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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

i r f by Har,unond and Horn of the American Cancer Society volunteers, and a study by Dorn of veterans and Canadian veterans. We had two studies in California-- one of members of the American Legion, whom we selected because their age was such that they were coming into the lung cancer period and also because we could have access. The second was carried out among several occupational groups. So we carried out two of the prospec- tive studies which along with five others were ultimately incorporated into the Surgeon General's report as the seven studies that were most compelling in relationship to cigarette smoking and lung cancer. Larry: You were doing the study on occupational and the smoking at the same time, integrating the two? Breslow: Yes. What we would do was interview the patients with lung cancer about their occupational backgrounds and about their cigarette smoking habits. The methodological advantage of the restrospective or case control type of study is that you can get information on several hy- potheses. In fact, we had a paper on this discussing the advantages and disadvantages of case control versus long-term studies. The advantage of the retrospective case control studies is that the patients already have lung cancer and you can ask them about cigarette smoking, other kinds of smoking, about occupational exposures, or any other factor that you may think worthy of investigation, and you can do this in the same investigation. It is no :norP--dfffi-cult- to--ask- a--€ewmori-quest#ons -once youtve got- to the person°-s - bedside, where this kind of study is usually carried out, and then find a . control and ask similar questions. So we were exploring the occupational hypothesis added in with the cigarette smoking hypothesis at the same time. In that study, we identified several occupations that we regarded as sus- pect and a positive factor in lung cancer. We, of course, also identified cigarette smoking as a factor. The second set of studies we did, the long-term prospective studies, involved assembling large scale populations of men in selected occupations. We went to the unions, to industry and:indicated that there was some reason to believe their occupation was a factor in lung cancer. So we carried out the study by getting from the unions or management the names of about 10,000 persons we could obtain and we simply entered them into our investigation, and ascertained subsequent mortality from lung cancer. There too, we were able to get information both about their particular occupations and about cigarette smoking. Larry: Was the executive branch supportive of this? Breslow: Executive branch of what? Larry: State government. Breslow: I don't think they were even aware of it. Larry: No problems then? Breslow: The only problem I remember was with one man who was a very prominent American Legioneer. He wrote to me expressing outrage that such a fool study was being carried out and that it was a waste of the taxpayer's money by the state, and what possible value could the maiden name of his mother be to any health study. I wrote back to him in a very nice way, enclosing another questionnaire'and also a copy of the California death certificate.\ I pointed out that the questions we had asked on the ques- (4) 1

ENDICOTT: Yes. I know they have a strong problem there now. I just don't know what the relationship is. Another thing that occurred which I think was of major importance was the establishment of IARC in France. ~ IARC) DEVRA: That was during your tenure? What particular stimulation did you give to this or did your office? DEVRA: And did you influence for example the mechanisms they developed for the studies that they did? ENDICOTT: Yes. I took a very active role. DEVRA: And the advisory committee set up and in the appointment of John Higginson?' ENDICOTT: Yes, I think I talked John into going. I played a very active role on the Board of Governors and so on. And tried to support him as best I could with NCI resources. DEVRA: In fact, in the beginning was a large part of their U.S. money NCI money? .r ENDICOTT: At the outset the basic contribution was the State Department. But we constantly supplemented that with contractual money and people. DEVRA: Is that still the pattern? ENDICOTT: I don't know. DEVRA: You're obviously very proud of that. Just about as proud probably as you are of the chemotherapy and national chemotherapy service center. (Carcinogenesis Regulation F, Management) ENDICOTT: Anyhow, I think it was the thing that needed happening and has a good purpose. I think as far as I know they are doing a good job. I kind of agree with "Satch" Page, the baseball player, "you should never look ba,ck, they might be gaining on you." So when I cut my ties, I really cut them.

, ~ a little in the public policy aspect, but the situation was such that we were pygmies compared to the industry and the prevailing attitudes and habits in Ar,.erica and other countries. Larry: Were you ridiculed? Did you find your views being ridiculed by public testimony? Breslow: I don't recall our being attacked on moral grounds, but the ciga- rette smoking industry began to respond quite early by forming a tobacco research council which did two things; one was to encourage the study of other factors in lung cancer, such as air pollution, etc. The other thing was to employ people like C.C. Little (and others) who did write polemics in the semi-scientific literature about the matter and ridicule it on scientific grounds. Further, they began to publish studies of others who began to look at the evidence critically and advanced notions as to why the evidence was not as compelling. Larry: Did you find that kind of combat f rustrating? Breslow: Oh no. I found it exciting. There were a Tot of statisticians in those days, and others, who began to point out alleged discrepancies in the evidence. I regarded it as an intellectual challenge and the thing to do was to bring forth more evidence and present it more compellingly. .• Larry: How about later when you came up against the intransigence of the industry? I take it your stronger feelings were reserved for those "scientists" whom you believed to sell out as opposed to the vested economic interests. You just figured they were playing their role and it was per- fectly understandable? Breslow: Yes. I can understand why the cigarette manufacturers would employ advertising agents and polemicists to espouse their point of view because that's the kind of society we live in. In example of the evolution of feeling, I recall seeing on television in the 60's, Elmer Hess, the urologist of Erie, Pennsylvania who was then the president of the American Medical' Association, smoking a cigarette while being interviewed by a news man and saying at the same time that cigarette smoking could not possibly cause lung cancer because he smoked cigarettes and he didn't have lung cancer. Approxi- mately one year after that television appearance, I read in 'a newspaper that Elmer Hess had died of lung cancer and I had a peculiar feeling about that. Larry: Graham died of lung cancer didn't he? Breslow: Yes, I knew Evarts Graham quite well. It happened early in 1952 when President Truman appointed the Health Commission on which Graham was appointed to be a member. I joined the staff of the Com- mission and became the study director and, in the course of that work, I had many conversations with Evarts Graham in and around the sessions. I recall his discussing the question of cigarette smoking and lung can- cer several times. We spoke of the medical student, Ernest Wynder, who I guess was still with him. I recall also that Evarts Graham had deeply stained fingertips from long exposure to tobacco in 1952. By that time he had quit smoking. i (6)

