Conversations with the Pioneers of Oncology: Dr Robert Mayer

Jul 13, 2020

Dr. Hayes interviews Dr. Mayer on his training at NCI and running DFCI’s fellowship.

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.

 

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.

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 role of cancer care. You can find all of these shows, including this one, at podcast.asco.org.

Today, my guest on this podcast is Dr. Robert J. Mayer. Dr. Mayer is the Stephen B. Kay Family Professor of Medicine at Harvard Medical School where he is also the Faculty Associate Dean of Admissions, in addition, the faculty Vice President for Academic Affairs for Medical Oncology at the Dana-Farber Cancer Institute.

Dr. Mayer was raised in Jamaica, New York. And, Bob, I always thought you were raised in Brooklyn, but I looked it up on the map. And it looks like Jamaica is about two blocks in the middle of Brooklyn. So we'll say you're from Jamaica.

Actually, I was a little bit to the east of there in Nassau County. That counted a lot then, Queens versus Nassau, but anyway.

So it gets even more esoteric. Bob received his undergraduate degree in 1965 from Williams College, which is way out west in Massachusetts, and then went to Harvard where he got his MD in 1969. He did his residency in internal medicine at Mount Sinai in New York City and then was a clinical associate in the medicine branch of the National Cancer Institute from 1971 to 1974.

He served a fellowship in medical oncology at what was then the Sidney Farber Cancer Institute. And then he joined the faculty in 1975. He has spent much of his career at leading clinical research in leukemia and GI malignancies. He was the chair of the CALGB, now called the Alliance TI Cancer Committee for years.

But, perhaps more importantly, he was director of the fellowship program at, originally, the Sidney Farber and then the Dana-Farber Cancer Institute for 36 years. And then he was also head of the fellowship program at the Dana-Farber/Partners cancer program from 1995 until 2011. And, frankly, he was my fellowship director from 1982 to 1985. So I owe a great part of my career to Dr. Mayer.

He's co-authored over 400 peer-reviewed papers and another 130 chapters and reviews. He serves as associate editor for both the Journal of Clinical Oncology and The New England Journal of Medicine. And, as have many guests on this program, he served as president of ASCO, in his case, in 1997, 1998. And he received the ASCO Distinguished Achievement Award in 2019 for his ongoing leadership in our society. Dr. Mayer, welcome to our program.

Pleasure to be with you, Dan.

So I have a lot of questions. And, again, I usually do this, you know, two guys in a cab. How did you do that in the first place? What got you interested in oncology coming out of Williams and at Harvard? And, at that time, there wasn't much in oncology. What made you want to take care of cancer patients?

Well, I was a third-year medical student at Harvard sort of sleepwalking through the curriculum, undecided what my life was going to be, planning to go back to New York, and I came across an attending physician on a pediatrics rotation, a hematologist by the name of David Nathan. And we hit it off. And I became really interested in blood cells and how looking at smears and bone marrow morphology could tell you a lot about the status and health and nutrition of individual patients.

Nathan took a shine to me. And, when I was a fourth-year student and was going to face probably a military service, and there were military actions going on in Southeast Asia, he called me to his home one night and shoved a whole pile of paper in front of me, said fill this out. I want it back tomorrow. And this was an application to be a clinical associate at the National Cancer Institute where he had spent several years I guess a decade before.

So I did what I was told. And, when I was a intern, I guess my first day as an intern, I got an overhead page from the-- in the hospital, call from Bethesda informing me that I had been accepted. I had had 10 or 11 interviews. One of them turned out to be a person who would be important in my life as a friend and a mentor, George Canellos, who was first time I met him. And, in 1971, I found myself at the NIH.

That's quite a story. And Dr. Nathan, of course, went on to start the Jimmy Fund, probably had already started the Jimmy Fund Clinic at the time, and became the CEO, I think, of Children's Hospital in Boston.

He became the CEO of Dana-Farber actually. I do want to just recollect with you my first day or two in Bethesda because some of the people who found themselves there took it more seriously than others. And I was assigned to the medicine branch.

And the medicine branch had a chief who was a breast cancer-oriented investigator by the name of Paul Carbone who went on from there to an illustrious career as the founding head of the Cancer Center at the University of Wisconsin and the leader of the Eastern Cooperative Oncology Group. And Paul, at that point, the first day I met him, told us that, if we messed around, moonlighted, didn't show up, we'd be on a Coast Guard Cutter as fast as he could do the paperwork because, technically, we had a position in the Public Health Service.

Under Carbone, there were two branches. One was leukemia, and that was headed by Ed Henderson. He was a lanky guy from California, a wonderful man, went on to a career with Cancer and Leukemia Group B and with the Roswell Park in Buffalo for many years. And he was my branch chief.

