing is that I'm very concerned about this dependence and this so self-assured idea that they can set up a field with a 1 millimeter margin and be sure they're treating it every day. And they're drawing a target that they don't know what they're doing. They don't know about the imaging. I was at a session yesterday and somebody was talking about there's at least a centimeter movement and somebody else got up and said, "Well, at our institution there's only a 5 millimeter movement," and I have heard this: "There's no movement." And my impulse is to get up. I must tell you another Gilbert Fletcher story when we were in Richmond at a conference and one of the surgeons was Dr. George Pack, which probably doesn't mean anything to most people but to some of the older folks it does. And Dr. Pack got up and they showed this patient he had cured with some horrible surgical procedure and he said the patient was still alive 20-odd years afterward, and he said, "Well, what do you think about that, Dr. Fletcher?" And Dr. Fletcher said, "George, they ought to close the wards and send all the patients to you." And that's what I feel when I hear these people, I say, "They ought to close all the radiation therapy facilities and send all the patients to you."

Question: We'll listen to another Fletcherism if you may. I was at the morning conference at the Anderson once and they presented a patient with a retromolar trigone lesion and they had every image that you could possibly conceive to show about this patient and Dr. Fletcher said, "Has anybody examined the patient?" And nobody had examined the patient. And he said, "Absolutely incredible." And, of course, he had his usual kind of comments to make. I was accustomed to that, but we all have stories about these people—Fletcher, del Regato and Kaplan. 

Dr. Levitt: But I think that that's why I'm concerned about the clinical training, and I also think that they need to get more. I'm not sure they're getting the knowledge of biology that they should. I think this is something that they need to get into more molecular biology. They need to understand or at least be taught something about it so they understand what they're doing.

Question: Well, it's being required on the boards, so they are getting some molecular biology. 

Dr. Levitt: Yeah, but technology is ...

Question: The problem that I have with that is you have the molecular biology that they're taught and what they get examined on the boards and we have the patients that they treat that they don’t get adequately examined about. And I'm not sure there's the connection. 

Dr. Levitt: They put the connection together, yeah. But I think when we're so engrossed with technology. I mean, there's only so much time and we need to re-evaluate how much time we want to put into that. You know, another story—this is ascribed to Dr. Buschke—in which he made the statement that if you would leave the treatment of polio to the radiation oncologists, we'd have the biggest and best iron lungs that you possibly could find anywhere. Which, alluding again to the fascination.

Question: Sometimes the technology is there and you have to seek a use for it. 

Dr. Levitt: Exactly.

Question: How many technologies have we had in the last 15 years that had a rise in very major interest and now sit in the closet under sheets, like hyperthermia, hyperbaric oxygen. You know, I'm really not quite sure how much more time we have. 

Question: We can go on. 

Dr. Levitt: We have another 40 minutes or so.

Question: I wanted to talk with you about the areas in which you think you have made the most important contributions. We've talked about your educational efforts, we've talked about your national efforts, we've talked about your international efforts. I know that you've had very significant impact in Hodgkin’s disease, in breast cancer management, in the statistical analysis of clinical trials and so on, so that's my interpretation of what I think you have contributed of a significant impact, but what do you think are the things that you've done that are truly important? 

Dr. Levitt: I think honestly that the contributions we made in Hodgkin’s disease were Important; I think are important. I think that breast cancer was also important in a sense of the lumpectomy versus the radical mastectomy and that was a battle that probably our present residents don't really understand. I mean, it's all so accepted now, but I can remember when in Minnesota the insurance companies wouldn't pay for a lumpectomy and radiation.

Question: And the surgeons were badmouthing it right and left. 

Dr. Levitt: Well, I can still remember when somebody who was a patient would come in and say that my surgeon told me that my breast would look like a hunk of charcoal. So, I mean that was, I think, important. I think that, to me anyway, what is something that I'm still interested in is the analysis of trials and the evaluation of the quality of the trials and the quality of treatment were things that I think that I really—I don't mean this in an egotistical sense—I think I really was one of the first people to start this evaluation that started back in 1976, 1975.

Question: Your ability to pick out the flaws in clinical research trials, particularly in breast cancer that I'm most aware of, were fantastic. 

Question: It really began, I think, as I would judge with Jon Chancewartand his public vocal comments that there was no role for radiation therapy in the management of patients with cancer of the breast, and you and Gilbert Fletcher and myself were invited to be on the White House Conference for Breast Cancer in 1976 and published the data having to do with the validity for post-operative radiation therapy in patients with cancer of the breast, which was really in direct opposition of Chancewart's position. And, of course, obviously the contributions of Nora Tapley and Eleanor Montague both from the Anderson and Nora, of course, at Columbia before she went to the Anderson, were very critically important in the evolution of the entire discussion. 

