By Martin Colman, MD
This conversation with William Moss, MD, and Martin Colman, MD, was conducted on January 12, 2004.
Question: Dr. Moss, tell us what attracted you to radiation oncology in the very first place. How did you get into the field?
Dr. Moss: I had rotated to the Missouri State Cancer Hospital from Washington University when I was a senior medical student on an elective. On that service, I met Dr. del Regato. He was just about the best teacher I had ever seen. I began to think about radiation oncology at that time. I then had an internship in straight surgery at Barnes Hospital and I had a residency at the Ellis Fischel State Cancer Hospital in straight surgery. During that time, I came in contact with del Regato again, and near the end of that service, he asked me if I was interested in radiation oncology. When I got out of the service two years later, he offered me a training slot.
Question: Very early in your career, you came into direct contact with two of the giants of radiation oncology and surgical pathology, Drs. del Regato and Ackerman. Tell us about their influence?
Dr. Moss: They were both wonderfully pleasant physicians. They would just give you any amount of their time. Students loved them. Ackerman would have dinners at his home, where the students would go along with staff, and the interaction there was just about the best you can imagine. del Regato was always available. We had lunch with him every day.
Question: Why don’t you also tell us a little bit about your background?
Dr. Moss: I was born in Ardmore, S.D. My father died when I was three and a half years old. My mother took the six of us to live in a small mill town in South Carolina called Rock Hill. When time came to go to college, I had several friends who were going to The Citadel. I was caught up in their enthusiasm, and I went to The Citadel. When I got to The Citadel, I took an extra course or two in physics, and a couple of advanced mathematic courses. The next thing I knew I graduated with a degree in physics. I had the opportunity to take graduate work at the University of North Carolina in physics. However, about that time, I was told I could go to med school, so that’s when I switched. My mother had remarried, and lived in Missouri. I went to Missouri, and took the necessary biological courses to get into med school, then applied for and was accepted at the University of Missouri Medical School. It offered only the first two years at that time. After two years I transferred to Washington University in St. Louis.
Question: You also went into the Air Force?
Dr. Moss: At that time, the Army had an Air Force, and the Navy had an Air Force. I don’t know how I got into the Army Air Force. I did not apply. They took me and put me there. That was a strange experience. I had to go to Fort George Wright in Spokane, Wash., for indoctrination. There were a bunch of physicians there just like me. The chief of the base called us in, and said, “Okay. I’ve got eight pieces of paper in my hat. Draw a piece.” I drew Guam, and that’s where I spent two years, on Guam, in the hospital part time, and in the dispensary part time.
Question: So you spent how many years in the military? And then, what happened after that?
Dr. Moss: Two. del Regato had offered me the residency in radiation oncology so I went back to the Missouri State Cancer Hospital for that training. During that time, he didn’t have a good physics course there, so he said, “You go to New York, and take Dr. Quimby’s course in physics.” She had written a little book on physics that was the Bible in physics. I took her course at Columbia University.
Quimby was a very gracious person, an extremely knowledgeable person. On the radiology boards, she was very strict. Everybody was scared to death that they were going to get Quimby. I had her on the board exam. She recognized me from her course and was very gracious to me. Maybe that’s part of the reason I passed.
Question: Tell us about the status of radiation oncology as a medical specialty during your residency and early years in the field.
Dr. Moss: Most of radiation oncology was done by people who were in general radiology. They had had one year of training in radiation oncology, and they did the best they could. They would do diagnostic in the morning, and go down after lunch and do radiation therapy. It was okay for the time that it was done, but comparatively, it was a very limited service and that was that. They were limited by the equipment, which was all ortho voltage. Their care was limited by the physics. They didn’t have ortho-proper physics or any dosemetrists. They had a technician that knew how to raise and lower the machine, but that was about it.
Question: What was the economics of radiation oncology, radiation therapy?
Dr. Moss: I was told when I planned to go into radiation oncology, “You can’t make a living,” and they were judging by how much the radiologist made from that part of their service. They also said that there would be a cure for cancer within 10 years, and I would be out of a job if I didn’t have diagnostic radiology to carry me along. Physicians didn’t go into radiation oncology alone at that time.
Question: You applied yourself entirely to radiation oncology early in your career correct?
Dr. Moss: Yes. I was the first resident in straight radiation oncology that del Regato had. There were not very many people at that time who were in the three-year training program. Most of them took diagnostic training for two years and radiation oncology for one year.
Question: You mention radiation oncology as not being a popular field to go into. You did an analysis of why radiation oncology was an unpopular field in the seventies. You gave a presentation, and I think you had a very significant effect on us turning things around. You told us that we needed to get up on the floors and see the patients, not bring them into the basement. Do you remember that?