He was also at that time, like many of his colleagues, a very vigorous exponent of stopping cigarette smoking. Subsequently he died and the diagnosis was lung cancer. I think, however, that the histologic type of the cancer in his case opened some question as to whether it was associated with smoking. Larry: Did he have a lung removed? Breslow: I don't recall, but that can be no doubt ascertained from Wynder. Wynder would know the complete detail and he might be worth get- ting information from. Larry: Yes, I hope to meet with him over the Christmas vacation if he's out here. Breslow: That's right, he's supposed to be coming out here. Larry: If not, I'll catch up with him. Let's get into the politics of the "64 Surgeon General's report. Dealing with the public policy realm, what were your expectations and did you quickly have to adjust your expectations? From the beginning, did you not expect to get too far too fast? Breslow: I guess my expectations were always moderated by the knowledge and belief that we were going to have to contend with a mammoth,industry and the economic thrusts of that industry in American life. My recollection is that in the late 40's we became interested in the problem; and in the 50's I explored with other :colleagues of mine. Then in the later 50's and early 60's, the prospective studies provided the evidence that later came in. By that time, the Surgeon General's report came along. I recall testi- fying to the Surgeon General's Committee with Bill Cochran and other members of the group who were considering the evidence. That body had been carefully selected to eliminate all of those who had been caught ' up in investigating the situation themselves--everybody of any merit scientifically and involved had already come to some conclusion by that time. So the Surgeon General, in selecting a committee, had to pick people who were unbiased so to speak, which meant that they hadn't investigated the problem, so that their findings would not be subject to challenge by the industry. By that time, the early 60's, my feeling was that the time had come to mount a campaign against cigarette smo- king. I don't remember exactly when, but increasingly I moved in that direc- tion, like a lot of other people in the field did. By the early 60's we felt that the time had come to act. So we looked upon the Surgeon General's report, not so much as a scientific venture, although it was that--it was sort of a summary of the scientific work by a prestigou§ neutral body that could not be attacked because they had personally become involved with the studies-- it was looked upon, not so much as a scientific venture, but as a public policy venture. That would make possible, we felt--I felt and I think others shared this view--the development of public policy in the country. So that was the feeling that I had toward it when it was being developed in '63-64' and was published. And then we found that it could be used for that purpose. So from that point on, I was no longer interested in the investigative aspect of cigar- ette smoking and lung cancer, although increasingly interested in the relation- ship between cigarette smoking and other diseases. That became a matter of scientific investigation. But with regard to cigarette smoking, now the time had arrived to begin a public campaign against cigaretts smoking. (7)

! tionnaire were identical in form and arrangement with those on the California dea:h certificate and the purpose was to make it easy to identify the people who died so that we could study the relationship of death to the things we were asking about including cigarette smoking. Ne wrote back and said that he understood and he enclosed his questionnaire. Apart from that incident we had a little, but not very much resistance from the hospitals who were concerned with our talking with patients. Actually, we had very little resistance from the hospital systems. Larry: When you were working on all of this, were you truly struck by the potential enormity of the human tragedy that was involved? Breslow: Yes, I was struck by that curve. Almost every year one could see that it was still going up. In the late 40's and 50's it was the men, and then we became convinced that cigarette smoking was a factor but did not account for all lung cancer because at that time it was also overwhelming- ly clear that a certain portion was due to other environmental exposure, particularly occupational. Then we understood why it was that women did not have lung cancer; that was because they did not take on smoking on a large scale until the 40's, whereas men did so before 1920. Although there was then practically no indication that the curve was rising in women, we pre- dicted that there would be a rise probably in the 60's which was about 20 years later. Larry: In the early 50's, when you and your colleagues around the nation were coming to the same conclusions, was there a sense of despair or optimism about it? In other words, was the expectation positive? Breslow: In those days, my colleagues around the country expressed a feeling of excitement for the investigation. Here was a major epidemic of a new kind that man himself created and the evidence was'now coming that a truly massive epidemic in disease and major killer in men was bound to occur also in women. The feeling that I had in the early days of the 50's was that we've discovered something. The policy implications and such came more slowly. If you examine some of my earlier writings, you may find that my recollection is not completely accurate as to when we began to emphasize the public policy aspect, but I think that as early as 1951 I raised the issue of campaigning against cigarette smoking. How- ever, in 1951, it was only an idea to campaign against cigarette smoking as the evidence had to obviously be more compelling. Larry: Let's say that by,1955 when the consensus among those who cared was pretty clear, and you take that as an important date and then look at the history of the cigarette policy, you have really at least a ten-year hiatus before Congress addressed itself to the issue. J Breslow: I recall writing a paper in 1955 entitled "Occupations and Cigarette Smoking as Factors in Lung Cancer," published in the American Journal of Health. By that time, as you can see, I was quite convinced that cigarette smoking was an important factor in lung cancer. I think that was the word we began to use. We stayed away from the word "cause" because that was a word we realized as not being very acceptable in the scientific com- munity, so we emphasized it as being a"factor" or sometimes a "positive factor." In some earlier papers you would see such words as "association," "relation," "factor," "positive factor," and then "cause," which was sort of the evolution that I recall. To get at your question, by that time, many of us began to involve ourselves (5)

6 half-rate effort. I think we missed the boat in several areas. I don't think we did too brilliantly in the area of personal health services either. I guess it began when we lost "water", and then the "air" followed after that, and it wasn't too long 'ti1 there was an EPA. DEVRA: What do you think contributed to that sort of demise of authority, demise of responsibility? ENDICOTT: I don't know. I've often thought that it was petty squabbling between the engineers and the doctors. DEVRA: That's very depressing. What about the level of competence, in general, of the PHS to handle these major pollution and environmental problems? ENDICOTT: I don't think that was ever really tested because it wasn't until after it was split off that any decent regulatory legislation was written. DEVRA: In that sense then, it was a boon that it was split off? r ENDICOTT: Probably. DEVRA: What about the level of technical and medical competence now within that agency? ENDICOTT: I really shouldn't comment on that. DEVRA: Do you think that if it had remained more integrally a part of the PHS, regulatory powers would have come or not? ENDICOTT: Yes I think it would have. I think there is essentially concern over health issues that would have brought the regulatory power. I think it was our concern over pollution and that kind of thing. DEVRA: Were there people in Congress, specific Congressmen, Senators, who were in this fight or has it been a slow fight? ENDICOTT: No, I think it was largely or as far as I can recall, decisions made in the executive branch. r DEVRA: I was wondering how much influence people like Ralph Nader and others may have had on this? ENDICOTT: Really Nader came along later. DEVRA: Well some of this is Rachel Carson's period, too. ENDICOTT: Yes, I suppose if you had to pick one thing that happened, her book might have been the most important one single thing. I suspect that it was. DEVRA: Were there any other major policy achievements or program achieve- ments before we talk about the resource achievements? There all sort of mixed in.

i 5 an Now there was/unfortunate thing that happened later..... . And the tragedy hasn't played itself out yet. And that was that the decision to split off the National Institute of Environmental Health Sciences. Shannon • had appealed to me personally to help the thing off the ground, and I gave them a big hunk of NCI, including Paul Kotin, and a lot of people. DEVRA: Are they the people who went to the Research Triangle? Left the area? Were strictly attitudinally separated? ENDICOTT: Yes. Now the tragedy is that our toxicology capabilities through the PHS were fragmented. It's even more fragmented now because another mistake was made, that was to launch the FDA as an independent competitor. Now we have three. NCI, NIEHS, and the thing down in Arkansas. DEVRA: That's a piece of the FDA down there? ENDICOTT: Yes. DEVRA: Is it conceivable that there is constant duplication of effort? ENDICOTT: It's almost-certain. DEVRA: What about protection of the public as a result? Since one of these, at least, is a regulatory agency. ENDICOTT: There has been recognition of the problem. Under Ted Cooper's policy board there is a Toxicology Coordinating Committee that tries to coordinate their activities. But it's a mess. Somebody else will have to straighten that out one of these days. DEVRA: What do you think the consequences have been for the public at large? ENDICOTT: I think basically wasteful. Now then the task of defining the chemical risks in the environment is so.enormous that I don't think the great nations can afford to squander their resources in this area by having a myriad independent enterprises. I think this is one area in which some degree of international planning and sharing of tasks is in order. For us to have it fragmented, the way it is, and the U.S. to be alone in this? DEVRA: Are we considered the leaders in toxicology research, internationally? ENDICOTT: I think probably we are. DEVRA: But when it comes to management, we are not setting a very good example? ENDICOTT: We can do a lot better. Unfortunately that's the way it is. but with the spinning off of EPA, the health component of environmental concerns has been substantially weakened. Well, it serves us right. I don't think we were doing an adequate job in the Public Health Service. It was a I ! ;

