work- life...feature and relocate in support of her spouse. and so, count-ing my blessings, i throw...

Volume 7 • Issue 1, 03.15

Planning Ahead for a Career

A War Story

Trends in Pediatric Cancers

Apps for the Healthcare Professional

Work-Life

BALANCESingle Life of a Peds HemeOnc

Fellow

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OncLive.com Oncology Fellows • 03.15 | 1

Interested in contributing to Oncology Fellows? If you’d like to submit an article for consideration in an upcoming issue, please e-mail Jeanne Linke at [email protected].

Table of Contents

2

Volume 7 • Issue 1, 03.15

Feature

Departments

Editorial & ProductionSenior Vice President, Operations and Clinical AffairsJeff D. Prescott, PharmD, RPh

Senior Clinical Projects ManagerIda Delmendo

Project CoordinatorJen Douglass

Associate Editor Jeanne Linke

Quality Assurance Editor David Allikas

Art DirectorRay Pelesko

Sales & MarketingSenior Vice President Mike Hennessy, Jr

Vice President, Integrated Special Projects Group David Lepping

Associate Publisher Erik Lohrmann

Director of SalesRobert Goldsmith

National Accounts ManagerAlbert Tierney

Digital Media AssociateKristin Lopez

National Accounts AssociateJames Maier

Sales & Marketing CoordinatorJessica Smith

Director, Strategic Alliance ProgramFrancine Durcan

National Accounts Manager, Strategic Alliance PartnershipHeather Shankman

Digital MediaVice President, Digital Media Jung Kim

Operations & FinanceGroup Director, Circulation and ProductionJohn Burke

Director of OperationsThomas J. Kanzler

ControllerJonathan Fisher, CPA

Assistant ControllerLeah Babitz, CPA

AccountantTejinder Gill

CorporateChairman and CEOMike Hennessy

Vice Chairman Jack Lepping

PresidentTighe Blazier

Chief Financial OfficerNeil Glasser, CPA/CFE

Executive Vice President and General ManagerJohn C. Maglione

Vice President, Human Resources Rich Weisman

Vice President, Executive Creative DirectorJeff Brown

For more articles, go to www.OncLive.com/publications/ oncology-fellows

A Word From Your Fellows10 Planning Ahead for a Career Dhaval Shah, MD, describes the

changing landscape of clinical practice in oncology and hematology and urges first-year fellows to plan for their future early on in their fellowship.

Online Oncologist14 Mobile Medicine

Apps for the healthcare professional.

By the Numbers15 Trends in Pediatric Cancers

Conference Center16 2015 Oncology & Hematology

Meetings

A War Story Christopher Dittus, DO, MPH, shares his per-sonal encounter with a US Navy veteran and discusses the patient’s prognosis, course, and overall goals of treatment.

Work-Life BalanceSingle Life of a Peds HemeOnc FellowNitya Narayan, MD, discusses the challenges of being a fellow in pediatric hematology-oncology and achieving a balance between her work life and her personal life.

6

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FEATURE



“Dr Narayan, aren’t you dating anyone YET? Maybe you work too much!” smiled Mrs Butler as she relaxed in her chair. Those tired lines around her eyes were gone. There we were in Exam Room 22, Nina’s room. I lovingly touched her soft, stubbly, baby-duck-like hair. This family had just lived through the worst 9 months of their lives, and now here sat their daughter, flushed cheeks and a cheerful smile on her face. Her recent test results revealed a perfect complete blood count and what one pathologist had described as “a beautiful marrow.” She was an acute myeloid leukemia survivor. “It’s growing,” she said self-consciously as she pulled her wig back on. I knew she wanted her hair back in time for high school graduation. That somehow seemed way more important to me than going on a date. I squeezed her hand. Nina is braver than I am.

As most of my colleagues discuss where to host their kids’ birthday parties or what to cook for their in-laws, I am mentally (or sometimes literally) scrolling through the list of guys on my dating profile, trying to decide who is worth getting dressed up for. I am a member of the cohort of 30-something single Indian women who were not lucky enough to snag the right guy during med school, and perhaps am not genetically engineered to be good at dating and studying simultaneously. I am subsequently generally the oldest of my single friends and the “singlest” of my same-age friends. Culturally I am a spinster, a has-been, a “well-at-least-she’s-smart” per my grandmother, who is genuinely perplexed by the notion that tall, handsome, Hindu, vegetarian, Brahman professional men aren’t a dime a dozen.

