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I N T E R V I E W Interviewee: Dr. Lester Breslow Interviewer: Larry Agran Location: UCLA - School of Public Health Date: December 2, 1975

, EXCf:.RPT: IN'lERVIEW WITH DR LESTER BRESLOW & JNTERVIEW WITH rR. };ENNETH ENDI COTT Prepared by the History of Cancer Control Project, UCLA School of Public Health pursuant to Contract No. NOI-CN-55172, Division of Cancer Control and Rehabilitation, National Cancer Institute; principal investigator, Lester Breslow, M.D., M.P.H. HEALTH, EDUCATION, AND WELFARE Public Health Service National Institutes of Health National Cancer Institute Division of Cancer Control and Rehabilitation DHEW Publication No. (NIH) 79-1519 A Hstory EOf Cancer Contro' in the Un'sfed States 1946-1971 Appendices r

Appendix 1. -rAri.E ur C.>NTENTS (:•,t i'i:.1)iCt:s) Databank of Cancer Control. Appendix 2. List of Persons Interviewed. Appendix 3. Interview Methodology. Appendix 4. Interview with Dr. Lester Breslow. Appendix 5. Interview with Dr. Charles Cameron. Appendix 6. Interview with Dr. John Dunn. Appendix 7. Interview with Dr. Margaret Edwards. Appendix 8. Interview with Dr. Kenneth Endicott. Appendix Appendix Appendix Appendix Appendix 9. Interview with Dr. Wilhelm Hueper. 10. Interview with Dr.Raymond Kaiser. 11. Interview with Dr. Leopold Koss. 12. Interview with Dr. Herbert Lombard. 13. Interview with Dr. Lewis Robbins. w Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix 14. Organization Charts, National Cancer Institute, 1947 and 1957. 15. An Over_view of_Cancer Control in the Regional Medic_al Proerams, prepared by Health Policy Analysis and Accountabili- ty Network, Inc. 16. Lists of: Surgeons General of the United States Public Health Service; Directors of the National Institutes of Health; Directors of the National Cancer Insti- tute; Directors of the Federal Cancer Control Program. 17. Members of the Cancer Control Program Advisory Committee, 1948 and 1962. J 18. List of American Cancer Society Chairmen of Board of Directors. 19. List of American Cancer Society Presi- dents. 20. Li•st of American Cancer Society Exec- utive Vice-Presidents. 21. List of American Cancer Society Medical and Scientific Directors.

i Larry: I understand that. I didn't pursue it further because I know of your interests along those lines, and they are well documented actually. (10) I

APPLNDIX 8 \ I N T E R V I E W Interviewee: Dr. Kenneth Endicott* Interviewer: Devra M. Breslow Location: Bethesda, Maryland Date: May 19, 1976

.%ean Lester Breslow December 2, 1975 Larry: As I mentioned, I wanted this interview to be exclusively limited to the cigarette issue. I thought initially, perhaps, I could begin by trying to draw you back as far as your mind can take you with respect to your recollections, on a non-professional basis, of your first experience with cigarettes. Perhaps as a child or teen-ager. Breslow: My first personal recollection about cigarettes was about the time I was an intern. I was then about 23 years old. Maybe it was a little before that time, but I think it was about that time when I thought that I would explore smoking. I bought a package of cigarettes and tried them out. I didn't especially care for them and I tried two or three different brands. I remember one in particular, Phillip Morris, which advertised that they were especially easy on the throat. After trying those two or three different brands, I gave it up and then I decided I'd try a pipe. So, I bought an inexpensive pipe and tried various kinds of pipe tobacco. Again, after a month or so of exploration I gave it up; it just irritated my throat. I may have smoked an occasional cigarette after that, but my experience was really limited to that period of exploration--it couldn't have lasted over a period of a few weeks--with both cigarettes and a pipe. I don't recall ever trying a cigar, although I might have done that too. Larry: This period of exploration was a personal matter, not as a profes- sional matter? Breslow: Oh, no, it was purely personal. Other people were thought I'd try it. Larry: Was it attractive to you? Breslow: No, it wasn't especially attractive. Larry: Sounds like you made a fairly persistant Breslow: Well, I gave it a reasonable try. Larry: You were 23. What year was that? Breslow: That was in 1938-39. effort. smoking so I J Larry: At this time were there any suspicions at all professionally, among any of your colleagues, that smoking might not be healthy, not necessarily in an epidemiologic sense but, perhaps, looking at some of their patients and thinking that their coughing might be induced by cigarette smoking? Breslow: Not among any of my colleagues either in the limited medical circles nor in epidemiologic or public health circles. To emphasize that point, I rec all a few years later, in approximately 1947 when I had become the chief of the Bureau of Chronic Diseases in the California State Health Department, I received routinely from the bureaucratic channel a request for comment on an educational pamphlet pertaining to the likelihood that ciga- rette smoking could cause a lot of terrible diseases. I remember reading (1) ~