If one would have had to deal with it and to deal with it effectively it would have to be economically: that is, combat the automobile, and not by exhortation--what wasn't done very much, but by building a good transit system. Well now, 20 or 30 years later we are getting around to the point that we have to have a rapid transit system. Too bad in America things are based so much on short range returns in industry, both to those who ire exacting a profit from industry and also those who are employed in the in- dustry. This leads to a poor quality of life, whether it's health or trans- portation. We have not yet arrived at the point socially in this country where planning is effective. Social values are always put second behind narrow, short range economic interests. Cigarette smoking is a very good example. The Los Angeles transport system is another good example. Larry: This is very useful. I appreciate this. If there is anything special that I may have forgotten,:.now would be a good point. Breslow: No, I think only to round out the thing, that I advocated at the First World Congress on Cigarette Smoking in New York City, I can't remember the exact year, that we would one day have to approach the matter economically. The sooner we got around to that the better. One day, the people determining public policy in the country, whether in politics or other ways of influencing public policy, would have to get around to the economic approach. I would still like to see th at. I will still advocate that as nationally the central thrust of endeavor. It's perfectly obvious that in the U.S. Congress, for example, there are just enough states, not very many if you count them, (one way three, another way six states and quite small states compared to California and New York), that hold up progress on the cigarette smoking issue because of their parochial, locally important industry. Until that issue is tackled and the Congress is willing to deal effectively with those few states, and their interests, then I don't think we are going to have very much progress. The Congress should come to the point of dealing with those states fairly. Their grandfathers, their fathers started out growing tobacco for cigarettes. You can't'blame them for becoming caught in an industry that is producing deaths. Larry:- I take it that you considered view is that in addition to the moral questions that might be involved, that approach would be a very cheap buy-out on our part. Breslow: Oh yes. Larry: I mean the amount that would be necessary to deal with any hardship would be very small, indeed, when compared to the economic savings if nothing else. Breslow: That's right. As a matter of fact, I am just now engaged in endeavor- ing to recruit someone to our school of public health who is particularly compe- tent and interested--a very serious petson--who would make this one of the central aspects of his work. If we are successful with that recruitment, I will be delighted. Larry: That would be great. Well, again this is very helpful. I will no doubt want to get back to you with some specifics that I may have omitted or documents that I may want to request. Breslow: My emphasis on the industrial and economic side--I don't mean in any way, however, to take away from my committment to education. Because I think we need to approach that as well. (9)

15a ENDICOTT: When Jim Shannon decided to transfer "cancer control" out of NIC and NIH, Rod Heller - Director of NCI - was strongly opposed to the move. He developed an organizational entity - The Field Investigations and Demonstrations Branch - to continue "cancer control" activities in NCI under the leadership of Ray Kaiser. When I succeeded Rod Heller, one of my first official acts was to abolish Ray Kaiser's Branch. I did so in order to get the activities back into the mainstream where more rigorous scientific standards could be assured and where the activities could feed out of the more generously financed "pots" of research and research training. The Branch contained a powerful intramural group in epidemiology and Biometry whose skills were urgently needed to develop better and larger efforts in research on etiology and prevention. Having had a favorable experience in the field of chemotherapy by combining intramural research with a big contract program, I decided to try the same thing in etiology and prevention first under Mike Shimkin and then under Paul Kotin.

DEVRA: Were they distressed since they were producing this? ENDICOTT• • Oh yes. They were distressed but so far as I could see they did not make any effort to suppress the evidence. In fact, I'm sure that he and Abbott took the initiative and carried the evidence to the FDA and laid it on a desk. He came and asked me what he ought to do, and that's what I advised him to do. DEVRA: Of course the battle is still going on. ENDICOTT• The research was his, and the credit is all there. (Aflatoxin) DEVRA: What about the aflatoxin one? What did your people do? ENDICOTT: There again the best one to talk to would be Paul Kotin. DEVRA: That happened while he was there? ENDICOTT• Yes. He provided quite substantial resources DEVRA: ...to the fish meal people? ENDICOTT: Yes. Ran the thing down, pinned it down as I remember it to peanut meal. Paul Kotin was in full charge of that. He kept me informed, but I wouldn't want to take any of the luster away from him. DEVRA: One thing I remember is that happened fast? ENDICOTT: It did, indeed. He can move fast and did. DEVRA: Faster in some ways certainly than some of these others that have been diddling around for the last 5 or 6 years. ENDICOTT: I really hated to see Paul leave. (Prevention) DEVRA: What role did the NCI during your leadership play in stimulating greater attention to mobilizing forces focused on prevention of cancer generally. We've talked a little about etiology, but beyond that, in the development of integrated, etiologic resources, what happened? ENDICOTT: From a resources standpoint, the main thing we did, I think, was internal and it really amounted-to putting dollars and space and slots into the area. I can't really point to anything. i 13 I

9 DEVRA: Was he a member of the Board himself? ENDICOTT: No, I was. DEVRA: This was maybe in 1963, 62? So you brought the message back to him that things weren't good in the Cancer Society? ENDICOTT: And convinced him that he ought to set up the committee or commission. DEVRA: Did you staf that commission? People from your office? ENDICOTT: Not entirely, but we supplied the bulk of the staff. DEVRA: Now, that's a very interesting vignette as a matter of fact. He wasn't ready really to take a public position stronger than what had been taken say in 1958? ENDICOTT: That's right. DEVRA: That was a way to gain time. And during that time what else would happen? Deals with the tobacco companies? ENDICOTT: No,not really. I don't really think that the commission came up with one iota of evidence that wasn't already at hand. DEVRA: But the times were different. ENDICOTT: A little. A blue ribbon commission, backing up the pronouncements I think was probably useful, but the British had already done that. DEVRA: We have plenty of research here. Research paid for by the NCI, by the ACS. ENDICOTT: But somewhere along in the middle of that Terry became a convert. I think one has to remember, of course, that the Government itself was in an awkward position. DEVRA: Why, because they were subsidizing the tobacco farmers? ENDICOTT: Yeah. Tobacco is still a major industry, and there are some states that are practically dependent on it. We get a hell lot of revenue out of it. DEVRA: Federal Governments, State Governments. ENDICOTT: And tobacco industry was well organized. It raised noticeable lunps on your head every time you... ..

j 15 was counting was clusters of leukocytes. It really wasn't needed. The thing that it did was to find little hunks of pus. Wasn't really detecting cancer cells at all. DEVRA: Was there any interest in such things as fiberoptic or other sigmoidoscopes? ENDICOTT: That was an area pushed by Robbins. Nadal was to survey the state of the art in diagnosis and develop leads. DEVRA: To evaluate what was already being developed or to stimulate development? ENDICOTT: To pursue leads and to see what he could do with it. DEVRA: What was his division called at that time? ENDICOTT: I've forgotten. Maybe Carl would remember. But it was a discrete organizational entity. DEVRA: And it may have come in part out of what was left over Diagnostic Aides Branch. from the ENDICOTT: It did. DEVRA: Ray Kaiser's program. Which was sort of the end of Ray Kaiser in the Federal establishment. That's what he was left with. So it was a reorientation of that program. Instead of being negative, it was trying to be more positive. (See insert on page lSa.) ENDICOTT: Well, in mammography we laid out a major study with HIP in New York. DEVRA: How did that come about? Did they come to you? (Mammography - HIP) ENDICOTT: No, we went to them. That was Mike Shimkin's doing. He convinced me that before this was sawed off on the public, we better find out if it really was any good. Did it really do anything about morbidity and mortality? Or was it just another gadget? We took the initiative. I think that much of the experimental design was Mike's and it was certainly his decision to put major resources into, there were many bucks he put into that thing. "Mega- bucks." DEVRA: You believed in this idea though? How about the Council? Did they go for this? ENDICOTT: We used contract funds which did not require council approval.