And the other branch was solid tumors. They weren't solid tumors like we think of them today. They were lymphomas. And that was headed by Vince DeVita and had Bob Young, George Canellos, Bruce Chabner, and Phil Schein, all illustrious founders of so much that has become oncology. So that was the setting.

And the last thing I'll mention was about this. I came there as a trained internist, but I was assigned to pediatric leukemia. And I learned very quickly that what separated the wheat from the chaff, in terms of families, parents thinking that you were a good doctor, was your ability to maintain the 25 gauge scalp vein as venous access in these children because there were no port-a-caths, no Hickman lines, and, obviously, access was something that was critically important.

You know, I think everybody who is listening to this needs to understand that what you just described started out really with just Gordon Zubrod who then brought in Frei, Holland-- or Holland first and then Freireich. And then they brought in the next group, which I believe you would agree is Canellos, DeVita, Bob Young, and others. And then you were sort of in the third wave. And you could just see it began to expand the whole field of oncology really just from a few people going out. Do you agree with that?

I do. I do. When I came to the NIH in 1971, there was no defined, certified subspecialty of medical oncology. The first time the medical oncology board examination was given was in 1973. It was given every other year. I was in the group that took it the second time in 1975, but this really wasn't a subspecialty.

In 1973 also was the time that the first comprehensive multi-authored textbook on medical oncology was published by Jim Holland and Tom Frei, Cancer Medicine. And I remember devouring that as I prepared for the board examination, but there was no book like that. There was no reference, no UpToDate, no computer to surf the web and find information. And so this was all brand new. It was quite exciting to be there as part of the action.

You sort of jumped ahead on what I wanted to ask you, but I'm interested in the establishment of medical oncology as a subspecialty. Can you maybe talk about Dr. BJ Kennedy and his role in that? I think he was pretty instrumental. Was he not?

BJ was at the University of Minnesota. He was an extraordinarily decent man. And, somehow, the internal medicine establishment viewed him as a peer and a colleague, which I would have to say was not what they considered many of the pioneers, if you will, in medical oncology.

I can remember, in my second or third year at the NIH, traveling around the country to look at fellowship programs. And I was always being met by senior established hematologists who arched their eyebrows and said now where's the pathophysiology. Where is the science here? They really thought that the animal models, the mouse models, the Southern Research Institute that Gordon Zubrod had been such a pioneer in fostering was pseudoscience.

I can also remember, when I found myself back in Boston, the establishment of Harvard Medical School didn't initially take oncology very seriously, but there were patients. And there was optimism. And all of us in that generation really believed that we could make a difference, and we could learn a lot and do good for patients and for medicine. And I think we have.

So, in my opinion, now, appropriately, our fellows have a very strict curriculum of what they're supposed to learn and how and when and why laid out, again, in a pretty rigorous formal manner. You told me before, at the NCI, it was just sort of learn it. It's up to you. Can you talk about that training? And then, when you went to the Sidney Farber, you then turned that into a training program.

The medicine branch was fantastic training, but it was learning from taking care of patients and from your colleagues. The quality of my peers was extraordinary, but there was no formal curriculum. The faculty there each were doing research, the members of the faculty. And, for a month, they would come out of their cave, if you will, their laboratory, and they were very smart and were doing fascinating things, but they didn't have long-term patients. Or there was no real process.

And the NCI was sort of like a Veterans Administration hospital in the sense that it opened around 7:30 or 8:00 in the morning, closed at 5:00 or 6:00 in the afternoon. One of us would be on call at night with a couple of nurses, but it was rather primitive in its support mechanisms. We were assigned a group of patients. And then, on rotation, those patient numbers would increase. And we were expected to do everything conceivable for that patient.

And, at that time, the oncology care offered in Bethesda at the NIH or the NCI was free. It was paid for by the government. And much similar care was not available in other places. So I would have patients flying in from Omaha and New York or Norfolk or Tampa, Florida. And they would be housed in a motel that was on the edge of the NIH reservation, but, if one wants to talk about continuity of care, you knew everything about every one of those patients because you were the only person who knew them.

So what were the circumstances then that you ended up in Boston?

Well, that's an interesting story because it gets back to David Nathan. I was working after my clinical year in a basic laboratory as I could find. It was run by Robert Gallo, Bob Gallo, who was one of the co-discoverers years later of the HIV virus.

But, one day, I got a phone call from Dr. Nathan's secretary saying that he was going to be in Washington a week from Tuesday or whatever. And he wanted to meet with me in the garden of the Mayflower Hotel. OK, fine. So I trotted over to the Mayflower Hotel, and there was Dr. Nathan.

