by Vida Foubister
Monica Morrow, director of the Lynn Sage Comprehensive Breast Program at Northwestern Memorial Hospital and a professor of surgery at the Medical School, is one woman who has never been afraid to speak her mind.
In a field that has been resistant to change, she built a reputation as a top breast cancer surgeon by her willingness to challenge the status quo.
"She's a leader," says Nancy Brinker, chair of the Susan G. Komen Breast Cancer Foundation in Dallas. "She's always willing to stand up and say what she believes, and she's always thinking about the patient."
At the American Society of Clinical Oncology's annual meeting in 1999, for example, Morrow presented data showing that less than 50 percent of women with early-stage breast cancer get breast- conserving surgery even though multiple studies have proven it is as effective as more radical procedures. Armed with this information, Morrow began pushing her colleagues to offer their patients a choice between mastectomies and lumpectomies.
"She thinks things through on her own and has both the courage and the eloquence to state her views very, very powerfully," says physician Larry Norton, director and head of the division of solid tumor oncology for the Evelyn H. Lauder Breast Center at Memorial Sloan-Kettering Cancer Center in New York City. "As a consequence, she's earned enormous respect in the community. She's somebody whose opinion you can respect and trust."
Those who know Morrow quickly learn to value her insight. "I find that when we disagree, she's almost always right," admits Steven Rosen, director of The Robert H. Lurie Comprehensive Cancer Center of Northwestern University.
True to her reputation, Morrow's only complaint about the schedule she keeps -- which would leave others gasping for air -- is that it leaves little time for reflection. "I wish that I had more time to devote to my writing and time to sit and think and do academic activities," she says.
Morrow balances a full clinical practice with the directorship of the American College of Surgeons' Cancer Department. In this position, she certifies that hospital cancer programs nationwide meet the organization's high standards, oversees the collection of cancer diagnosis and treatment information for a national database and runs cancer education programs for surgeons. "It gives me the opportunity to influence cancer care on a national scale," Morrow explains.
Teaching students and residents is another area in which she excels. "If you go to the operating room, she's going to ask you what you know about the patient and what you know about the disease," explains Susan Clare, an assistant professor and breast cancer surgeon who trained with Morrow. "You won't just be a body standing there holding a retractor; she'll engage you during the case."
In addition to Morrow's Chicago commitments, she holds numerous other positions in which she helps to advance breast cancer education, research and policy nationwide. They include editorial board member of the Breast Journal, board member of the American Society of Clinical Oncology, executive director of the American Joint Committee on Cancer, member of the Institute of Medicine's National Cancer Policy Board and medical adviser emeritus for the Y-ME Organization for Breast Cancer Information and Support.
Her faculty profile on the surgery department's Web site lists nearly 100 presentations she has given since 1997 in locales ranging from Haifa, Israel, to Oporto, Portugal, to Auckland, New Zealand. That represents only a fraction of the speaking invitations she receives -- up to about 10 a month.
"She is committed seven days a week to working," says V. Craig Jordan, the Diana, Princess of Wales, Professor of Cancer Research and Morrow's husband. "This is her life calling." When pushed, Jordan admits that in an "exceptional year" they might enjoy up to 10 free weekends together.
Says Clare: "I can't imagine too many other people being happy with her lifestyle. She is constantly on the go -- constantly speaking, constantly lecturing, constantly teaching other surgeons. ... She wants to know everything one can about breast cancer, because that's the only way we're going to make inroads into the disease."
Morrow grew up in Abington, a suburb of Philadelphia, and from a young age was eager to learn how the body works.
"When I was in elementary school, I brought to show-and-tell the heart and lungs of a cow from our butcher," she says, laughing at the memory. "I'm sure it did not particularly excite the teacher, but my father thought it was a good idea."
It was her father who encouraged her to consider medicine, and Morrow was accepted into a five-year accelerated program at Pennsylvania State University/Jefferson Medical College when she was in high school. In medical school, she knew from the start that she wanted to be a surgeon. Though Morrow was attracted to the immediacy of surgery, it turned out that the specialty she now practices involves much more "talking and patient interaction" than most surgical disciplines. "It offered a lot of variety, and unfortunately it also offers something that we never run out of needing to treat," she says.
After finishing a five-year general surgery residency, Morrow spent two years in a surgical oncology fellowship at Memorial Sloan-Kettering Cancer Center in New York City. For her first five years in practice, she treated all kinds of cancer: "Modern cancer therapy is a much more multispecialty thing than it used to be, so if you really want to understand cancer treatment, you need to know about chemotherapy, radiation therapy and epidemiology of cancer."
Recognizing that she could never become an expert in every cancer, Morrow chose to focus on breast cancer, now the second-leading cause of cancer deaths among women in the United States. "From an intellectual point of view, breast cancer is very interesting," she says. "It's a disease that covers a huge age range, from very young women to being actually more common in elderly women. It's a disease where the whole way we approach treatment changed completely starting in the 1970s. And although the surgery has traditionally not been considered 'very challenging' to other surgeons because virtually nobody dies from breast surgery, there now is such an emphasis on cosmetic outcomes, treatment options and ways to communicate with patients that it really does offer a lot of surgical challenges."