/ 4 through that pamphlet and red penciling out implications that cigarette smoking and disease were related. This all appeared to me to be nonsense at that time. I don't even recall what diseases were mentioned. Larry: But you remem-er it that strongly that you regarded it as not simply unproven, but actually as nonsense? Breslow: Right. Larry: This was 1947. Breslow: Spring 1947. I was aware thai there were indications and announcements by Overholti and Graham that cigarette smoking was an important factor in lung cancer, because they noticed in their patients that this was a very common thing. So many people smoked, woman as well as men, and lung cancer was basically appearing in men, that it didn't make sense to me that cigarette smoking could be cancerous. Larry: Did you entertain other possibilities for lung cancer? Breslow: Oh yes. The hypothesis that was most prominent in my mind at that time, and still remains a hypothesis was the substantial relationship be- tween.lung cancer and certain occupations, such as chromate ores and radio- active ores. Larry: This was in a sense reinforced, I take it, by the experience with women. Breslow: That's correct. That led nationally to the notion that it must be an occupational factor because of the very strong sex relationship. So we began making studies in the late 40's of the relationship between occu- pations and lung cancer because that was a very important hypothesis, and studies that were undertaken in the California State Department of Health in those days did contribute to the knowledge of this matter. Larry: So this was the avenue in which you were pursuing? In other words, you were concerned about the lung cancer? Breslow: I was concerned about lung cancer because it was very rapidly growing and it was evident by the latter 1940s that we were dealing with a long-term epidemic disease. That is what most impressed me about the phenomenon. Also it was a prototype, possibly, for other chronic diseases where the epidemic curve was not a matter of days, weeks, or months but of decades. I first got that notion in connection with lung cancer in observing that the disease was bareljr known in the 1920's and began to arise in the 30's and about the late 40's, it was obviously an epidemic swing. Larry: Were you able to get much support among your colleagues for this concern? r . Breslow: Yes, there was growing interest among people in chronic disease about epidemiology of lung cancer. I recall meeting Bill Hueper and others who were exploring occupational factors in lung cancer, and they stimulated my interests along that line of inquiry. About 1947-48, we were visited in Berkeley by a medical student named Ernest Wynder and he came with the (2)

DR. }:E;,;%'ETH ENDICOTT/Devra Breslow, May 19, 1976 (Impact of CC Separation) DEVRA: During your tenure as NCI Director, what mechanisms were implemented or sustained to relate research findings and resources to the Cancer Control Branch, which was then physically and programmatically separated from the National Cancer Institute? ENDICOTT: Well it's hard to recall back then. Don't think anything very active was done. I did try to maintain contact. Robbins, I think, was in charge of the program. He would meet regularly with the advisory council. DEVRA: He had his own advisory committee as well? ENDICOTT: They were pretty much hell bent to go their own way. I tried always to keep an open door to them but there wasn't anything on the horizon to get excited about. DEVRA: How did the people at NCI feel about that, that they were going their own way? . r ENDICOTT: I'm not sure. I'm pretty sure of one thing, that to have them rseparate is a bad idea. But I don't really have an answer for that question. DEVRA: When you came in, it had already happened? ENDICOTT: Yes. DEVRA: It had happened in the SOs. Did you ever have any discussions either with Dr. Robbins or, let's say working down or working up, with Dr. Shannon about the possible reintegration of cancer control? ENDICOTT: Shannon was responsible for splitting it and there was just not much point to it. DEVRA: How did the Council feel about all of this? ENDICOTT: I think they were pretty indifferent about it, really. It was a period of time when cancer control efforts were sort of eclipsed, wasn't much on the horizon to get excited about. I don't know if it would have made much difference if it had still been part of NCI. In the applied and development research programs, and there were several, the tendency was to carry them right on through, by the NCI. DEVRA: Even to the point of field testing? ENDICOTT: Yes.

t }.~YoL~csis L.,L ~: ;areLLC ~:. ',ittg ~ as t`te fr.CCOl invelvcd wiLh limng cancer. Larry: Did he just show up? Was he introduced by someone? Breslow: He came after some introduction, by himself or a telephone call or letter. He didn't just drop in. He came in rather suddenly with an obvious and very strong conviction that cigarette smoking was a factor in lung cancer. He got this notion from his association in St. Louis, where he had gone to medical school,with Evarts Graham. Wynder had undertaken a retrospective case control study and he came by to let us know that he was going to be visiting the hospitals in the Bay Area to inter- view patients and controls in regard to cigarette smoking practices as a part of his studies. We thought that he was a rash young man and asked whether a member of our staff could accompany him. Our staff member came back with a horrendous story of poor technique, so we decided that we ought to do a proper kind of a study. Consequently, we combined the cigarette smoking hypothesis with our occupational hypothesis in the studies we were about to undertake and did undertake, and publish in the early 50's. We were quite astonished with the results which were almost identical with those that Wynder was obtaining. Larry: Your own studies that you mentioned, when were those published? How might we relocate them? Breslow: The first study listed in my bibliography that refers to cigarette smoking was published in 1951, a publication in the Journal of the California State Departemnt of Public Health under the title "Does Cigarette Smoking Cause Lung Cancer?" Larry: When Wynder came around and tried to interest you in his hypothesis, did you regard it still as far fetched or by that time did you already give more consideration to the cigarette smoking/cancer hypothesis? Breslow: By that time, the hypothesis was being advanced nationally and we were aware that studies were underway, Wynder's in particular, so it seemed desireable for us to make our own study. Larry: _When you completed the study to that point, were you a believer? Breslow: I began to come around to the notion. In 1950, it seemed to me that the retrospective and case control studies of the matter were vulnerable methodologically on the grounds of biased samples, people already having the disease, and select people being further interviewed. It did cause a certain amount of doubt about the significance of the restrospective studies. As I recall, I suggested to Harold Dorn that the issue was only going to be resolved when we had prospective studies, and I also suggested that there should be studies carried out by assembling large populations to obtain people's cigarette smoking histories before there were any ill- nesses. Then we would not have to be concerned with restrospective falsi- fication and lack of memory. If several populations were studied in that fashion, then the evidence would be overwhelming. So quite early, it was evident to us that kind of study would be necessary. We then, of course, started those kind of studies. Larry: Did yours proceed Horn and Hammond's? Breslow:. No. This idea was not unique to us, several people had the same idea. A whole series of studies--by Doll of the British physicians, a study (3) 01