Conversations with the Pioneers of Oncology: Dr Anne Moore

Dr. Hayes interviews Dr. Anne Moore on pioneering the field of survivorship.

Dr. Daniel F. Hayes is the Stuart B. Padnos Professor of Breast Cancer Research at the University of Michigan Rogel Cancer Center. Dr. Hayes' research interests are in the field of experimental therapeutics and cancer biomarkers, especially in breast cancer. He has served as chair of the SWOG Breast Cancer Translational Medicine Committee, and he was an inaugural member and chaired the American Society of Clinical Oncology (ASCO) Tumor Marker Guidelines Committee. Dr. Hayes served on the ASCO Board of Directors, and served a 3 year term as President of ASCO from 2016-2018.

TRANSCRIPT

SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

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DANIEL F. HAYES: Welcome to JCO's Cancer Stories-- The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org.

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Today, my guest in this podcast is Dr. Anne Moore. Dr. Moore has been instrumental in the field of breast cancer, especially related to her clinical and educational contributions to our field. Dr. Moore was raised and spent much of her formative years in Peru. She received her undergraduate degree at Smith and her medical degree at Columbia University College of Physicians and Surgeons.

She completed a residency in internal medicine, as well as her hematology and medical oncology fellowship at Cornell, where I believe she's basically spent the rest of her professional life now as a professor of clinical medicine, and a director of the Iris Cantor Weill Cornell Breast Cancer Survivorship Program at the Weill Cornell Medical College of Cornell University. Dr. Moore, welcome to our program.

ANNE MOORE: Thank you, Dan.

DANIEL F. HAYES: I hope I got all that right. I think I did. Very happy to have you. And I consider you a real pioneer in that regard, being a woman physician in the decade and decades when that wasn't very common, and a woman oncologist, when it was almost unheard of, frankly.

So I know you've probably got some great stories about your med school class, where I think you were 1 of 10 women in your class or something like that, and in your training. Can you fill us in on what it took for you to become a physician?

ANNE MOORE: Well, I must say, I went to all women's college. I went to Smith College. So coming into a class where 10% of the class the women was a big change for me, but a very exciting one. The women, we respected each other. We were respected by our male colleagues. We were well-treated. We were included at Columbia.

The faculty were always gracious. We didn't have a sense of being excluded. So it was very-- it was a fabulous place to be and very exciting.

DANIEL F. HAYES: Did you feel encouraged to pursue your ambitions? Or were there efforts to pigeonhole you into places that were better for women that you might not have wanted to? For example, I interviewed-- I did interview Clara Bloomfield before she passed away. And she made it clear that the things she wanted to do weren't considered ladylike where she trained, but she did it anyway. Did you run into that?

ANNE MOORE: No, we didn't. I remember the head of orthopedics speaking to me about an orthopedic fellowship. Some of my classmates did become pediatricians, which of course, was a typical field for women. But I was interested in hematology/oncology even in medical school. And there was never a sense that that was not an appropriate place for me.

DANIEL F. HAYES: Well, that's good to hear. I also know in a chat you and I have before this that you were telling me, by the way, I Googled you. And I found your original New York Times wedding announcement. I won't betray the date, but you had a very nice picture. You looked very young. You told me an interesting story about how much time you got off for your honeymoon.

ANNE MOORE: That's right. We got married over a Labor Day weekend so we could get an extra day. And I had to go to my chief resident, whom I called Dr. Steinberg, and request not just a two day weekend, but a three day weekend. There was a lot of thought, but my fellow interns jumped in and covered for me for that great event.

DANIEL F. HAYES: Those are different times, that's for sure. So I want to talk a little bit about your career. I know in the early 1990s, you began a multidisciplinary breast clinic at Cornell, which at the time, even in the country, was pretty unusual. I'm going to throw out my mentor, Craig Henderson, had started one in the early 1980s in Boston. But now it seems like everybody has a multidisciplinary clinic for every disease in oncology. What made you think that was a good idea then?

ANNE MOORE: Well, it was a very practical idea, but we saw a patient for a new diagnosis of cancer. And at that time, I was already becoming very interested in breast cancer. And the patient would come with her slides, with her mammograms. And I would run to surgical pathology, look at the slides, run over to the radiologist, interrupt them to look at the mammograms, run back downstairs to see the patient. And each specialist that I saw was teaching me so much while I was there, just looking over the microscope or looking at the screens.