I ENDICOTT: Well, Hueper was much more inclined to a laboratory study which he thought was conclusive and a lot of people wouldn't agree with that. And then going after them with a meat ax, he'd go after industry. DEVRA: So that alienated him from the places where replications of this research would have to go on? ENDICOTT: You see, he was ready to "lower the boom" on them before others would concede that the evidence was there. DEVRA: Of course the NCI didn't have any regulatory powers? ENDICOTT: No, it didn't. (Regulatory Agency) DEVRA: I've always been intriqued why a man who was as much of an activist as he appeared, certainly in his writings, was content to stay in a non-regulatory agency. Of course, I'm probably naive, maybe there was no other regulatory agency at that time. ENDICOTT: What little regulatory power the government had_was_so diffuse, that it wasn't really very much. A good example would be the agricultural chemical area. There was a little piece of it in the FDA, had and a little piece of it that the Department of Agriculture had, would be hard to pick a place to be"where you really had much leverage. But Heuper was a genius when it comes to ferreting out carcinogenenic agents. He really had a genius for that. DEVRA: So he did make a contribution? ENDICOTT: Oh yes. Unquestionably. He's a great man. DEVRA: How about the food additive carcinogenetic link? People talking about that even in the 60s, getting suspicious? ENDICOTT: I suppose that major things occurred in the 60s. Cranberries. Aflatoxins and cyclamates. DEVRA: What position did the NCI take in these? Assistive, probing? ENDICOTT: Probably the one that I'd pull out, the place where we played the most active role,was in the area of aflatoxin. diet of the DEVRA: That's when we found it in the/fish, with: liver tumors, fish in California? (Cyclamates) ENDICOTT: Abbott carried the ball with cyclamates. I really thought that was heroic. Miller didn't make any attempt to suppress the information. Because they really brought the evidence forward themselves. Miller of Wisconsin. I know he came to me and laid the evidence before me.

i ENDICOTT: They really are hard to separate. (Etiology vs Therapy) DEVRA: Maybe we could talk about the promotive influences of some of these activities that you've referred to and some of the obstacles. For example, in addition to your own initiative, what really promoted the strengthening of the biometry/epidemiology, the whole etiologic approach to cancer control? What did you have going for you? ENDICOTT: I think I was fortunate in picking a handful of key people. DEVRA: So your judgment was obviously... ENDICOTT: Well we always had substantial representation of basic scientists on the Council and I think really with the exception a virologists or two and Phil Shubick, we never really did succeed in getting people on the Council who were really strongly motivated in this other area. And I had to conclude at that time at any rate there was very little stomach anywhere in the scientific community for the kinds of things that needed to be done. It is just not an area where you are apt to get a two-way ticket to Stockholm. DEVRA: There was a lot of that going on? Did you have a couple of Nobel Laureates on the Council in those days? ENDICOTT: Yes we did. DEVRA: Wendell Stanley? 7 ,. ENDICOTT: Wendell was one. He sure as heck supported me. He was very outspoken in getting the cancer virology program launched. DEVRA: Helped to persuade some of the others that this was vital?

14 DEVRA: Did you attract any good people at that time? ENDICOTT: Yes. DEVRA: Just as you were able to attract Paul Kotin, were you able to entice anybody else to really get interested philosophically and practically in the whole concept of cancer prevention? ENDICOTT: Paul Kotin recruited many excellent people. DEVRA: I realize that there was an enormous amount of emphasis then on what was happening with treatment because chemotherapy really was making substantial inroads. ENDICOTT: Other than what I've already talked about, I really can't point to anything very much. DEVRA: What role did the NCI play in promoting the development of early detection procedures or propagating those such as the Pap smear? ENDICOTT: I did set up a special program under Eli Nadel. He left and passed it on to Nat Berlin. I really don't know what has come of that whether its fizzled out or whether they still have something going. (Early Detection) DEVRA: Was that considered a major emphasis of fundamental research at the NCI? The search for early detection mechanisms? ENDICOTT: Well the approach really was more applied and development rather than basic. We set up an organization and gave it resources to really concentrate on evaluating and promoting whatever was in sight. DEVRA: Being developed elsewhere? In industry, anywhere? ENDICOTT: Earlier efforts that were set up under Rod Heller were, I thought, principally directed toward discrediting phony diagnostic tests. And some worthwhile work was done in that area. But the attitude was, as I would characterize it, as "here we are, we will evaluate what you have. Pr.ove to us that it is not phony." DEVRA: Rather than putting out some kind of seed money to develop, for instance, a better fibreoptic instrument to detect colon cancer or lung cancer? (Automated Cytoscanner) ENDICOTT: Yes. I undertook to turn this thing around and see what the heck we could do in a positive direction. For example, there had been a lot of money put into an automated scanning device for screening Pap smears and so on. I asked them to do whatever was necessary to find out if this thing is a feasible approach or wasn't? If it is, let's wind it up. If it isn't, let's quit. As a result, they brought in evidence that what it

(Carcinogenesis & Etiology) ENDICOTT: The level of inquiry in the area of chemical carcinogenesis was shameful, especially with clear history that there was "gold in them thar' hills." It seemed to me that also that there was undesirable fragmentation of effort. DEVRA: Throughout the Institute? ENDICOTT: Well, in the etiology area again. By virtue of the fact that the radiology component was split off and mostly being addressed by AEC, the virologists and the chemical carcinogenecists were not communi-cating. If we're going to addresse the problem in that.,we had.• to have a very strong epidemiological program~backed up with in-depth laboratory work. So I think one of the major policy decisions was to pull the whole area of epidemiology/biometry/virology/chemical carcinogenesis together under one man. DEVRA: Who was that? ENDICOTT: Mike Shimkin and then Paul Kotin. DEVRA: And give them enough budget to do something? . 61 • r: ENDICOTT: Really it was Paul Kotin. Mike was responsible for pulling epidemiology and biometry together but it was when he left actually that I recruited Paul Kotin and finished the job. There was one fairly weak organization which I abolished and the that was the Field Investigations and Demonstrations Branch. They had a bunch of soft programs . That was really the beginning step, to liquidate that, and then begin to build the other. At the time I went to the Cancer Institute they were strong in applied and developmental research only in cancer chemotherapy. And I had set that thing up before and knew that it was good. Then I decided to use the same basic management techniques to push along the other areas. DEVRA: Did it work? ENDICOTT: Yes I think that it did. There were several elements in this: One was to make contract money available at that point for large-scale efforts both in chemical carcinogenesis and viral oncology. Another was to join hands with the AEC and get interdenominational effort under way and bridge that. I don't know what the current situation is. We always had a lot of turf problems, though. DEVRA: What they (AEC) should be doing and what you (NCI) should be doing? ENDICOTT: About who was in charge. As long as you had Paul Kotin at one end and Alex Hollander at the other, there were bound to be these problems. DEVRA: He was the AEC man?

