Dr. Julia Smith, Clinical Director of the Cancer Screening Program at NYU Langone, on Genetic Testing & Democratizing Access
Dr Julia Smith is an icon in the world of women’s cancer prevention and gynecologic oncology. Four decades ago, she was the first woman in the NYU MD PhD program, ever. Today, she is the Clinical Director of the Cancer Screening and Prevention Program at the NYU Isaac and Laura Perlmutter Cancer Institute. In this very special interview, Dr. Julia Smith discusses the shifting landscape of ovarian cancer prevention and the tremendous impact of genetic research in the field. “You know, nobody believed — not the doctors, not the scientists, not the lay public — nobody believed that cancer had a genetic basis. They laughed, in the '60s ,'70s, and even the ‘80s, when someone would say there could be a genetic basis.”
Amy Cohen: I am so excited to be able to talk to you today, Dr. Julia Smith.
Did you always know that you wanted to be a doctor and go into medicine? And then at what point on that trajectory did you decide to go into oncology?
Dr. Julia Smith: Well, my father was a surgeon. So, you could say that it was in the family blood. But none of my sisters ended up going into medicine. I liked science a lot. I enjoyed it. And when I was in college, I majored in biology and in English as well. And I loved that. I was the first woman in the NYU MD PhD program ever. I love science but what I love is taking care of patients. And I love the connection with patients and the stories. And that made me very happy. So, I ended up doing the MD PhD program, which was terrific for me. I got to really delve into molecular genetics and biology, retroviral, genetics, and then I got to do medicine.
And then you do your residency, where you're just, you're just getting pounded — especially in those days, because there were no rules limiting how hard they could work interns and residents. You spend a lot of time thinking, "Well, I don't think pulmonary, I'm not really interested in sputum (laughs). I don't think gastroenterology; I don't want to spend my life with feces. I'm not sure I want to do urology.”
Anyway, oncology was perfect for me. That was the time when everything was bursting open on the oncology field. And it was the first place that molecular genetics and molecular biology was able to be translated to the patient and the clinical situation.
Everything just burst open at that point. So it was ideal for me. So this was the 1980s. Oncology combined all my interests in science and in biology and molecular biology and genetics. And then, of course, what happened in in the early '90s was that Mary-Claire King cloned the BRCA genes. And when she cloned the BRCA genes, I knew that I wanted to be involved in cancer prevention. Because once she was able to show that there was a genetic predisposition to cancer, it was clear that the whole field was going to just burst right op- wide open.
And that was really the beginning. And then, it was you and your family, The Lynne Cohen Foundation. You understood very early on, when most people didn't get it — even most doctors didn't get it. Many scientists did, but most doctors did not understand how important it was to really pursue the issue of genetics and genomics. (Genomics is the genetics of the tumor tissue. And genetics usually refers to what's called germline genetics, which is the genes you're born with.)
Lynne Cohen understood that you could use this information and do research and help women prevent cancers.
So that was my journey.
“It was you and your family, The Lynne Cohen Foundation. You understood very early on, when most people didn't get it — even most doctors didn't get it. Many scientists did, but most doctors did not understand how important it was to really pursue the issue of genetics and genomics.”
Amy Cohen: Right. You said something really interesting. Doctors didn't understand it at the time, but scientists did. What is the distinction?
Dr. Julia Smith: I have a PhD in molecular biology. But most doctors… they understand a lot of science. They're exposed to a lot of science. But they're not at the laboratory bench.
Amy Cohen: Right.
Dr. Julia Smith: They’re not looking at the molecular level, or the cellular level at the impact of different maneuvers. Back then, genetics was a whole new concept. You know, nobody believed — not the doctors, not the scientists, not the lay public — nobody believed that cancer had a genetic basis. And they laughed when, in the '60s or '70s or even the ‘80s, someone would say there could be a genetic basis.
Nobody doubts the genetic basis now. But it’s a hard thing for doctors who are incredibly busy trying to take care of all kinds of difficult problems and trying to be there for their patients. It's not an easy thing to then integrate an entirely new concept and field.
So, it takes time. And some of that is good, because you don't want doctors jumping on bandwagons, which has happened.
Amy Cohen: People ask me, when they’ve have a loved one who has been recently diagnosed with ovarian cancer, “Where should I go? Who should I see?” And I always say, "You need to be at a research institution seeing a doctor who is a scientist and researcher,” because their level of knowledge is significantly different from someone who has not been in that kind of setting. Obviously, to be with someone like you, who, in addition, has this incredible patient care, is the best of both worlds.
I had one other thing I'd like to get into with you. My mom talked about this so much, and you know, she passed away over 20 years ago. But it was relevant then, and it's certainly relevant now. Cancer knows no boundaries. It doesn't care how much money you have. It doesn't care the color of your skin. It doesn't care of your background. It doesn't care if you have insurance. It's just one of those things that happens to anybody. It is completely non-discriminatory.
Dr. Julia Smith: Yeah.
Amy Cohen: My dad came from nothing and worked his whole life to be able to give his family everything that he didn't have. It was the hardest thing for him to have my mom get cancer and then pass away, because it didn't matter how successful he was financially. There was nothing he could do. It really did change him for the rest of his life. That is why it was always so important for us as a foundation to try and offer our preventive care services to all women from all walks of life. And you've been so involved in that. How can we do that better? How can we better serve the uninsured and minority women who really need these preventive services?
Dr. Julia Smith: This is so important. It's just like women have different biology than men; you can't look at heart disease in men and try to treat women that way. You can’t treat every group the same… And that's something, you know, a lot of women don't know. They're like, "Wait, what? I'm an Ashkenazi Jew so I'm at greater risk for breast or ovarian cancer. I didn't know that." My hope is that when we focus on other ethnicities, other communities, that maybe there are other things that come out.
At NYU, every week, we have what's called the multidisciplinary conference. And everybody's there who could be involved in a case. So, you know, the medical oncologists are there, the surgeons, the breast surgeons are there, the gynecologic surgeons are there, the radiologists, the radiation therapists, the radiation oncologist, the pathologists are there. Everyone who could have a role in this woman's care shows up. The majority of doctors who are at this conference are women. I don't know if this is true, at every institution, but it's true at NYU.
Amy Cohen: That's amazing. My last question: Are you a mentor to other young women in medicine?
Dr. Julia Smith: Yes.
Amy Cohen: They're so lucky.
Dr. Julia Smith: I think that has always appealed to me about being at an academic. Being at an academic institution, everyone's trying to be at the cutting edge of what's going on clinically and scientifically. So you have an opportunity to teach and to mentor, which is wonderful, because you get to see the next generation coming along.
Amy Cohen: Are you hopeful for the future of preventive care with ovarian cancer?
Dr. Julia Smith: Yes. I really am. I think what we're going to see for all cancers is that once you can understand genetically what's going on in the tumor and in the patient, you will have a target. You know, you hear a lot about immunotherapy checkpoint inhibitors.
You don't have to worry about whether the cancer started in the lung, in the ovary, in the breast, in the pancreas. All you need to do is find out in that case, in that cancer, what went wrong that in the cell that allows them to divide and proliferate and then target that defect.
This next decade is going to change the way cancer is treated.