There's too much running around, number one. We all need to learn from each other. And it would certainly benefit the patients. And the decisions were becoming, at that time, a little more complex. We were beginning to think about adjuvant chemotherapy, adjuvant radiation therapy for the new class of patients that had breast conservation. So it was clear that we had to get together.

We realized that we had to speak to each other and it would be much easier if we were all in one room. So we started, in 1991, picking up illustrative cases. And we didn't discuss every case by any means. And we would talk to the radiation therapists, the pathologists, the radiologists ahead of time. They would prepare their sections, and we would all meet.

The joy that we had of doing this and the excitement in those first few meetings, it's the first time we had ever had a meeting like that. And everybody was very excited to be there. And we met solidly up until today with those multidisciplinary meetings. They have become much more common. And now the group tries to present every case in some form of a multidisciplinary format. But those early tumor boards were enormously important and exciting for us.

DANIEL F. HAYES: And who were we back in--

ANNE MOORE: It was basically the surgeons, of course, played a big role, the medical oncologists, the radiation oncologists, the pathologists, the radiologists. And they were sort of the center of the group. We brought the nurses. We brought-- we didn't have genetic counselors involved at that time. We certainly do now.

If we had special issues, we would bring in a specialist to help us, a gynecologist, for instance, or a gynecologic oncologist if we had a case that involved removal of the ovaries or risk of uterine cancer, to talk to us. We had the obstetricians come with our first case of giving chemotherapy during pregnancy back in 1991, 27-year-old woman with an inflammatory breast cancer. We needed to give chemotherapy in the six month pregnancy. We had never done it before. And we had a conference including the obstetricians, again, all together in one room.

And then, I had the practice of scheduling a telephone call with the patient who was presented. Because very often, they were my patients. I was the person doing the most with breast cancer. We would have a scheduled telephone call the night of the conference after the conference. And I would review who was at the conference and tell them what the recommendations were. And sometimes, we had two recommendations, one from one group, and one from the other. And I explained that to the patient. And of course, they were thrilled at the idea of all those people sitting there thinking about them.

DANIEL F. HAYES: Was the surgeon Mike Osborn?

ANNE MOORE: Michael Osborn was later the chief of breast surgery. The original surgeons were really, our private practitioners. Because at that time, most of the surgery was done by private practitioners. And most of the medical oncology, primitive though it was, was also done by private practitioners. I was one of the first to be a full time employee of the hospital doing medical oncology.

DANIEL F. HAYES: Wow. In Boston, it was interesting. There was a, I won't call political split, but there was reluctance among some of the surgeons to engage in such an activity because they felt it would take away their autonomy and they didn't need it. And others who wouldn't miss a week, who loved it. Ultimately, everybody joined. But did you run into that as well, people who just didn't want to do this?

ANNE MOORE: No. I must say, our surgeons were eager. Because this was the time when the question about breast conservation was coming up from the patients. And these are surgeons who all had trained in the radical mastectomy. And New York City women weren't keeping their work quiet. They were really in there, saying, what do you think about breast conservation?

And I must say, the surgeons at our hospital-- wasn't true probably at every hospital-- were willing to listen, but they hadn't had the experience of breast conservation. And that's one reason why they were happy to have the multidisciplinary group discuss that.

DANIEL F. HAYES: So you must have been at the same time or just before that, this was started at Memorial as well. And I know that then it became that. Was there a citywide breast cancer group that met routinely?

ANNE MOORE: Memorial was later with the multidisciplinary tumor board at their hospital, as were the other hospitals in New York. However, we did meet together starting around 1971 with the New York Metropolitan Breast Cancer Group, which was a multidisciplinary group of the surgeons, oncologists, pathologists, the same group that we were meeting with on a smaller scale.

And this was an enormous benefit to the doctors treating breast cancer in New York, that we were able to not only hear our own group, but we could hear the doctors from Memorial, from Mount Sinai, from Columbia, from Albert Einstein, from Montefiore come. And we would meet together. We'd always have a social hour.

They like their scotch, these surgeons. They like scotch. So we would buy the scotch.

DANIEL F. HAYES: That must have been a real cast of characters. Was that, like, Jerry Urban in those days?

ANNE MOORE: It was just after Jerry Urban. It was just after Jerry Urban.

DANIEL F. HAYES: After him? Wow. And how about Ezra Greenspan? Would he come to that?

ANNE MOORE: Ezra had his own ideas. He was not so interested in this group, but he was just a little bit too early.

DANIEL F. HAYES: And could you get Jim Holland to come to that?

