COMMENTARY

Hard Lessons From Year 1 of Oncology Fellowship

Ravi B. Parikh, MD, MPP

Disclosures

November 07, 2018

The transition from residency into an oncology fellowship may be the starkest in medicine—it's because of the loss of autonomy. As a senior internal medicine resident, I ran codes, supervised junior residents, and was the primary care physician for nearly 100 patients whom I loved. I was a doctor.

Ravi B. Parikh, MD, MPP

Fast-forward to my first month of fellowship: I was now an apprentice. I felt uncomfortable making independent decisions. Ordering chemotherapy required a half-hour conversation with a pharmacist. And breaking bad news became just as terrifying as it had been during my first year of medical school.

I wasn't alone. I spoke with three colleagues across the nation to reflect on what we had learned after completing year 1 of oncology fellowship. Nearly everyone mentioned how unfamiliar the first few months of fellowship were. Things have since gotten much better; we've all found more stable footing as fellowship moved on.

But what emerged from these conversations were common themes: comfort with uncertainty, respect for mentors, and a profound realization that patients view cancer differently from other diseases. Some of these reflections will ring true to any Medscape reader who has completed similar training. But there are unique aspects of an oncology fellowship in 2018, aspects that are vastly different from oncology training 20, 10, 5 years—or even 1 year—ago.

Ultimately, four themes emerged from my conversations that encapsulate my first year of fellowship.

It is awe-inspiring to treat cancer in this era of innovation. For many first-year fellows, a large proportion of the year is spent on the liquid oncology service, treating hematologic malignancies like leukemia and lymphoma. Coming from a residency program with considerable exposure to leukemia, it was reassuring to start on the liquid oncology service in June 2017. For my first 2 months of fellowship, "7+3"—a regimen I had seen countless times during residency—remained the standard induction chemotherapy regimen for patients with new acute myeloid leukemia (AML). While everything else in fellowship was new, it felt good to be familiar with at least that chemotherapy regimen.

The excitement of observing—and sometimes participating—in revolutions in cancer therapy has been one of the highlights.

After a 3-month hiatus, I returned to the leukemia service in January 2018. On my first day back on service, an older man with prior myelodysplastic syndrome was admitted with likely AML. My attending lit up: "Now we have Vyxeos!" Vyxeos, or liposomal daunorubicin and cytarabine, had been approved in late 2017 for treatment of therapy-related or myelodysplasia-related AML. Throughout my first few days of that block, I learned about other AML induction therapies—FLT-3 and BCL-2 small-molecule inhibitors, CD33-directed antibody-drug conjugates, IDH2 inhibitors—that had completely upended the generations-long paradigm of induction therapy. Kaysia Ludford, a fellow at MD Anderson Cancer Center, had a similar experience: "I was floored at just how much treating leukemia changed during my first year of fellowship."

This would have been daunting if I had walked into this new treatment environment on day 1 of fellowship. But having seen the toxicities—and often ineffectiveness—of 7+3, it was exhilarating to watch a treatment paradigm transform overnight. Now, attending physicians, residents, and I were learning together, reading about unique toxicities and biologic mechanisms on rounds.

While leukemia may be an extreme example, treatment paradigms for metastatic cancers like non–small cell lung cancer and renal cell carcinoma have been similarly upended during my first year of fellowship. Some of us are even participating in that innovation: Max Wattenberg, a co-fellow at the University of Pennsylvania, is studying the immune biology of pancreatic cancer in the lab, as well as participating in several phase 1 trials. "For metastatic pancreatic cancer, where treatment options are limited and tumor biology isn't well understood, it is exciting to see novel immune therapies translated to patient care." Many of the insights Max generates in the lab could lead to therapies for pancreatic cancer. The excitement of observing—and sometimes participating—in revolutions in cancer therapy has been one of the highlights of my fellowship so far.

But learning in the absence of evidence is frustrating. The apprenticeship model used for oncology fellowship would be more valuable if it provided a consistent set of lessons to learn. And for clearly evidence-based practices—aromatase inhibitors for postmenopausal women with hormone-positive breast cancers, for example—that has happened. But almost as frequently, oncologists practice in the absence of evidence. Which first-line immunotherapy should I use in metastatic bladder cancer? How long should I give maintenance therapy in multiple myeloma? When should I discuss hospice?

This is the "art", not the "science," of oncology and it is where the most variation in care happens.

It's harder than it looks.

The art of oncology is what many mentors love about practicing, but it's what makes oncology difficult to learn. As Sor Piawah, an oncology fellow at the University of California, San Francisco, said about her first year, "One thing I struggled with was asking attendings, 'Why are you choosing this drug?' when there were several different options. The answer would often be, 'That's what I have had the most experience with.' As a young oncologist, I often had no idea which drug was actually the best for all patients."