Dr. Levitt: I actually just had a paper accepted by the Red Journal related to the breast cancer situation, the post-mastectomy situation, in which I go over the history of what's happened. Stern's work was followed by meta-analysis and the meta-analysis was picked up very quickly by medical oncologists, including some of our colleagues. And medical oncologists, actually there was an editorial in the New England Journal in 1982 in which the statement was made that essentially using post-operative radiation therapy was akin to malpractice. This was followed by a couple of our well-known colleagues.

Question: Pito? 

Dr. Levitt: No, it wasn't Pito. No, it was a medical oncologist who was at the NCI. I can't remember the name. I can't remember, but it's in the article.

Question: Tom Baylor 

Dr. Levitt: No, it wasn't Baylor. It was a medical oncologist. I can't remember his name right now, but there were a couple of our own colleagues who are very prominent in the treatment of breast cancer who wrote an editorial and said something to the effect that, the editorial was titled, "Let's Put the Hockey Stick on Ice."

Question: I know... 

Dr. Levitt: You know who they are. But those Pito studies had a tremendous impact. The problem, I think maybe one of the things that I've been doing, I suppose most of us have been sort of fighting our colleagues who are trying to demean us and get rid of us in a sense or diminish the special. But the Pito meta-analysis included all these flawed trials, both statistically and technically, but it was accepted as gospel and until the recent trials out of Denmark and British Columbia, were never really challenged. And now there was another meta-analysis from I think Whelan in Canada, again showing the improvement in survival based on post-operative radiation. But I mean these are things that you know, I think we would have been not doing postoperative radiation if we depended on what trials.

Question: Well, following these articles, that there was a period where post-op had kind of fallen by the wayside. 

Dr. Levitt: Absolutely.

Question: until ... 

Dr. Levitt: Until as recently as 1997.

Question: And that was the first plenary session I think at ASTRO. 

Question: But you know the evolution of events if you go back to the 1950s and 1960s, every patient who had a radical mastectomy had postoperative radiation therapy with no discrimination. And in due justification to Chancewart, the key word in his comment, I think, is there's no role for routine postoperative radiation therapy in carcinoma of the breast. He doesn't agree with this, by the way, but nevertheless I think routine is the word. And I would agree with that. That there is no role for the routine use, but there is a role for properly selected patients. 

Dr. Levitt: The problem, Luther, is that if you read that, you get out of it what you want.

Question: Of course. 

Dr. Levitt: But I think most people ...

Question: At Anderson they did distinguish to a certain extent which ones needed Post-operative radiation. 

Dr. Levitt: Oh, I don't think there's any question about that; there's not any question about that.

Dr. Levitt: Of course, I think we've all had indications. But the implication from Chaucerat’s work and also out of the meta-analysis was that no patients really required radiation therapy. That was, which, sort of got me to going, but I mean if you look at the data, the trials, the one argument that's come out in favor of the meta-analysis was it pointed out that there was this increased mortality because of the internal mammary treatment. The fact of the matter was it wasn't out of the meta-analysis. It was the first trial that came out of Norway, the Hooes ttrial, in which they demonstrated that that there was an increased mortality in the Stage I versus Stage II patients. And then there was analysis by Redkus and a number of other people, but I think in that sense it's been a service because it's made people more careful about what they did and how they did it. But in essence we abandoned it all. I mean, the people would call and say, "Well, how do I treat the nodes?" because they hadn't been treating the nodes. So, I mean, that's been, I would say if you ask me if I've made a contribution—and I think it's not just the thing with the breast—my hope is that people will read the literature and be very careful about how they analyze it and also have some idea of what they're dealing with.

Question: Do you believe that clinical trials ought to be reviewed by statisticians before they have been published in order to really assess the validity of the conclusion? 

Dr. Levitt: I think they need to be. I think there are many guidelines and whoever in the editorial board should look at those guidelines and see that they're following the guidelines—that the randomization is blind and a number of other things. I mean, there are certainly guidelines that have been set up and don't have to be. You know, I don't have to repeat them here. Those guidelines need to be followed and the same thing with the meta-analysis. There are guidelines that are set up for the meta-analysis, which are not necessarily followed. For example, the Pito meta-analysis, you cannot, you're supposed to be able to find references or anything in the literature. I mean, there are two schools of thought on that. But basically there are studies that were done by Pico that you can't find in the literature; you can't find references for it.

Question: Apropos to this kind of discussion, let me tell you of an incredible experience that occurred in Rome at the meeting at Gemelli and both you and Dr. Bonadano were on the same program for the first time in either one of your careers. 