ANNE MOORE: The answer is Jim Holland was also not someone who felt he needed to hear a lot of opinions about management of cases. But on an individual basis, Jim Holland was very helpful with patients.

DANIEL F. HAYES: I would have loved to have been at those meetings. That sounds like a lot of fun.

ANNE MOORE: It was great. And we still have them to this day. We meet four times a year with an annual meeting on one Saturday every year.

DANIEL F. HAYES: And I know now that the last decade or so, you've really focused on survivorship as well as your breast cancer work. I talked to Patty Ganz as part of this series. And in my opinion, she really began the field of survivorship. She started thinking about it 25 years ago. But you've really been a mover and shaker now, especially, I think, in the New York City area. Can you tell us about the clinic you've started and how that works?

ANNE MOORE: Well, the survivorship has always been interesting to me, partly because I started so early giving chemotherapy, for instance. And the patients, many of them, had early stage II or stage I breast cancer. And 10 years has gone by, 20 years, 30 years, some cases, 35 years. And they still come to see us once a year. And I became more and more interested in what was going on with them, as well as obviously, with the new patients and the new treatments.

So it's always been an interest on an informal basis. I have followed Patty Ganz wherever she goes. I'm always asking her advice. I go to any lecture that's anywhere near me.

DANIEL F. HAYES: And I'm pretty sure she stays as late as she needs to and gives it to you well. I've never seen anybody as gracious as she is.

ANNE MOORE: Absolutely. Absolutely.

DANIEL F. HAYES: Let me ask you. This is an opinion question on my part. There are three models. One is that we just keep our patients as long as we're alive and they're alive. The second is that we start separate survivorship clinics, probably run by not by us. And the third is we say you've had enough of oncology. Go back to your primary care. And we trained our primary care doctors to be the survivorship. Which of those do you prefer?

ANNE MOORE: Oh, I think about it a lot. Our primary care providers or gynecologists, to whom we could refer patients, especially our very early stage patients after, let's say, five years for their follow-up, I think they're very happy to have an oncologist on board. They have questions themselves. They don't have the confidence that they're giving the best follow-up, whereas of course, they are. But they're anxious that they don't know how to do it.

So I think if we're going to hand them over-- that is, the patients-- we really have to prepare the gynecologists and primary care providers with what we think is the most helpful way to follow these patients. And I don't, at least in New York, we have not been good about that part. I know other programs are trying hard to educate their primary care providers to take these patients back in.

I think it depends a lot on who's available. In New York, we have a lot of oncologists. Some of the oncologists will continue to follow their patients for the rest of their lives. Many of our oncologists are finding that they just don't have enough chairs in their waiting rooms to continue to follow the patients. And they want to hand them over. The patients themselves would like to stay with a breast cancer specialist or a special clinic for breast cancer survivors. And that's the model we've used. And some institutions have made it a nurse practitioner program, which I think, again, in the right situation, is certainly suitable.

DANIEL F. HAYES: Yeah, that's what we've done, sort of a hybrid. It depends on the patient, depends on other factors. By the way, I found this is a wonderful problem to have. I was talking to a patient a few years ago. And I was saying, you can just go back with your primary care doctor. You don't need to see me anymore.

And she said, no, I want to stay with you. And I said, well, the problem is there are too many of you for me to take care of. As soon as I said, that I thought, no, no, no. That's not a problem because there's too many of you for me to take care of. So we've all come up with it.

All right, to move on a little bit, you've already kind of alluded to this. But why oncology, and why and when breast cancer? I will tell you that I read your CV and I saw your first paper was titled "The Development of Neural Control of Elementary Motor Function in Vertebrates." And this, in surgical journal, a far cry from breast cancer. And I know some of your earlier work as a fellow was in hematology and platelet function. So when did you change gears?

ANNE MOORE: Well, I did my fellowship in 1973, 1974, finishing in '75. And really, the work in solid tumor for oncology wouldn't have filled up a half day in the clinic. We had 5FU for colon cancer. We didn't treat lung cancer with chemotherapy. Those were two of our top cancers. And breast cancer pretty much was treated by the surgeons. The surgeons had a surgical oncology clinic where they give their 5FU to the breast cancer patients.

So they're really, or they did, of course, the oophorectomy followed by adrenalectomy followed by hypothesectomy for the estrogen receptor positive from their patients whom they didn't know whether they were estrogen positive or not. So there wasn't much to do. And so hematology, I really took a hematology fellowship later on called hematology medical oncology.