2 DEVRA: And would they get money to do this so that you almost had two different competing bodies within the Public Health Service that were doing field testing? ENDICOTT: Well the major field testing was in the therapy area. We had an enorinous program. It would not have made any sense to.have discontinuity. DEVRA: How about in diagnosis? ENDICOTT: In diagnosis, I set up a special contract effort in the diagnostic area under a man named Eli Nadel. And then subsequently Nat Berlin took it over. There again we didn't really have anything much. There weren't many leads. DEVRA: Nothing was really coming out of the laboratory that had much pertinence to mass application? So the things that Robbins was doing-- he was promoting the Pap smear and smoking and eventually mammography and some subventions to states--they could.be safely separated out from the NCI regular activities to go their own way? ENDICOTT: Well I'm pretty sure that the things that were already well e3tablished probably were sustained with more enthusiasm with the separated group than they would have been with a primarily research-oriented group. ' DEVRA: Do you think they would have been swallowed up by the research group? Eventually they were bigger in the old days, in the 40s, but as the scientific aspect of the NCI grew the force in what was called cancer control by comparison was diminished. And then pieces of it would split off, one piece being epidemiology, another piece being biometry. It sort of was the "mother," and before you knew it the children were all out there and there wasn't anything else for mother to do. ENDICOTT: I elected to make epidemiology and biometry a strong part of the research program. ~. DEVRA: You needed them there? ENDICOTT: They had the potential to make a great contribution through strengthening of the capability team to do research in the etiology area. DEVRA: Now that was at the NCI? The stimulus had come from cancer control experience. But we had to do more in etiology? ENDICOTT: Well I'll tell you, I took a look at the whole cancer program when I arrived on the scene and decided that it was poorly balanced and that we had done more than enough in . mouse cancer and it was time we really addressed the human condition and cast about for ways to do that. Now there were certain glaring inadequacies in the program. DEVRA: Such as?

,. . . A History of Cancer Control in the United States • 1946-1971 Appendices 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

i 20 example of their impatience. I think they really felt this was their bag. There were some pretty shrewd, level-headed people there. I think that the ACS was sort of uneasy about the giant that the NCI was in terms of the resources it had for research. Clearly, they were never going to raise that kind of money. DEVRA: They say in. a lot of ttie annual reports that of course when a cure for cancer is found; they'll go out of business. Do you think they really believe that? Either part of that statement? One, that there will be a cure for this whole battery of diseases, and two, that they'll go out of business. Or will they get like the T.B. Association? ENDICOTT: Anyway, I don't think it's a cause for immediate concern because it's not imminent. I really think that the relationship between the NCI and the ACS is sort of a model. DEVRA: There isn't anything like it that I've found. I don't know whether the Heart Institute behaves the same way with the American Heart Association. ENDICOTT: I don't think so. The groundwork, I can't take credit for. The groundwork was really laid by Rod Heller. I just came along and played a very active role. DEVRA: Did he give you some points on how he had done it and how to keep it up? ENDICOTT: No, I don't think we ever really discussed it. DEVRA: His predecessors really didn't pay much attention to the Cancer Society? Spencer, Scheele. ENDICOTT: Rod was primarily a "public healther." He was thoroughly at home in public health, was sort.of uneasy in a research environment. But in a public health arena he was thoroughly at home and a real pro. I doubt if I'd have had enough common sense to really stroke the relationship, if he hadn't gotten it started. It was really easy,for me. (American Colle¢e of Surgeons) DEVRA: How did your office relate to the American College of Surgeons? ENDICOTT: Well, we had very good relationships with the American College of Surgeons. More than any other one thing, I attribute-thi8 to a close personal friendship I had with Ravdin. DEVRA: IA. Was he the president in those days? ENDICOTT: No, I think he had already gone through that stage and was on the Board of Regents. I went to Ravdin and persuaded him to become chairman of the clinical panel in the chemotherapy area. Out.of that grew all sorts of joint effort things we did with the American College of Surgeons. ,. DEVRA: Did the College testify for regular appropriations?

16 F DEVRA: So here we are a good example. Did you issue an RFP for this mammography study? Or how did this wind up going to the HIP group in New York? ENDICOTT: It's so long ago, I really don't recall precisely. The formalities of RFPs hadn'tTeally evolved much then. It was not a competitive kind of thing. DEVRA: Going around and see who had a big enough population, who had the interests, and maybe the technical competence? ENDICOTT: As I recall it, Shimkin simply decided that-HIP was the best place • to do it. You'd have to ask him about details DEVRA: And Sam Shapiro, right. But you were proud of•that. Felt this was something that was either going to make or break this as an early detection device for cancer. ..• DEVRA: Why? ENDICOTT: Because they believed in it. They really did believe in it. DEVRA: R. Lee Clark had been convinced by Bob Egan that it was really going to save lives? And Lew Robbins was doing these reproducibility studies to find out if local radiologists could do these mammograms. Was this really a battle between the M. D. Anderson people saying we've got,something here that we think we own? (Technology Assessment) ENDICOTT: No, it wasn't that. They had real missionary zeal about it. It was sincere and honest. To my mind, what Shimkin did was reallx a_pioneering effort in technology evaluation, which is something that is still something that is largely untouched. And it's haunting PHS right now. And Ted Cooper and Don Frederickson and I are spending a lot of time, I suspect, in the privacy of our own bedrooms wondering what the hell to do about it.

DEVRA: Did they attempt to do that to you? (Tobacco Lobby) ENDICOTT: Oh yeah. They'd always be troublesome at the time of appropri- ations. There were two Congressman on the appropriations subcommittee in the House who always came to the Hearings loaded with questions prepared by the tobacco industry. And we had plenty of trouble with interstate and foreign commerce committees. Quite hostile hearings. DEVRA: There are several Southern Senators on that committee? ENDICOTT: Oh sure. And it really was a drawn battle to get the first warning label on the cigarette pack. DEVRA: Do you remember any specific events that really led to that decision finally? Any decisive events? ENDICOTT: I don't really recall whose idea it was to do that. There were certainly some fascinating hearings on it though. On the cigarette smoking, lung cancer issue, I think one of the interesting things we got going during the 60's was the first time a program with the tobacco industry aimed at developing a less hazardous cigarette. . ~, r DEVRA: Whose initiative was that? ENDICOTT: That was mine. DEVRA: That this was the way to go. The other things might work but ENDICOTT: It could be a]ong, long time before tobacco smoking disappeared, and we shouldn't put all our chips on an exhortation. It would be a good idea to see what we could do to make it less hazardous. DEVRA: How much money did the NCI put in it originally, because I gather the industry was putting money into it also? ENDICOTT: You're going to see Carl Baker, aren't you? DEVRA: I did and I'm going back to see him again. Would he know about the dollars? What about occupationally induced cancers? What role did the NCI play in stimulating greater attention to bladder cancer among certain workers or lung cancer among others? (Occupational Protection) ENDICOTT: I think the most direct thing that we did was done under Paul Koten. And it's probably spun off to the NIEHS, I really don't know now. The two of us discussed this a lot about how to tackle a problem. There still is, I'm sure, a tendency on the part of the industry to deliberately ignore occupational hazards for economic reasons. We felt that there were excellent research opportunities in selected occupational settings if we could just get access.