Dr. Levitt: Yes. That was the last time Dr. Bonadano and I were on the program together.

Question: Dr. Bonadano presented in the morning a general background for chemotherapy and breast cancer and then presented the cytox and methotrexate-5FU story, and you presented the analysis of the validity of all the clinical trials and pointed out the major deficits in the CMF trial relative to the unequal distribution of cases and not all patients had radical mastectomies. Some had quadrantectomies, some had extended radical mastectomies, 60 percent of the patients didn't finish chemotherapy, and the fact that, over time, the patients had the tendency to migrate back and forth from one category to another. 

Dr. Levitt: Yeah, premenopausal/postmenopausal. He changed the definition of premenopausal. You know, if you followed the papers, he lost, somewhere along the line, he lost 13 patients. There were 13 patients that were present in the first paper that weren't there, that gradually disappeared...

Question: Your conclusion, if I remember correctly, was that in any clinical trial the investigator had the obligation to ensure that the data were accurately processed at each time interval because it had such an incredible impact financially in the management of patients with cancer of the breast, if not actually in terms of the patients who were treated. But at lunchtime, Johnny Bonadano came to me and said he would like to reply to your presentation, obviously disturbed by your presentation. And I said, "That's fine." I was chair of the afternoon session and I said, "I'll let you go first." And I said, "Johnny, would you present in Italian or will you present in English?" And he said he would present in Italian, but there was simultaneous translation. But when he got up to present, he really was incredibly critical of Dr. Levitt's presentation and said it didn't really make any difference how he shifted the patients back and forth from one category to the other, and there was an audible gasp in the audience who understood immediately—because a considerable portion of the audience were Italian—and then you replied to him with the fact that he had a responsibility to report accurately because it had such a dramatic impact on changing the practice of medicine. And then Dr. Bonadano stormed out of the meeting. 

Dr. Levitt: He stormed out and that's the last; we were never on a program together after that.

Question: Fascinating.
 
 Question: But it was the first and only time. But let me tell you, that was what? Fifteen years ago? 

Dr. Levitt: Yes, probably.

Question: And they still remember it in Italy. When I was there last week, that story came up almost exactly; not exactly the way I told it, obviously, but very similarly to the way I told it, but they still remember that particular episode and what a dramatic impact it had on all of the oncologists in Italy who were there plus a number of other people from Europe and the United States who were there on the program at that time. So you have impact sometimes in ways that are very interesting. 

Dr. Levitt: Yeah, you don't expect.

Question: And you don't expect, that's very true. But I'm sure that when Professor Romanini put the program together, that he had no idea that this confrontation kind of situation would occur, but yet on the other hand it was probably one of the highlights, obviously, if they still keep remembering years later. 

Dr. Levitt: Yeah, really.

Question: So what do you think about people specializing and sub-specializing? You have, I saw in your CV things beyond what we've described along head and neck and lots of areas that you've had a lot of impact on. Is it, are we now to a point where people should really, if you see a budding academic radiation oncologist, should you tell them focus on one area or what would you recommend? 

Dr. Levitt: Well, I think it depends on certain things. For instance, implants. I Think, let's just take the prostate. I think somebody really has to have experience to do prostate implants. It’s ok if you do five a year or 10 a year, you know, that that's really a good way to go. I think you need to have experience with it. You know, I hate to say that you need to sub-specialize to that extent, where you're just doing one thing, but I think it's important to limit. I think we're going to have to limit ourselves to a couple three areas that we work in. I think it's very difficult with the technology and the techniques and the treatment planning requirements and everything like that that really do a lot of different areas and keep up with the literature. I am trying to keep up with prostate and breast because those were areas that I've either been interested in or more or less developed an interest in and I find it extremely difficult, extremely difficult. In Swedish, they did another study there, they're trying to update their study on the use of radiation therapy in the treatment of cancer. They just did an update looking at all the literature on prostate cancer and it's just incredible. Even if you limit studies to patients where they have more than 100 patients, it's almost impossible. And, you know, this is the other thing and I'm glad you brought this up because I think there's stuff in the literature, I mean, they're talking about 20 patients. I think unless you’re dealing with an extremely rare disease that you see one case a year, when you're talking about 20 patients and say there's a significant improvement if somebody gets chemotherapy and somebody doesn't get chemotherapy, I mean, that's nonsense. I'm sorry. It just doesn't fit...I'm not sure that we're doing anybody favors by allowing those people to publish papers or allowing them to present papers.