But it was such an early time. What happened there was that all of a sudden, around 1976, I think it was, right after I finished my fellowship, came the reports of adjuvant chemotherapy improving disease-free survival for node positive patients. All of a sudden, these were now healthy women who'd had a mastectomy, most of them. And somebody had to give them the chemotherapy.

And my first case was a doctor called me, a surgeon. And he said-- I hadn't really known him. He said, is this Dr. Moore? I said, yes. He said, I got a lady here. She just did her surgery. She wants a lady doctor for therapy. I said, great. I'll do it. So it was my first oncology patient. And she was exactly my age in her 30's. And I gave her the adjuvant chemotherapy, trembling.

My hands were trembling when I started doing it. We gave, of course, our own chemotherapy. And she did well and went on to live about 30 years, and did die of metastatic breast cancer.

DANIEL F. HAYES: So you mixed up your own chemotherapy and gave it yourself?

ANNE MOORE: Oh, sure. Yeah, absolutely. There was nobody else to do it. There were no nurses who specialized in oncology. So we mixed it up. While we sat and talked to the patient, we shook the bottle of chemotherapy on the desk, took a syringe, drew it up, and put on a little butterfly needle and pushed the chemotherapy.

DANIEL F. HAYES: I hope there are young people listening to this.

ANNE MOORE: No worries, no nothing.

DANIEL F. HAYES: I mean, the flip side is I think they're overwhelmed with the vast amount that there is to learn now. As you pointed out, when you started, it was 5FU. On the other hand, I don't think they realized how difficult it was to be an oncologist in those days. You must have been in one of the first rounds of the boards that BJ Kennedy pushed through.

ANNE MOORE: The first round of the medical oncology boards, I was. I wasn't in the first class, but I was pretty close to it.

DANIEL F. HAYES: Yes. And then you sat on the ABIM for a while, correct?

ANNE MOORE: I did. It was 10 years for the ABIM on the hematology board.

DANIEL F. HAYES: Oh, really?

ANNE MOORE: And then I chaired the hematology board. And by the end of the time I was chairing the hematology board, I really was pretty much just doing breast cancer. Well, I was still doing sickle cell disease, thalassemia, breast cancer, lung cancer. And during those 10 years, slowly drifted just into breast cancer. I just scraped through as chair of the hematology board.

DANIEL F. HAYES: That's fascinating. So I'm going to take you way back now. Tell me about why you were in Peru. Were you born in Peru?

ANNE MOORE: When I was two years old, my father worked for WR Grace and Company, which was Grace Lines at that time. And they were very active in South America. And he was sent to Lima, Peru. And he went there with four children, came back with five, had a sixth later on. And we just went along, started school there, and then came back to the states.

And then I went back right after high school and worked in a medical clinic outside of Lima, and what they call a barriada, which is a poor area where very, very poor people lived. I said, I would love to work in a clinic. I had been a candy striper, that was my experience. So they let me work there.

And literally, they would give me syringes. I don't know what was in the syringe and they taught me to give injections to these patients. I had no idea what I was doing.

DANIEL F. HAYES: I suspect you did not have malpractice insurance.

ANNE MOORE: There was no malpractice insurance involved in these situations. But I sure learned a lot, loved it.

DANIEL F. HAYES: And have you been back on medical trips or anything to Peru?

ANNE MOORE: Not to Peru, no. I haven't been back to Peru since that time.

DANIEL F. HAYES: Wow. That's fascinating. All right, another question that I've been dying to ask you, I'm going to call it an obscure role you've had, which has been the president of the American Clinical and Climatological Association. A very interesting group, to which I frankly belong. But it is the oldest honorific society in America, I believe. Is that true?

ANNE MOORE: It was founded in 1884.

DANIEL F. HAYES: Can you just give-- I suspect very few people on this call have ever heard of it. Can you give people what's the climatologic about? What's the story on this organization?

ANNE MOORE: The American Clinical and Climatologic Society was actually founded in 1884 as a group to study climate. And the reason they were studying climate was they were trying to figure out how to treat tuberculosis. So they figured it had to do with climate. So they studied being near hot springs, being near cold springs, being in a warm climate, being in a dry climate, and gave papers on that subject.

It was an all-male group for many, many years. The first women were elected around the 1980s. The wives were invited early on to come to the meetings and to sit in on the lectures, but they had to sit in the back rows of the auditoriums. There was one woman member, and then pretty soon, there were two women members. Then I came along as the next wave of women in the American Clinical and Climatologic.