Dr. Moss: That paper was titled, “Bringing Radiation Oncology out of the Closet.” I thought at the time — and I still do - that the best way to promote the knowledge of radiation oncology was by the referring physician, and by teaching the medical students, to get them some way or another onto the service. They can see that you are a real doctor, you’re taking care of patients and that your specialty is interesting. That was essentially the message of that paper.
Question: Tell us about the equipment when you first got into the field.
Dr. Moss: The equipment was all 250 KV, and maybe a 400 KV machine here and there with superficial beams for the skin cancers. There were a few megavoltage machines around—one in Seattle, and one in Boston (a Vandergraft). They had several in Europe at the Royal Cancer Hospital and in two or three other hospitals. In fact, I think they had more in Great Britain than they had in all of the U.S. That was about it. Of course, we had radium. It might have been after my training the telecobalt unit—the experimental unit was at Oak Ridge. The Canadians put one in London, Ontario, and that was a marvel. Everybody flocked there to see it. We got our cobalt in 1952 or 1953 in Chicago.
Question: You also did training in Britain and France?
Dr. Moss: Dr. del Regato not only suggested I go to Dr. Quimby for physics. He suggested that I go to an institution where the radiation oncologists took care of patients in a broader sense, and it was for that reason that he suggested Dr. Paterson. Dr. Paterson had visited Washington University to give a talk. Dr. del Regato had heard the talk, was impressed and he suggested I go to Manchester to take their nine-month course on physics, radiation biology and clinical skills. He also suggested that I go to Paris to spend six months with Dr. Baclesse. Paterson accepted me very warmly, and was a wonderful teacher. The physics there was absolutely superb. Then, I went to Foundation Curie in Paris with Baclesse. I learned a heck of a lot there, and it was fractionating head and neck cancers primarily. You know, it was very long treatments. Part of that was necessary, because skin reactions were so severe with their equipment.
Question: Could you discuss a little bit the limitations of radiation oncology during the early days?
Dr. Moss: The big headache was the skin reactions. Wherever I worked, we had a separate room where after the treatment; a nurse dressed the skin, and took care of skin reactions. Sometimes, they got infected, and that impaired the treatment. It was a shame that we had to put up with that so long. When megavoltage came along, that was seldom a problem. We didn’t have good gadgets for localizing the cancer. No CT, no MRI. Very rare that you could get a laminogram to show the tumor volume that you had to treat. So much of it was guesswork, and even when you take port films, and look at them. Often you didn’t know where the margins of the cancer were. You knew where the bony landmarks were but that’s about the best you could do.
Question: You began billing to Medicare very early on. What impact did Medicare have on radiation oncology?
Dr. Moss: I think if there had not been Medicare, there would not have been radiation oncology. It’s almost that important, because a significant portion of the income at that time came from Medicare, and that was one of the reasons that radiation oncology was able to separate and survive.
Question: What happened before Medicare?
Dr. Moss: You were charging five dollars a treatment. A lot of patients didn’t have even that much, but many of them were paying. At Wesley Hospital, we had very few patients that didn’t pay. I think the maximum treatment went up to seven dollars before Medicare came along. It’s kind of a pathetic thing.
Question: In looking to the future, what do you think are the things we should be thinking about in radiation oncology to improve the specialty, improve the profession?
Dr. Moss: Well, I think they’ve done a marvelous job in fashioning the programs as they are. I think the number of years required is good. If there’s anything that I would like to see improved, I think it’s the clinical care aspect. I don’t want to say “compete” with the medical oncologists in clinical care, but the clinical oncologist gives therapy. He takes care of the patient in a clinical way, and I don’t mean that we need to dominate the care of the patient, but we should be able to care for many things when they come along. I think if there’s any place where a big step could be made, it’s in that area. You know, we have good physics in most places. Sure, there is a single machine here and there, and they don’t have decent support, and maybe that should also be looked at, but I look at clinical care as one area that I would like to see improved. I don’t think there would be any real advantage in lengthening the training period. Physics support in most places is good. We should work towards getting the isolated facility more physics help.
Question: Do you think that we’re close to curing cancer?
Dr. Moss: There are some cancers that are quite curable, but if you mean all cancers, there are still a lot of problems. You can take the work of people like Dr. Drucker, and essentially control it, but in localized cancers of the oral cavity, and of the cervix, and you can pick out a whole group of them—they’re really quite curable in their early stages. To change that, you’re going to have to make earlier diagnosis, which is a real problem. I don’t know how close they are to defining a fundamental cause of cancer and correcting that.
Question: You’ve contributed significantly over a lifetime, and it’s been wonderful to spend two hours with you today. Thank you very much.