Question: There's another, more critical issue that was addressed today by Catherine DeAngelis about conflicts of interest, which is another major area. Not only meta-analysis and 20 patients who had this and 10 who had that and so on, is actually that so many of the protocols that are coming actually out to publication really represent, seriously derived from funds zero industry derived protocols with major problems relative to conflict of interest. 

Question: I think the problem has been there a long time. 

Dr. Levitt: It gets more obvious.

Dr. Levitt: I think it's getting worse. I think the drug companies are putting more and more pressure; they're putting pressure on the public through public information, public advertising. They're putting pressure on the physicians. You know, a lot of the research that we're doing is funded and not just for the medical oncologist group, in our group too. I mean, a lot of these things are being funded by these drug companies, and I think we have to be very, very careful.

Question: You have received so many accolades that, if I may run through some of them for you. Distinguished Alumni Achievement Award from the University of Colorado, your medical school. Honorary Fellowship in the Royal College of Radiology in London. Honorary Membership in the German Society for Radiation Oncology. Honorary Membership in the, I think in the German Society for Radiology also. 

Dr. Levitt: Yes.

Question: And the Berven Lectureship in Sweden with the Berven Medal from the Swedish Academy of Medicine. Plus the Gold Medal from ASTRO and from RSNA and you've done the Janeway Lectureship and the Gold Medal from the American Radium Society, to just name some of the things that I think are important hallmarks of the accomplishments that you have made in your career. Recognition nationally and internationally of the importance of your contributions to oncology in general, not just in radiation oncology, but oncology in general. And I guess actually it might be worthwhile to ask you now, is there anything else that you would like to tell the History Committee that you haven't been cued to tell thus far? 

[Laughter]

Dr. Levitt: I can't think of ... well, I think I'd like to say one thing. Maybe just, I think this is pretty true. I think that people that have accomplishments, have made contributions, these contributions could only be made if you're supported by your staff and your family, which I think is really important. And sometimes maybe we don't think our wives or kids really appreciate us, but they do and they do make all these things possible. I'd also like to say that I have been extremely fortunate in, for whatever reason, having really wonderful friends and colleagues in this profession. And I'm including, of course, you, Bob Parker, David. I can't forget Gilbert and Nora and Dr. del Regato. I mean, I think one of the things that maybe is a little sad but it's natural is the fact that we were such a small group. We were fighting the war together. It was a more collegial, more familial. we knew each other better and we knew each other more and we were all for the most part pretty good friends. And so I think that I'm very happy that my career developed in that kind of era.

Question: The wonderful thing was that however much we disagreed, when push came to shove, the decision was made for the benefit of radiation oncology and oncology, not for personal gain. And I think in some degree that may very well have been lost sight of today, but perhaps maybe I'm being too critical. 

Dr. Levitt: Well, we're big. We're big. It's a big Society. I mean, the initial meetings you knew everybody that was there at the meeting and everybody knew everybody else, and now you've got 10,000. God knows how many members we have—5,000 members and 10,000 coming to the meeting—so I think that's part of the game, but I do feel very fortunate that I developed in this period and I'm certainly very happy about the friends I have had and still have and my family.

Question: David, is there anything else you wanted to ask? 

Question: When Howard Latourette died, his son gave the eulogy at his funeral, and among other things, he commented that he thought his father was extremely lucky in finding his wife and moving to Iowa City and so forth, but one of the things that caught my attention, and I'd be interested in your opinion on this, was that he was very lucky to have picked a specialty that was blossoming right at that time, and he is basically a contemporary of yours. Howard was maybe a few years older than you, and at a time when it was just coming to be, I think. Would you say that there is any truth to that? 

Dr. Levitt: Yeah, I think so.

Question: I've felt that myself. It was a unique opportunity that not many physicians had. Howard Latourette’s career spanned almost the entire history of radiation oncology. Now, I guess there are some fields like molecular biology today where this is occurring, and some other fields today and maybe even still radiation oncology. But I don’t think it happens very often. 

Dr. Levitt: You know, you asked me early on what was it that attracted me to radiation oncology. I think I like people and I felt that there was a real need—number one—there was a need for people who knew what they were doing to take care of patients. It was important to take care of the patients. The patients needed somebody with expertise. I mean, there were a lot of people practicing radiation therapy and with good intentions, but they really didn't have the background or the experience or the ability, really, in a sense, to do the best they could for the patient. Just like I was saying before, when you're talking about somebody doing five implants a year or something like that, we really needed to have people. We needed people. We still need people who have the real concern about the patients and the skills. They need to have the skills, too, and that's why, I think.

Question: Well, I'd like to thank you and Luther both for providing us a lot of information about our past and I think some directions for our future.
 
 Question: Thank you very much.

Dr. Levitt: You're welcome. Thank you. That was fun.