8 ENDICOTT: He did better than that. He had a number of inspirational talks with Lister Hill? (Carcinogenesis) DEVRA: You mentioned Phil Shubick earlier. What kind of a role did he have on the Council in stimulating interest in chemical carcinogenesis as a priority for the NCI? ENDICOTT: Well, he's an ardent advocate of research in that area. You know Phil, of course, he's oftentimes his own worst enemy. But he can certainly be counted upon to support the area and to bring pretty good critical judgment there on technical issues. DEVRA: Can you think of some of the other promotive influences and some of the obstacles? (Smoking) r ENDICOTT: I think probably one of the promotive things we did was to finally convince Luther Terry that he had to do something about smoking and health. He certainly was a reluctant dragon, for a long time. DEVRA: Let me ask you something. Lester saw Lee Burney yesterday, and said to him, "I have a question of you. I'd like to know why your statement of 1958, your Surgeon-General Statement, had so little impact?" I haven't seen his reply, but it is rather discouraging as we look at this history to realize that it just takes forever and forever for some things to sink in. Now you say Terry was a reluctant dragon, and the pressure was coming from where to push him to do something more than what obviously wasn't happening already? ENDICOTT: Pressure was coming from the ACS, American Heart Association, American Public Health Association, and I remember at the meeting of the Board of Directors of the ACS, I just barely headed off a vote of censure, promising that if they lay off, I'd get back down to Washington and persuade them to do something. DEVRA: They had been appealing through conventional routes--lobbyists, friends, and so on--and he wasn't responding? ' ENDICOTT: No he wasn't.

A 23 DEVRA: How did that go over? ENDICOTT: Well, it was before the Cancer Panel that Sidney Farber was chairman of. It went over with a bang. DEVRA: As lvng as it had Regional Heart Disease, Stroke, and Cancer Centers? ENDICOTT: That was the beginning of the end of the whole thing I think. Because they began to mix apples and oranges. And they are really three different areas, and it just didn't make sense. DEVRA: You really felt there would be more integrity if the categorization could be maintained? That they were different diseases, treated by different people? ENDICOTT: You know you can move a cancer patient quite aways, but a coronary is another kind of an animal. And the stroke victim still another kind of problem. Well by the time all the cooks in that broth got through with it, by the time it emerged from the Congress, it was a"swoose." It was not swan,_. and it was not goose, it was a"swoose." It was a"swoose" to its dying day, which hasn't quite arrived yet, but its imminent. DEVRA: Did it siphon resources away that might have gone into NIH, into other things? ENDICOTT: No, I don't think so. Matter of.fact, probably got resources that wouldn't have otherwise ever been created. DEVRA: So it did some good perhaps. siphon away funds ENDICOTT: I.was afraid that it might/at first. But it became obvious that it wouldn't. It was a discouragement to me that it really had so little come out of it that was relevant to the cancer field. It seemed to have been primarily focused on cardiovascular disease. DEVRA: Then ttMP got into the health services area, which of course really overlapped what you were involved in (health manpower), and that made life rather unpleasant, I am sure--confused if not unpleasant. ENDICOTT: I must say that in spite of all the bad marks that people have given RMP, I have found that they were putting their fine Italian hands in some pretty splendid enterprises. Because its mission was vague, though, and suffered frorrconstant change of leadership or lack of it. DEVRA: Do you think it was a victim of all this reorganization and something that maybe it was innovative? We always scream about innovation. We don't even see it when it hits us sometimes or we don't know how to handle it. ENDICOTT: I think it was a born target for a Nixon administration. One that tried to diminish the Federal load and look around for weaklings and knock them off.

I 11 DEVRA: So you tried to put out some "carrots?" ENDICOTT: Yes. And my feeling was too that if you could really get big outfits like the steel industry and the automobile industry and so on in- terested in defining their hazards, you've taken a,first importance step in getting them to do something about this. DEVRA: Did you offer them incentives such as grants or contracts and technical assistance? ENDICOTT: It was primarily technical assistance and this was one of Paul Kotin's great talents--getting into a place and working out with them how to maintain surveillance and potential high-risk occupational groups. DEVRA: Did he succeed with a number of major employers? ENDICOTT: He did. Steel industry, automobile industry, and some of the aerospace industries, even Proctor and Gamble. He knew how to talk to them. DEVRA: Larry Agran, whose writing this section, has talked to him but after reviewing these notes, he might want to see him again. Dr. Hueper had left the NCI when you came in. He was still around? What was he doing? (Hu eper) DEVRA: You brought Paul Kotin in above him, certainly? ENDICOTT: It's very interesting. Hueper was approaching mandatory retirement. I went to him and said who is the best man in carcinogenesis in the U.S.? And he thought about a while and said Paul Kotin. I then asked him if he'd help me, and he said he would. And he did. I think he sort of regarded Paul as a protege. DEVRA: Had he trained in his laboratory? ENDICOTT: I don't think so. DEVRA: But he did respect him? ENDICOTT: Oh yes, very much. Once Paul arrived, I think Hueper was a little chagrined. He's a very proud man. But he was instrumental in getting Paul there. DEVRA: It never occurred to Hueper to provide technical assistance to these industries, did he? .. ~

DEVRA: OAe of the things he got working on toward the very end of his tenure, about 1964, was to get somebody to work on a 6 inch fibreoptic Sigmoidoscope, to use in lower colorectal cancer diagnosis. Was that idea brought into the Institute as something that maybe the Institute should work on, or was it taken out into industry generally? ENDICOTT: I don't really remember. I kind of think maybe he persuaded Eli Nadel to put some dough into it, but I don't remember for sure. But I do remember his keen interest in it. DEVRA: And here we are, 11 years later, and what do we have? Well, we got a colonoscope finally and we got a heminocult, hemotholte, that may or may not pan out. There hasn't been very much glamor or enthusiasm for people to work in early detection or in prevention. I don't think everybody is looking for Nobel prizes, but somehow that has just not become something very appealing. ENDICOTT: No it hasn't. I thought.on the plane this morning about what my recommendations for future directions are. I really don't have any. DEVRA: If you were czar of cancer control today? back then ENDICOTT: I would never had taken the job/unless I had some pretty clear cut ideas about what I was going to do about it. ButI really don't have any red hot ideas in this area. today. DEVRA: You have enough integrity to.admit it. That's very healthy. ENDICOTT: ~On the other hand, in this job, I can see 1Qts of things. DEVRA: Health resources administration. .When you first came here though, it must have been a big puzzle? ENDICOTT: Oh, what a can of worms. Still a can of worms. But you know it takes a while to launch an agency out of pieces of other agencies and get really working together. We've got.a long ways to go yet. But we have some interesting resources. We've got . awfully fine people, including a gal I stole from the Social Security Administration. And we've got a good bunch of people in Health and Manpower. Still have a lot of things to be done and finally winding up a bunch of previous reorganizations and disposing of all the leftover parts. DEVRA: You going to be reorganized again? We're going to have a national election this fall. ENDICOTT: I don't think there is any end to reorganization. If I had to guesswTiere the next big reorganization is going to come, I'd say it's in the interface between Public Health Service and the Social Security Administra- tion. That's long overdue. Just how it's going to come out, I don't know. But I don't think that HEW can afford the luxury of forever of having things the way they are. 25 O V, ~