It may be frustrating as a learner, but I have grown to love these evidence-free zones of oncology, the areas where the National Comprehensive Cancer Network guidelines list many—or no—options. Here is where we can be honest with patients about what we don't know and where the question "What's important to you?" really matters.

End-of-life care is harder than it looks. I went into oncology because I enjoy having hard conversations. I think transitioning patients from a curative to a palliative course of care is one of the most difficult but rewarding aspects of medicine.

I also thought that I would be part of a revolution in end-of-life and palliative care. Whenever co-residents and I were on the oncology service, we would get angry when oncologists gave chemotherapy to sick patients. As Piawah put it, "In residency, I disliked how some oncologists would recommend intervention after intervention for dying patients." Ludford, who studies end-of-life communication, told me, "I thought that I would go in and be the oncologist who was first to bring up end-of-life conversations."

It's harder than it looks.

Later in my first year, I saw a new consult, a 47-year-old woman with two children, a husband, a dog—and extensive-stage small cell lung cancer. She had everything to live for but had a cancer that was refractory to first-line therapy. I read her inpatient discharge summary—her third in 4 months. Worrisome phrases jumped out: "Refractory ascites." "Multiple liver metastases." "Painful bony lesions." "Discharged on supplemental oxygen." "30 pounds of weight loss."

I thought to myself, "She needs to be on hospice." But when I walked in the room—a room with at least eight family members—I could tell from everyone's wide eyes that hospice wouldn't be what we discussed today. She made it clear what she wanted: immunotherapy or a clinical trial. As I listened to her talk about her goals in life, about how every potential extra day was worth the agony of treatment, who was I to deny her that?

As Piawah told me, "As a resident, I was only seeing half of the picture. Coming in as an oncology specialist who knows of other treatments that haven't been tried and has a relationship with a patient, I now understand why outpatient oncologists recommend treatments when others think it is crazy."

It's undoubtedly hard for oncologists to disassociate themselves from the hope they and their patients once felt. Good news seems like it will last forever. Bad news lasts only until the next treatment starts. Is it even possible to approach the end of life rationally?

I always thought that the best time to discuss advanced care planning is when people are healthy. After all, that's when they are thinking clearest.

But patients come to oncologists because they want to be treated. According to Ludford, "It's hard, especially when dealing with young patients. Some patients are in denial."

Piawah says, "Say you start a patient on therapy. Perhaps they have a good scan result. At that point, it's hard to bring up the end of life because the treatment is working!" She's right; why ruin a good moment by bringing up death?

Fellowship has taught me to take a more practical approach to end-of-life care, allowing patients to dictate the timing and content of conversations rather than having a set agenda. Ludford has learned from mentors to take an iterative approach: "I am very transparent at the outset. I tell patients, 'I am going to be very honest with you, whether it's good news or bad news.' I try to engage patients about end-of-life planning frequently, and always with family in the room so that the burden of decision-making isn't solely on the patient."

Wattenberg takes a similar patient-centric approach: "I've learned to ask, 'How much do you want to know?' whenever a patient asks about prognosis. Whenever someone asks about a treatment I don't agree with, I've learned to say, 'This probably isn't the right thing to do at this time.'"

I like Max's strategy. We put too much blame on patients when we tell them that they "aren't strong enough" or "can't tolerate" a therapy. A patient's cancer—and not the patient—is usually the reason why treatments don't work.

Patients have cancer, but they aren't cancer patients. I never liked the term "cancer patient"; it defines patients by their disease, and in medical school we were taught never to do that.

So I was surprised at how often oncologists, oncology social workers, and others in the field use the term. And I felt guilty when I caught myself using it, including one time when I unwittingly referred to a veteran as a "cancer patient"—to his face.

It's natural to dehumanize sick patients who have a high likelihood of dying. Perhaps referring to someone as a "cancer patient" allows oncologists to emotionally separate themselves from such patients.

But in my prostate cancer clinic, I often saw patients several years after treatment. They had long-term disease control and lived lives full of travel and family. Cancer was the furthest thing from their mind, and they often didn't even like me mentioning their prior cancer, as if it were a traumatic event.

Even though cancer is our patients' biggest medical problem at the time we see them, most of their lives are spent outside of the oncologist's office. Advocacy groups, health systems, and pharmaceutical companies put forth a public image that emphasizes how cancer must be fought continuously. This again puts too much on our patients. Cancer shouldn't have to dominate our patients' lives.

As one of my mentors told a patient, "You have nothing to worry about. You only have cancer on the day you get your scans." This is perhaps the biggest lesson of fellowship, and maybe of being an oncologist: Even though we treat patients because they have cancer, we form the strongest relationships with patients once we know them beyond their diagnosis.

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