Socially I apparently do not know how “lucky” I am to be alone, according to the fellow with marital problems, or the one who had to stop her whole career

Nitya Narayan, MD, is a pediatric hematology-oncology fellow at the University of Illinois at Chicago, RUSH University Medical Center, and John H. Stroger Jr Hospital.

ABOUT THE AUTHOR

By Nitya Narayan, MD

Work-Life BALANCE

Single Life of a Peds HemeOnc Fellow

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for

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FEATURE

and relocate in support of her spouse. And so, count-ing my blessings, I throw myself into my work and the gym. Most days I leave both places feeling thank-ful and happy, and admittedly a little wistful for the day I can go home to cook for my husband or play with my own kids.

My days of fellowship generally end with signing clinic notes, preparing lectures for residents, or send-ing one last e-mail to the Institutional Review Board, pleading for approval of my research project. Many of my evenings entail putting on expensive makeup and uncomfortable shoes to go on yet another date, with a quick prayer before I run out the door. I push the ele-vator down button and tell myself with determination, “Maybe this will be the right guy,” as I fight to not think about the day’s events. Omar ’s leukemia relapsed again, leaving him very few options…little Corey’s brain tumor is gone, and now he can hold a sippy cup... Mara died last night after a long fight with a bleeding dis-order…but Heidi, who honestly nobody thought would beat her cancer, started college today! The emotional ups and downs of the day are exhausting—which frankly makes it that much more difficult to listen to a

guy state all his likes and dislikes over the appetizer. I get the familiar rant as he lets it be known he will not ever move from his current job, home, or city, so mar-rying him means “dealing with it,” all while he sprays a mouthful of crumbs in my face between words. Did I really pause my Netflix for this?

These days it seems there is another degree of screening involved. This is no longer only about this person getting along with my family and sharing my

values. Can this person handle my career? Will he listen to me cry when a toddler with a brain tumor dies, one who let me hold her special dolly only 2 weeks earlier? Will he help me remember I did the best I could?

I think back to residency to the guy who was per-fect on paper, who I thought had serious potential. I remember calling him over a tiny infant who had been beaten so badly she had 2 black eyes, only to have him say to me, “Your stories are kind of depressing—I real-ly don’t want to hear this.” While I could hardly blame him, that was a game changer.

Remembering the advice of one of my favorite mentors during residency about “work-life balance,” I had always convinced myself I had that part in the bag. I worked my 80+ hours a week, went to the gym religiously, leaving just enough time for family and friends, and occasionally even slept a full 8 hours. I was balanced! I was happy. I had, after all, survived a major hurricane at my Caribbean medical school, a computer shutting down during the medical boards, and having “black cloud” status all 3 years of resi-dency at a busy children’s hospital. I am tough, I often thought. I can survive anything. But my pediatric he-matology-oncology fellowship has been the true litmus test of those statements.

There was this one afternoon in clinic, trying to teach a helpless young woman how to mix apple juice with chemotherapy into her infant’s bottle. I had flashbacks of helping my mom wash my then-baby brother’s bottles—the careful way she scrubbed them, the pride she took in filling them before we went out to the exact plastic fill mark on the side, working tirelessly to protect us with the precision only a mother has.

My heart went out to this wide-eyed, horrified mother as the nurse taught her how to pin her baby’s arms down to make him drink the bitter potion. Fif-teen months old and no fair shake in life—I stepped out and cried in the clinic bathroom. No mom ever imagines having to deliberately poison her own child in order to save his life, and no mother should have to.

I am tough, I often thought. I can survive anything. But my pediatric hematology oncology fellowship has been the true litmus test of those statements.



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Your emotions and perspective change multiple times a day in this field. The question I get asked the most is some derivative of “Wow, children with cancer—how do you DO that job?” It almost seems silly to simply say “I hate cancer.” I think the real answer is selfish. It is because they make me a better person. They make me thankful. They make me appreciate every moment I can go outside and not have to worry that cold weather will trigger pain, treasure every moment I can eat, or play, or run, cherish every moment I can talk to my family and every moment I am lucky enough to feel love. No matter how broken my heart is from the one who didn’t want to work it out, I have a boundless love inside that makes me not want to give up—one that I gain from these chil-dren. I realize if they can bear multiple IV needle pokes and severe nausea, I can bear a few more terrible dates until the right one comes along. I realize how lucky

I am to have a mother who tells me to dress nicely to work because “There could be a handsome single doctor there,” and a dad who proudly tells anyone who will lis-ten that his daughter is a pediatrician. I realize that you can feel close to other people’s children and love them with all your heart, in spite of some who are older and wiser and advise you to keep your emotional distance. I realize that parents can feel it when you care about their child, even if all their kid needs is a little more iron and a little less milk.

