Denis Parsons Burkitt (1911–1993)

His approach to medicine led to the discovery of Burkitt’s lymphoma and established the importance of a fiber-rich diet.

Denis Parsons Burkitt was born on February 28, 1911 in Enniskillen, Ireland, to a protestant family. His fascination with geographical pathology, an interest encouraged by his father’s work with birds, guided Burkitt’s many contributions to oncology, hematology and nutrition.

The strong foresight Burkitt displayed later in his career is not something that always came easy. After completing preparatory school, Burkitt expressed no particular career ambitions, but enrolled in the School of Engineering at Trinity College in Dublin. Burkitt’s tutor expressed doubts about his sense of direction and his ability to actually obtain a degree.

Denis Parsons Burkitt Source: Albert and Mary Lasker Foundation

During his first year, Burkitt joined an Evangelical group within the college. The support he received as a part of this group, along with his uncle Roland Burkitt’s work as a missionary in East Africa, inspired Denis to switch from engineering to medicine.

Burkitt earned a Bachelor’s of Medicine from Trinity College in 1933 and graduated from Dublin University in 1935 with a medical degree. After receiving a fellowship from the Royal College of Surgeons of Edinburgh, Burkitt boarded the Glen Shiel, a freighter bound for Manchuria, as a ship’s surgeon. Upon returning to England, he worked as a resident surgical officer in at the Prince of Wales Hospital in Plymouth and began seriously considering missionary work. After World War II started, Burkitt volunteered for the Royal Army Medical Corps and served in Kenya and Somalia as a surgical officer.

After the war, he joined the British Colonial Service and served first as a public health officer at a 100-bed hospital in Lira, Uganda, and later as a surgeon at Mulago Hospital in Kampala, Uganda. As a surgeon, Burkitt performed frequent amputations due to ulceration and elephantiasis and established a small workshop to manufacture plastic limbs in an effort to improve the lives of the many patients that did not have access to prosthetics.

From ornithology to oncology

Burkitt first encountered the facial tumors that would later be named Burkitt’s lymphoma at Mulago in 1957. The first patient Burkitt examined was a young boy with swellings in all four quadrants of the jaw. As time went on Burkitt began photographing the increasing number of young patients that he saw with similar symptoms. He noticed a trend of histologically similar tumors occurring in the abdominal viscera of many of these patients as the disease progressed.

Although Burkitt did not understand the exact nature of the disease, he published preliminary observations in 1958 in the British Journal of Surgery suggesting that the jaw tumors were a presentation of a single disease with various manifestations.

Concerned with the severity of the tumors and the lack of available treatment options, Burkitt decided to conduct an epidemiological study. As a child, Burkitt observed his father’s interest in birds. James Burkitt was credited as the first ornithologist to band birds to study the geographic distribution of certain species. It occurred to Burkitt that tracking the geographical distribution of occurrences of these tumors might be useful in determining their origin.

Burkitt mailed more than 1,000 illustrated pamphlets and questionnaires to every government and mission hospital in Africa that he could find, and put together a distribution map based on the responses he received. Burkitt determined that the tumors occurred most frequently in an area spanning central tropical Africa, which he referred to as the “lymphoma belt.”

Along with two colleagues, Ted Williams and Cliff Nelson, Burkitt embarked on a 10,000 mile road trip, visiting 56 hospitals in Kenya, Mozambique, Nyasaland, Rhodesia, Swaziland, Tanganyika, Transvaal and Uganda to further examine the etiology of the condition. After determining that factors such as altitude, temperature and rainfall affected tumor occurrence, Burkitt and colleagues hypothesized that an insect vector might be responsible. Further study revealed a correlation between incidents of malaria and the tumors; however the specific relationship between the two remained unclear.

Although Burkitt’s research was met with relatively little interest early on, the 1960s marked a change in attitude among the medical community. Virologist Michael Anthony Epstein attended one of Burkitt’s lectures at the Middlesex Hospital in London, in 1961. Soon after, Burkitt began sending Epstein tumor samples from his patients. Meanwhile, the publication of Burkitt’s compilation on malign lymphomas among African children in the journal, Cancer, increased interest in the subject. At an International Union Against Cancer conference in 1963 the tumors became known as Burkitt’s tumors, and eventually as Burkitt’s lymphoma.

Three years later, Epstein and colleagues used electron microscopy to identify viral particles in the cells of the tumors Burkitt had sent them. Epstein–Barr virus became the first infectious agent identified in the pathogenesis of tumors in humans.

Treating Burkitt’s lymphoma

It was also around this time that Burkitt began to seek new ways to treat patients with these tumors. Previously, surgical excision was the only treatment option, and the tumors often came back leading Burkitt to view the procedure merely as a way to extend a patient’s life. Because X-ray technology was not available in Africa at the time, the environment provided a setting for controlled studies of chemotherapy drugs. Burkitt was able to secure supplies of methotrexate and cyclophosphamide (Cytonax, Bristol-Myers Squibb) and began treating children with the medications.

Patients’ responses to the drugs were dramatic. Although few received the full recommended course, patients achieved long-term remission in 15% to 20% of cases. Similar outcomes also were achieved by other physicians treating patients with Burkitt’s lymphoma. Because of these favorable outcomes, the use of cyclophosphamide and vincristine, along with combination therapies were also studied, and the Makerere College Medical School in Uganda partnered with the U.S. National Cancer Institute to conduct trials into the most effective courses of chemotherapy for Burkitt’s lymphoma.

Mapping healthy diets

In the late 60s, Burkitt became involved in tracking epidemiological relationships between gastrointestinal disease and geographic location. Burkitt applied many of the same techniques he used while studying lymphomas to establish the “fiber hypothesis,” which implicated a low fiber, or Western diet, in the increased incidence of heart disease, appendicitis, diverticular disease, gallstones, varicose veins, hiatus hernia, hemorrhoids, colon cancer and obesity in the United States compared with the relatively low incidence of these diseases in Africa.

Burkitt wrote several short papers on the subject in the early 70s, co-authored the book, “Refined Carbohydrate Foods and Disease: Some Implications of Dietary Fiber,” with Hugh Trowell in 1975, and wrote a shorter book, “Don’t Forget Fiber in Your Diet,” in 1979. Through these works, Burkitt is credited with simplifying the relationship between dietary fiber and disease and making it understandable for everyone. This promoted a sustained interest in the topic that lead to additional, more in-depth research.

Burkitt’s contributions to oncology, hematology and nutrition remain salient today, and many of his discoveries still generate new research. Throughout his career, Denis Parsons Burkitt received many awards. In addition to receiving the Bower Award and Prize for Achievement in Science in January of 1993, Burkitt accrued numerous honorary degrees, was a fellow of the Royal Society, an honorary fellow of Trinity College and a member of the French Academie de Sciences. – by Nicole Blazek

For more information:

• Coakley D. Denis Burkitt and his contribution to haematology/oncology. Br J Haemotol. 2006;135;17-25.
• Story JA, Kritchevsky D. Denis Parsons Burkitt (1911-1993). J Nutr. 1994;124:1551-1554.
• The American Cancer Society. Denis Parsons Burkitt (1911-) CA Cancer J Clin. 1972;doi:10.3322/canjclin.22.6.345.