And the group has no longer concentrates on tuberculosis. It's a very diverse group with very different medical interests. The vast majority are internists. We meet and listen to papers. and the papers are from all different fields, which again, for an oncologist who loves going to ASCO and listening just to the breast cancer talks, it's really exciting to hear the latest in kidney disease, the latest heart disease.

Perhaps one of the medical doctors who's interested in history of medicine will give us a talk. So it's a very varied group, different from our usual meetings. And everything is published in the transactions, which is on PubMed. And the papers are absolutely first rate.

DANIEL F. HAYES: Yeah, I have to say, I've loved going and listening to things I know nothing about. One talk was on the importance of the oak tree in history. Because we built ships out of oak trees, they made all kinds of things, and how that then related to medicine. I'll never forget that.

ANNE MOORE: That's right.

DANIEL F. HAYES: OK, I want to end up with one other. It's timely, and I understand that when you were a resident, you worked with the now legendary Tony Fauci. How did that happen?

ANNE MOORE: Tony was at the National Cancer Institute, the NIH. He had been at Cornell. They invited him back to be chief resident. He came on July 1 and I was his assistant chief resident. So we shared a very small office, as chief resident and my entire house staff just loved Tony. We would do anything for him.

He was smart. He was fair. He was hard, hard working. Working next to him was absolutely a joy. It turns out, I didn't know at the time, and I wish I had, his father and mother graduated from the New Utrecht High School in Brooklyn in 1928. They had lived in Bensonhurst. Well, my father graduated in that same class and was class president. So I know he knew the Fauci's, mother and father.

And I just wish I had known, because of course, that generation has gone now. But they all were alive at that time.

DANIEL F. HAYES: He's been kind of busy lately. I don't know if you've heard, but maybe when this all boils over, you can have dinner with him and ask him that question.

ANNE MOORE: A Brooklyn reunion, absolutely. But we loved him as a resident, as you can imagine.

DANIEL F. HAYES: So I want to finish with the work you've actually done for ASCO. You are a fellow of ASCO. And I'm sure you're proud of that. You should be. And you've had a lot to do with the self-evaluation program. And I know you've been a mentor for the IDEA program. You were one of the lead of the leadership development program. And now you're on the board for the Conquer Cancer Foundation.

And would you just give a few-- this is a little self-serving because I'm one of the foundation's greatest supporters. The stuff they do is amazing. But tell us a little bit about the Woman Who Conquer Cancer that Sandy Swain has started.

ANNE MOORE: Women Who Conquer Cancer is a very focused initiative from the Conquer Cancer Foundation, started by Sandy Swain, to try to support with young investigator awards, with career awards, specifically, women. And I think it's so important. The ones I think are the most important are the young investigator awards for women who are coming out of their fellowship. Maybe they're married. Maybe they have a baby at home. They've got their hands full.

And to have somebody recognize their work and say, we're going to support you, I think, is fabulous. I think that's a very hard time for women. They can begin to flounder right at that moment. And there's the Women Who Conquer Cancer awards to be able to focus on them.

DANIEL F. HAYES: It is their most vulnerable time. And it's actually not a lot of money, but it keeps them alive. And all they got to do is get one paper with their name on it, and we got-- and they're hooked. And I've had two or three now who've had them. And they're wonderful awards. So for those of you who are listening, sit down and write a check to the foundation.

ANNE MOORE: That's right. Absolutely.

DANIEL F. HAYES: I'm shameless. Well, that's about all. We've run out of time now, unless there's any other great anecdotes or anything you'd like to share with us with your career.

ANNE MOORE: No, just how important ASCO is, and very central to my career. And I hope anybody who's listening appreciates ASCO and the opportunities to serve on many, many, many of the committees and facets of ASCO.

DANIEL F. HAYES: It's a lot of fun. Thank you for the shout-out. Well, thanks for taking your time to speak with me today. You've been very important to our field in general and to especially women in New York City with breast cancer. I don't know anybody who doesn't know of and respect Anne Moore if they live somewhere in the New York City area, let alone the rest of the world. So thanks for your time. I very much appreciate it and look forward to seeing you in person when this COVID thing goes away.

ANNE MOORE: Thank you, Dan. And thank you for doing this series.

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DANIEL F. HAYES: Until next time, thank you for listening to this JCO's Cancer Stories-- The Art of Oncology podcast. If you enjoy what you heard today, don't forget to give us a rating or review on Apple Podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories-- The Art of Oncology podcast is just one of ASCO's many podcasts. You can find all the shows and podcast.asco.org.

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