I realize every day what a privilege it is to care for somebody’s loved one. When a 6-year-old offers you his last Skittle as a “thank you” for his spinal tap, how can you feel anything but gratitude? When you see a dad come to the annual party with only his child’s framed photo in hand, instead of his actual son, you under-stand that the depth of one’s pain is a reflection of their love, and that is a beautiful lesson to learn.

Although these anecdotes are based on true events, names

have been changed to preserve anonymity.


By Christopher Dittus, DO, MPH

A War Story

“I’d be back out on the water in a heartbeat.”

FEATURE

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Those were the words spoken by my favor-ite patient when I asked if he had enjoyed his time in the US Navy. Technically, doc-tors are not supposed to have favorite pa-tients, but, since we are human, we all do.

I met Charles about a year ago during my first year of training as a hematol-ogy and oncology fellow. I remember him standing up slowly in the waiting room, cane in hand. Getting started took some time, but once he gained momentum, he could practically run.

I could tell immediately that he was a kind man, but this gentle demeanor was enveloped by sadness. I would soon find out that his wife had passed away several months prior to our first meet-ing, and he was in a state of bereavement. Fortunately, he was not alone; he and his wife had raised 3 wonderful children. His daughter, Mary, often accompanied him to appointments along with her husband.

Charles was referred to our hematology clinic at the Jamaica Plain Campus of the Boston VA for pancytopenia, and for a man in his 70s, this laboratory finding was con-cerning. Charles described to us how he lacked an appetite, was feeling increasing-ly tired, and had been losing weight over the past few months. He attributed these symptoms to his bereavement, but certain,



Christopher Dittus, DO, MPH, is a hematology and medical oncology fellow at Boston Medical Center.

ABOUT THE AUTHOR

more ominous, details emerged. He had developed substantial back pain about 6 months prior and was diagnosed with compression fractures. Additionally, he noted worsening dyspnea on exertion. Taken to-gether, his symptoms were suggestive of a primary bone marrow disorder. He underwent a bone marrow biopsy, and the results confirmed our suspicion of multiple myeloma.

Between 1975 and 2006, the 5-year survival rate for multiple myeloma increased from 23% to 45%, with the greatest gains occurring after the year 2000.1 This trend reflects the myriad new treatments now available, including medications from entirely

new pharmaceutical classes. Despite these advances, myeloma is rarely curable, and most patients will ultimately succumb to their disease. With this in mind, we started Charles on a very effective, and generally well-tolerated, regimen of lenalidomide and dexamethasone. Because of his age and comorbid conditions, he was not a candidate for bone marrow transplantation, so our goal was to put him into re-mission and keep him there as long as possible.

Unfortunately, Charles did not have the favorable initial response we had hoped for, and after 3 cycles we added a proteasome inhibitor, bortezomib, to his regimen. His myeloma responded, but again, not ad-equately. After 3 cycles, his back pain worsened and it was decided that he should be treated with radia-tion therapy to his involved thoracolumbar vertebrae. Once his radiation therapy was completed, we initi-ated a new regimen, consisting of a traditional che-motherapeutic agent, cyclophosphamide, as well as bortezomib and dexamethasone (VCD).

Over time, I developed a professional friendship with Charles, and he told me more about his family,

For cancer updates, research, and education

for patients, visit curetoday.com

ON THE WEB

military experiences, and life after the military. In the US Navy, he served on 2 different vessels starting in 1959. He described, proudly, how the first ship he served on was an ice-breaker that ultimately went on to be the first ship of its kind to overtake an enemy ship. He recalled only good memories of being at sea, except, of course, for when there were severe storms. After the military, his love for the sea continued, and he enjoyed fish-ing and lobstering from his 30-foot fishing vessel.

Recently, Charles completed his third cycle of VCD, and he now has stable disease. If and when he stops responding to this regimen, we have many more options avail-able. For now, he is able to enjoy spending time watching his grandchildren grow up and excel at sports.