And he said, you know, Dr. Farber is getting old, but there's a new building. And there's going to be a cancer center. And he's just recruited Tom Frei to come from MD Anderson. And it's time for you to come back to Boston.

Didn't say would you like to come back, would you think about coming. No, he, just applied to the NIH, shoved the papers. Here, it's time for you to come back to Boston.

So, a few Saturdays after, I flew up to Boston. And, in that interim, Dr. Farber passed away. He had a heart attack, an MI. And there was Tom Frei who I met for the first time, made rounds with him. We hit it off. And he told me that he would like me to spend one year as a fellow and then join the faculty and become an assistant professor.

Well, I didn't need a plane to fly back to Washington. I thought this was tremendous because I was looking at hematology scholarships around the country. And there was no career path. And this seemed to be a career path in a field that I was really interested in.

And he talked to me really about coming back to do leukemia because that's what I had been doing at the NIH. And, a year later, I found myself, July 1, 1974, being part of the second fellowship class at what's now Dana-Farber. There were six of us. There were six the year before.

We were piecing it together step by step. There, again, was nothing chiseled in marble. There was no tradition. This was try to make it work and learn from what works. And, what doesn't work, we'll change.

You must have had a lot of insecurity coming into a program that really had just started. There had to be chaos involved in that.

Well, there was a little chaos, but, to be honest, I was really engaged in it because it was exciting. I thought that oncology, as I still do, is this marvelous specialty or subspecialty that unites science and humanism. And, because other people weren't interested or maybe weren't capable of providing what we thought was the right level of care, to be able to sort of write the playbook was a terrific opportunity.

We sort of-- and it extended into the year that you were a fellow as well-- followed the medicine branch mantra in the sense that we assigned fellows patients. And they took care of those patients and were expected to do everything that was necessary for them.

There weren't rotations at that time that you would spend a month on the breast cancer service and then a month doing lymphoma. You would see new patients or follow-up patients. We didn't really have enough patients or enough faculty at that point to be smart enough to think about that being a better way or an alternative way to structure a trainee's time.

I remember, at the end of my first year, when I finished that year as what I think Tom Frei called a special fellow, I was the attending on the next day, which was July 1. And I remember that a fellow, a first-year fellow who was just starting, Bob Comis who became also the chairman of the Eastern Cooperative Oncology Group years later, a marvelous lung cancer investigator, was the trainee. And, on that day, we went ahead and did a bone marrow on a patient with small cell lung cancer and being a fellowship director just started because there was no one doing it. And Frei said please move ahead.

I have to say, when I started in 1982, I just assumed this was the way everybody in the country was training fellows in oncology. It really didn't occur to me that that was only a few years old and the way you had set it up.

A few years ago, the Dana-Farber had a banquet to celebrate the 48-year career of a guy named Robert J. Mayer. And I was asked to speak. And I got up. There were over 300 people in the audience, all of whom had been trained there.

And, as I looked around, I sort of put my prepared words aside and said look at the people sitting next to you. They are either former or to be presidents of ASCO, ACR. They're cancer center directors, department chairs, division chiefs, and a bunch of really terrifically trained oncologists all due to one guy, and you're the one. So you started with Bob Comis-- I've never heard you tell that story-- to really training some of the greatest oncologists in the world in my opinion, myself excluded in that regard, but, nonetheless, you must be quite proud of that.

Well, yes, but I want to flip it around the other way because, for me, this became a career highlight, the opportunity to shape the patterns, to make the people who trained here leaders, and to have them-- right now, the director of the NCI is a Dana-Farber alumnus. To have people who are of that quality-- and you certainly represent that, as an ASCO president and one of the hallmark leaders of the breast cancer community-- this is what a place like Dana-Farber and Harvard Medical School, hopefully, not too much arrogance, is supposed to be doing.

And to have that opportunity, to be able to fill a vacancy that nobody even appreciated was a vacancy, and then to develop it over enough time that one could really see what worked and see what didn't work is an opportunity that most people don't have. And I'm so grateful for it.

Now, Bob, I want to just, in the last few minutes here, you've obviously been a major player in ASCO. Can you kind of reflect over the last 25 years since you were ASCO president, the changes you've seen, and what you think of your legacy? I know you don't like to brag too much, but I think there's a reason you got the Distinguished Service Award. And can you just reminisce a bit about what's happened and then where you think we're going as a field?

Well, ASCO has been my professional organization. The first meeting I went to was in a hotel ballroom in Houston, the Rice Hotel, which doesn't exist anymore. And it was a joint meeting of ACR and ASCO in 1974. There were 250 people. And everybody was congratulating each other at the large number of attendees.