18 DEVRA: That's correct. ENDICOTT: Probably for the next few decades the most important thing they are doing in my view is developing better triage of cancer patients to get them into first-rate places for care. DEVRA: Well that's not something the NCI is doing on its own. That's something that's come out of the center's mandate in a sense. The system of the centers with outreach. 11 ENDICOTT: But we already had that. We had a bunch of cancer centers before. DEVRA: Right. We had Roswell Park and Ellis Fischel and M. D. Anderson, Sloan-Kettering. ENDICOTT: And McCardle in Wisconsin, and Kaplan and Company at Stanford. 7EVRA: But they were not multidisciplinary in all of them, especially the anes in the West. They were site-selected or they were therapy-selected. If you have Hodgkin's disease, it's fine to go to Stanford. I'm sure if.you have several other things, it's fine to go to Stanford, too, but they didn't have equal kinds of competence in all the diagnostic and therapeutic modalities. The movement for centers--that whole concept of centers was already present, do you think, when you were the director? ENDICOTT: Yes. DEVRA: It wasn't reinvented in 1971? ENDICOTT: Had some expansion or something? I can't take credit for it, because they were already there when I got there. During my tenure we launched an organization, I'm sure it still exists, but-I don't know:what the title of it is now, it used to be The Association of Cancer Institute Directors. Really responsible for getting that off that ground. (ACS) DEVRA: How did your office relate to the American Cancer Society? ENDICOTT: Very closely. DEVRA: You were obviously on their Board? Some of them were'on the Council? ENDICOTT: We had a very good working relationship. DEVRA: With the Washington staff. ENDICOTT: Not the Washington staff. But we worked very closely with the headquarters people in New York. DEVRA: Were there tradeoffs?

. Larry: Let me ask you about the '64-74' period. Let's say you ad been cigarette czar for this country, in 1964, assuming that they had such a post. You didn't have to contend with political problems. What kind of public policy would you have instituted? Breslow: Well, I would have instituted the policy that I advocated at the First World Congress on Cigarette Smoking and Health. I don't recall exactly when that was, but it was in the middle 6n's. I think probably we could even • find the paper, or at least some fragments of it, that I presented at that time. That was the position that I would have advocated, or tried to carry out if I were as you say, czar for cigarette smoking in 1964. That position was that it was primarily an economic issue. Of course we wanted to educate the people on it. We have an obligation to give people the facts and seek to motivate them to do the things that are in their own personal health interest. So I am not denegrating the importance of education of the public. I think we have that as a social obligation, and so I strongly favor the development of_eduoational- pra-grams,--per- sonal and mass education. But, to really get control of the situation, I was early convinced that the approach would have to be an economic one. Therefore, if I had been czar in those days, I would have initiated a Federal Government program to convert the use of the tobacco growing land in this country to other uses. The tobacco industry, like any other industry, consists of land, people, other capital resources that are put in, as well as the operating costs of the industry. If one is really going to change it in a reasonable tirne, then it seems to be that we have to approach the matter in the same way that we approached ship building in World War II. We had some ship building, but it was necessary to build a so-called Liberty Ship and a lot of other kinds of ships in a hurry, in those days. We did have the capital, the other resources necessary to build the ships that we needed to win World War II. It required a tremendous Government investment to do that and we made it. Now, I believe that we could and should do the same thing regarding the cigarette industry. We should acknowledge the fact that some land, some people, other resources are devoted to an economic persuit. It supports the livelihood of many people, and the way to approach it is economically, to offer a substitute. I would, for example, suggest that the land be converted to growing soybeans and other crops that are very much needed in this country to feed humans, to feed cattle, to use for overseas shipment, both humanitarian and economic exchange purposes. It would be a great advantage. So I would have done that in '64. Larry: That deals with the supply side. What about the demand side? I don't know how many people were smoking at that time, 50 million or so habituated to one degree or another to cigarette smoking. How would you have dealt with that side? Breslow: Well, with education as I mentioned. But, as long as you have in America an industry with a product that is being pushed upon people, that had a tremendous impact on what you call the demand side. In Los Angeles, inJthe 20's and 30's there was a transit system. I remember it even in the 40's, riding in some of the so-called red cars. So there was a transport system around which Los Angeles could have been built. It would have perhaps appeared a little different, I am not sure how much different it would have appeared, if we had those street cars, or electric cars plus buses. But the automobile indus- try in this country found that Los Angeles was a prize market. They began developing automobiles and passing legislation in the State Legislature to use tax money from gasoline to build freeways and other highways where automobiles could go. The industry built what you call the demand. So I don't think that one could have dealt with autor.,obile driving in Los Angeles by educating people not to drive automobiles. They were relying on automobiles for transportation. (8)

17 s DEVRA: The whole idea of how do you evaluate technology? ENDICOTT• Yeah. Which is pressing on me particularly hard right now, because of the responsibilities we have under the new planning legislation and pro- viding national guidelines. This is powerful charge to the Council and therefore to us in the area of technology assessment in connection with it. And I am also responsible for the National Center for Health Services £NDICOTT• So somehow between NIH, FDA, and to some extent CDC and HRA are going to•tackle this thing. Because there is just no way I can wiggle out from under it. And I don't have the technical competence. We have virtually no scientific competence in the biomedical area in HRA. DEVRA: But you're being charged now by law with evaluating the effectiveness of certain technologies. ' r ' ENDICOTT: I have a political scientist in charge of health planning and resource development. A great guy, Harry Cain, is first rate. An economist in charge of NCHSR. I think Harold Margulies and I and a little handful . of guys over at the Bureau of Health Manpower represent our whole competence. in the biomedical area and that's not saying very much. So we have to draw somehow on the really tremendous power of NIH. DEVRA: Are they cooperative? Are they willing to share some resources with you? ENDICOTT: Well, Don Frederickson is properly motivated, but by and large, the attitude within NIH is, ho hum. "We does our thing and we publishes our papers and the world ought to be God damn glad we're here." And I can't help saying the world should be glad they're here, but they don't have any enthusiasm for technology assessment- DEVRA: This sounds like a broken record. This is the same story with cancer control. It's all right, let them go downtown because you know, they're applied, and they're kind of fooling around and trying to get things into private practice. And you know, we're lab men. We're the pure scientists. (Current Cancer Control Program) ENDICOTT: I did what I could and that was•quite a lot to get the Cancer Institute really concerned about.solving the cancer problem. Honest to God. I still don't think they know quite what the heck they're doing with the cancer control program. At least that's the impression that I have. Carl Baker, I don't think he wanted a cancer control program.