She is also inspired by the resolve of cancer patients and their friends and family members to find a cure. "She admires commitment," Jordan says, "so when she sees the dedication of individuals who are willing to go to enormous lengths to provide help and support, it is clearly emotional to her."
It was the University of Chicago, where Morrow spent five years heading up the breast cancer team, that drew her to the Midwest. She made the move to Northwestern in 1993, along with her husband, a pharmacologist best known to the public for his discovery that the drug tamoxifen could be used to prevent breast cancer. They had recently married and were looking for a university where they could work as a team. Northwestern offered them that opportunity and more.
"We were attracted to Northwestern by the fact that the Lynn Sage Foundation was interested in supporting breast cancer research and treatment. Plus, there really had not been an established breast cancer program here," Morrow says. "It gave us the chance to build one."
Morrow directs the Lynn Sage clinical program, which is part of the cancer center, and its treatment center (see sidebar), which is located in the Galter Pavilion of the new Northwestern Memorial Hospital. Jordan, a professor of molecular pharmacology and biological chemistry, heads the Lynn Sage Breast Cancer Research Program.
In less than a decade the entire program has attracted some of the leading experts in a broad variety of breast cancer specialties. By virtue of the funding from the Sage foundation, the center is also able to support services that do not generate revenues but do enhance patient care, such as nutrition counseling and psychosocial support. Each year physicians at the Lynn Sage center treat more than 500 new breast cancer cases and perform about 40,000 breast-imaging procedures.
Richard H. Bell Jr. (M71), Loyal and Edith Davis Professor and chair of Northwestern's surgery department, is eager to replicate Morrow's success by establishing additional centers focused on other common cancers. Part of the concept's appeal for him is its ability to provide patients with comprehensive disease management in one location. Also, "she has assembled a group of people whose entire clinical attention is focused on a single disease. There are very few places where you can find [this]," Bell says.
Morrow's research has focused on incorporating into practice advances already proven in clinical trials. Her studies on the number of women obtaining breast-conserving surgery, such as lumpectomies, revealed that not all clinicians know when their patients are eligible for this less disfiguring procedure. "The data suggest that there are some problems with physicians understanding patient selection criteria," she explains.
These days, Morrow is working on a project to develop a computer program that will help women choose the treatment that's best for them. Their answers to a series of questions enable the software to evaluate attitudes toward risk -- both risks associated with the type of breast cancer treatment and risk in general. "We're just to the point where we're going to see whether or not that model accurately predicts what patients will choose on their own," Morrow says.
Another study, the results of which Morrow presented at the American Society of Clinical Oncology's annual meeting in May, looks at the relationship of hospital volume to breast cancer outcomes. She found that high hospital volume is associated with an increased survival rate from breast cancer. Although this finding also has been demonstrated for more complex cancer surgeries, breast cancer is somewhat different from the norm because, unlike other cancer procedures, there is no mortality attributable to the surgery.
"So if we want to improve the quality of breast cancer treatment for all people in different settings around the country, we need to understand what is causing these differences," Morrow says.
Cancer treatment, and the way physicians approach their patients, has changed dramatically since the 1960s, she says. At that time it was common for physicians not only to make patients' treatment decisions for them, but also to refrain from telling them that they were suffering from cancer. In 1951, Eva Peron, the first lady of Argentina, underwent a hysterectomy for cervical cancer. When she died a year later, Peron was still unaware of her diagnosis, according to a recent article in Lancet.
Today, with the explosion of health information on the Internet, television and other popular outlets, it could be argued that at times health care consumers have too much information. Though it's often easier to consult with an educated patient, not all sources of information prove helpful.
"People come in having read that someone had their cancer cured by eating 40 pounds of seaweed a day, so they don't want to have any traditional treatment," Morrow says. The Lynn Sage center has developed a Web site at www.lynnsage.northwestern.edu to give patients basic breast cancer information.
Morrow's advice to women, in general, is to stay calm. "Most young women overestimate their breast cancer risk," she says, adding that it's not a common disease for those under the age of 40. "The people who should be worrying about breast cancer risk are women in their 60s and 70s, and that's never who's coming into the office."
Yet that's not to say good breast health shouldn't start at a young age, Morrow emphasizes. After a woman at average risk for breast cancer turns 40, a mammogram every year "is clearly of benefit," she says. For those who believe they are at increased risk, she recommends a predictive assessment, developed by the National Cancer Institute, that's available at most breast centers. "For most women the risk is much, much, much lower than they think, and this helps put their mind at ease," Morrow says.
Despite the current interest in diet as a health factor, Morrow believes there is no evidence that nutritional changes alter breast cancer risk. "A healthy diet that's relatively low in fat is good for your heart, and it reduces the risk of colon cancer, but I'm not convinced that the data say it does anything for breast cancer," she explains.
For those who are found to be at high risk, there's a relatively new treatment option -- tamoxifen. This drug reduces breast cancer risk by 50 percent, but it does slightly increase the risk of uterine cancer. And like hormone replacement therapy, it can cause blood clots in older women.
"The whole next phase of cancer treatment," Morrow says, "involves working toward individualizing our approach to risk assessment -- risk of getting cancer, risk of having cancer recur and risk of dying of cancer -- so that we can give less treatment to low-risk people and more treatment to those at the highest risk."
Vida Foubister is a senior reporter at American Medical News, where she writes about medical ethics.