I had the opportunity, in large part because of Tom Frei and George Canellos and other people, to become involved in picking abstracts for leukemia presentations, being part of the training committee, and then chairing the training committee. I actually had the opportunity to be one of the four people who started the awards program, which now has the Young Investigator Award and Career Development Award and things of that sort. These are just opportunities because they weren't there before. And, if you're willing, and you put in the time, I guess people come back to you and give you the chance to do these things.

I became then involved in the JCO, the Journal of Clinical Oncology. I became involved in the debate about physician-assisted suicide and palliative care that led to some very educational debates and probably spawned the field, to some degree, of palliative care.

I had the opportunity to be at the forefront of starting the Leadership Development Program that was really Allen Lichter's idea, but I was able to devote the time to make that happen. And, most recently, I've been on the Conquer Cancer Foundation now for almost two decades. And watching that grow has been a joy.

ASCO, when I came, was a very small trade organization, if you will, didn't quite know the questions to ask, had a hired office, a management office, that was based in Chicago, came to Alexandria in about 1994 or somewhere in that range with its own office and its own staff, and now is the world organization for oncology. And I think that that growth, that expansion, that international, multidisciplinary pattern, if you will, is a reflection of the growth of oncology in medicine.

I have to say, if you take a look at the popularity poll of what the best and the brightest young physicians choose in their careers, when I was in training and, Dan, when you were in training, most went into cardiology. Maybe some went into GI.

Now there are more people going into oncology than any other medical subspecialty. Maybe that'll change after COVID, but that's the way it's been. And our hospitals now are filled with cancer patients, and those hospitals are very dependent on the care that we provide cancer patients.

I guess the other thing I would say is, looking from a guy with some hair left, although gray, but looking at it from afar, all of those high-dose chemotherapy programs, the notion of dose, of cell poisons, alkylating agents, the solid tumor autologous marrow programs that were so fashionable in the 1980s, have been, in large part, replaced by such elegant, targeted therapy, now immunotherapy, circulating DNA. Who would have thunk any of that when I was taking care of those children with leukemia 45 years ago?

So I think this is such an exciting field. I'm so-- continue to be so pleased and proud of the quality of the trainees. Last night, we had a virtual graduation session for the people completing their fellowship here. And I hate to say it. They're as good as ever.

And, if we thought and, Dan, if you thought your colleagues that you all and we all were the best, they're all phenomenal. And it's really a reflection on how the pioneers in this field had a vision, how the need for science to understand cancer was so important, and how medicine has changed and how oncology now is a respected and acknowledged discipline of scholarly work.

Well, you had two things that I'm fond of commenting on. One of those is I frequently say publicly I wish I was 30 years younger for a lot of reasons, but because of the scientific excitement that's going into oncology and, also, so that I could run the way I used to, but I can't. That's one.

The second is I don't think I would choose me to be a fellow. I'm really intimidated when I do interviews with our residents and say, you know, I wasn't nearly in that kind of category of the people we're interviewing now, which is great. I think our field is in good hands, going to move forward, and things are going.

Bob, we've talked about a lot of your contributions to training and education, but you've also had a major influence on the way patients with leukemia are treated. Can you talk more about where the 7 and 3 regimen came from?

The 7 and 3 or 3 and 7 regimen-- 3 days of an anthracycline, 7 days of continuous infusional cytosine arabinoside, was developed in the early 1970s. And it was developed by Jim Holland, more than anyone else, when he was at Roswell Park. And it emerged from a series of randomized, phase III trials conducted by what was then called the Acute Leukemia Group B, what became CALGB and then the Alliance.

In the early 1980s, the late Clara Bloomfield, who I considered a giant in the world of leukemia, invited me to write a review of the treatment of acute myeloid leukemia for seminars in oncology that she was editing. And, in preparing that, I started reading a series of manuscripts published in the early 1970s, which meticulously, step by step, examined the value of two versus three days of anthracycline subq versus IV push versus infusional cytosine arabinoside, 3 days, 5 days, 7 days, 10 days of infusional cytosine arabinoside.

And this was all really work of Jim Holland. He was a magnificent scholar, a humanist, and a tremendous booster too and giant in the start of this field.

Thank you. I agree. Bob, we've run out of time, but I want to just thank you for taking time today to speak to me and our listeners, but also thank you for what I consider the many contributions you've made, both scientifically-- we didn't really even get into that, your work on leukemia and GI-- but I think, more importantly, establishing a training program that's been the model for, probably worldwide, how to train people in oncology and the contributions you've made to ASCO. So, for all that, I and everybody else are very appreciative. Thanks a lot.

My pleasure. It's a pleasure to be here with you.

Until next time, thank you for listening to this JCO's Cancer Stories-- The Art of Oncology podcast. If you enjoyed 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 at podcast.asco.org.