22 College. You know that's kind of a fragmented area. We put resources and efforts into second generation hardware, into defining what a center really ought to be, what kind of hardware and staff you need, what kind of a popu- lation it could serve. There were things bubbling and boiling all the time. That was a very active area. In international cancer control area, I think that is about the size of it really. (UICC) DEVRA: Do you still maintain some involvement with the IRAC. No. What about the UICC? Were you involved with that too? ENDICOTT: Tangentially. There were a couple of key people in the Institute who reallv devoted a lot of energy there. I managed to give it a lot of support by making it possible for Murray Shear to devote essentially full-time to it. My motives were mixed. (I had to get him out of the labor- atory for one thing), but we did put a lot of effort especially through Murray. He and Harold Dorn were prime movers in this. And I always encouraged it, but I didn't take an active part myself. The Cancer Institute though, when I left there, was still a major source of support for the International Union. DEVRA: I haven't asked you at all about the RMP period. I have a question I want to ask Carl about. I guess maybe I'm a little mixed in my own understanding of where you people were. Your tenure really ended at the time ENDICOTT: 1969. DEVRA: 1969? Well RMP had already been created? Had cancer control already been sort of slipped in to RMP. Bill Ross's program that was downtown. ENDICOTT: Yeah, that occurred during my tenure. DEVRA: Did you have any feelirigs about that or were you even asked to express them? ENDICOTT: No. The RMP didn't really work very effectively with the Institute. DEVRA: Even when it was within the NIH? ENDICOTT: Even when it was in NIH. I was never very keen about RMP. DEVRA: How did you perceive RMP in relation to this sort of familiar established program priorities? (RMP) ENDICOTT: I thought it was kind of an abortion from the beginning. I made a very strong plea to the DeBakey commission to support the idea of regional cancer centers.

ENDICOTT: No, I don't think. Ravdin did, but it wasn't in that capacity. Things that we worked on together were to reinforce their efforts in upgrading registries and establish criteria for various levels of sophistication on the part of hospitals. This carried over and blended into RhlP. A number of those enterprises were underway before RMP was spawned. (College of American Pathologists) DEVRA: What about the College of American Pathologists? ENDICOTT: That was I think sort of minimal. Probably Lew Robbins and his cytology staff worked with them more closely than we did. DEVRA: Did they bother you? ENDICOTT: Oh no. The door was always wide open. But really I can't put my finger on anything much. We did support the field through various enterprises with the AFIP,.that was funded through the National Research Council. Tumor registries and all that kind.of stuff. I- DEVRA: Did you have any big fights with them? ENDICOTT: Oh, no. DEVRA: The big fight had already taken place over what to do about the Pap smear. ENDICOTT: I can't recall we had any hassles with them. Matter of fact, I think we've had a very warm relationship so far as I can recall. I can't think of any animosity. I can't on the other hand put my hand on anything very positive. (Endicott was originally a pathologist.) (American College of Radiology) DEVRA: How about the American College of Radiology? Because you mentioned that you got the HIP study going. ENDICOTT: I personally had very active relationships with the whole radiological community. Not all, but mostly. Henry Kaplan convinced me that we really had to do something about therapeutic radiology and we did. We established a major training effort in therapeutic radiology. It did create kind of a running battle with Dick Chamberlain and that element of the radiology community that was convinced that they ought to stick with general radiology. DEVRA: Diagnostic radiology? ENDICOTT: The general radiologists got very iittle training in therapy and the rest of it was diagnostic. Even after all these years, I still will meet with the radiologists now and then, and we will mutually hold hands. This is an area in which Paul Kotin's wife, Pauly Stephan., played a very active liaison role with the radiology community. We undertook a variety of things. Not always the American

. .Z 24 (Cancer Control Progress) DEVRA: Would you like to evaluate the progress of cancer control during your tenure or indicate your recommendations for the future? ENDICOTT: I don't think we got very far. DEVRA: What about the cooperative clinical trials? ENDICOTT: I think we've made some major progress in developing organized target research in the cancer field during my tenure, ... but I really can't really. .. .claim that I did anything for what is normally identified as cancer control. DEVRA: Or what we call it now. What about the environment in those days, within the Institute though. You brought in good people. You stimulated good people. The philosophy may not have been what we call classic cancer control. ENDICOTT: I think we laid a good framework on which you can build on for the future. DEVRA: And you certainly did something in the environmental health area. ENDICOTT: But I'm basically a research guy. My contribution is in the kinds of things that a research guy would be broadly interested in. I don't think by that time I had any hang ups about the virtue of basic research. I did at the outset. I was just as biased a guy as anybody you'd find at first. But I had gotten over that pretty much by 1960. DEVRA: But the cooperative clinical trials and the chemotherapy program in a sense, were applied research. That, you considered a natural progression. But demonstrations of early detection techniques or strategies to inform people that smoking was hazardous to their health, how did you perceive those, apart from the fact that they weren't in NCI, did you ignore them entirely? ENDICOTT: No. I didn't feel they could be ignored. I wanted them to prosper. •But basically I don't think I really had anything too much to contribute in that direction. DEVRA: What about other members of your staff or other resources that you had? If Robbins came to you, and I don't know if he ever did--he did.?, what kinds of things would he ask for? ENDICOTT: I think he really was on the alert for something you could give. But I didn't have anything much for him. DEVRA: Was he discouraged do you think? (Robbins) I ENDICOTT: No, no. If he was I wasn't aware of it. I think he was disturbed by some of the organizational shuffle through, that sort of thing. He was a stout hearted fellow. He didn't give up easily.

19 ENDICOTT: Oh yeah. There were many things we did jointly. DEVRA: Not just conferences and funding of research activities? ENDICOTT: No. Let's see, what would one be, there were so many. I think probably the most significant had to do with lobbying. DEVRA: Of your budget? ENDICOTT: Yes. Now, Rod Heller and I both took a very active role in the American Cancer Society, as best we could in helping them raise funds. An effective working relationship between NCI and ACS in advocating appropri- ations, I think, clearly was the most significant. DEVRA: It helped you immeasurably. ENDICOTT: The other principal area of extensive collaboration other than joint sponsorship of meetings, which we did constantly, was pretty effective blending of our.staff resources in the general area of public education. _ r DEVRA: That's kind of interesting because NCI and NIH generally really never had much of a mandate and didn't really seem to have much of a budget to do public education. Some professional education obviously. Quite a bit of that. (Public Education) ENDICOTT: Both NCI and ACS plowed that field pretty.thoroughly but it struck me that the ACS because of its enormous volunteer organization really had tremendous power in this area and so my feeling was let them take "center stage" and put our resources behind them. One of the things which you have to understand to work effectively with a yoluntary organization is that they have to have a lot of visibility if they are going to get money. And I think a secret of really effective working relationships between the -Society and NCI is to let them take the lion's share of the credit and don't get uptight about it. Because they reciprocate by pushing for a big budget for NCI. Okay, let them get the headlines, what the hell. I used to have an awful time with that because they continually annoy our public relations people. DEVRA: Because they were getting so much... ENDICOTT: Yeah, we'd jointly sponsor something. ACS would be prominent, way down here, in tiny print would be the NCI. We'd be putting in 90% of the budget. I just laughed about it. DEVRA: They have to go out and raise money, too. Do you think there were any people on the ACS Board who particularly thought the government, NCI, even in their public education mission was slow, on the cigarette issue, early detection, and so here they were in there doing all the work in a sense, or they were doing what they felt was the government's work. ENDICOTT_: No, I don't think so. Clearly the example I cited to you of the ACS Board of Directors almost censuring the Surgeon General is a good