Charles’s war is not as dramatic as those we see in the movies, or even those recalled in the waiting room by his fellow combat veterans. His is one of at-trition, with an enemy that cannot be seen with the naked eye. Although he may ultimately lose this war, right now, he is surely winning.

REFERENCE

1. National Cancer Institute. Fast stats: an interactive tool for access to SEER cancer statistics. Surveillance, Epidemiol-ogy, and End Results Program website. http://seer.cancer.gov/faststats. Accessed February 6, 2015.

Although this anecdote is based on a true event, names have been changed to preserve anonymity.

Charles’s war is not as dramatic as those we see in the movies, or even those recalled in the waiting room by his fellow combat veterans. His is one of attrition.

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A WORD FROM YOUR FELLOWS

Planning Ahead for a Career



F rom the earliest days of medical school, I had a special interest in hematology. This interest became stronger during my residency and cul-

minated in a fellowship in hematology and oncology. The 3 years of my fellowship training were a life-changing experience that will stay with me forever.

I still remember the first day of my fel-lowship, when I was assigned to the general oncology clinic. The second patient I saw that day had end-stage lung cancer, and we had to discuss end-of-life care with him. I vividly remem-ber the way my attending handled the conversation, which has had a lasting impact on me. Over the next 3 years, I experienced several tough patient interac-tions, ranging from the explanations I provided at the time of new diagnoses, to discussions on appropriate treatment plans, to end-of-life care discussions. At the same time, I found that the learning curve during these 3 years was the toughest since medical school.

It is a very exciting time to be in the field of he-matology and oncology. The treatment paradigm for melanoma that I learned at the start of the fellowship has completely changed over the course of 3 years. As a first-year fellow in training, I found it very difficult to grasp all the information and apply it to patient

care. Right from the beginning, it was important for me to focus on my overall career plan, which included identifying areas of interest in which to pursue fur-ther research.

I believe that the biggest struggle for many during fellowship is identifying long-term goals. It is important to identify them as early as possible if one is interested in an academic career. This becomes very im-portant toward the end

of the first year of fellowship or early on during the second year, to help plan for the remainder of fellowship.

It is also an important time to identify a mentor and a research project in one’s area of interest. It takes time to put together a research proposal, and therefore I cannot emphasize enough the need to start this process early. There is not enough time to complete a substantial research project in the third year alone.

Of course, the structure of the fellowship program varies

By Dhaval Shah, MD

FELLOWSFIRST-YEAR

for

SUGGESTED READING

Dhaval Shah, MD, specializes in hematology and oncology for Regional Cancer Care Associates, LLC, an affiliate of the Virtua Fox Chase Cancer Program.

ABOUT THE AUTHOR


A WORD FROM YOUR FELLOWS

throughout the country. Some pro-grams emphasize clinical work in the first 18 months and devote the last 18 months to research. Some assign clinical responsibilities to fellows during the first 2 years and allow for a flexible third year devot-ed either to research or to clinical pursuits. For this reason, it is im-portant for every fellow to identify the structure of their program early in their fellowship. This can help you establish your career goals.

In terms of an academic career, there are 3 different tracks one can pursue: a clini-cian-educator track, a clinician-investigator track, and a research track. In a clinician-educator track, the emphasis is on education for academic success. If you desire to pursue this track, it is very important to identify the correct academic program based on medi-cal education contributions. A clinician-investigator track, more traditional in oncology, focuses on clini-cal trials and investigations; regular clinical duties are also included. A research track can involve either translational or basic science research. Translational research is definitely an exciting area in medical oncology, and one that allows for collaboration among those involved in bench research and clinical care. Again, I cannot over-stress the importance of plan-ning for a career path early in your fellowship.

In terms of clinical practice, several variables fac-tor into selecting the right practice. These include geographic location, availability of clinical trials and tumor boards, and the relative advantages of hospital-based practice versus private practice. The healthcare

system is changing, and many private practices are merging with hospital systems. This should influence your decision as well. If you join a private practice, it is important to consider the financial stability of the practice and the possibility of a partnership in the future.

I really enjoy hematology and I had always thought that I would be happy pursuing a career in pure he-matology. However, I had very little laboratory experi-ence prior to starting my fellowship. Therefore, right from the start, I knew I wanted to focus on clinical research during my fellowship training. Although I struggled with making clinical decisions during my first year, sometime during the middle of my second year it all began to fall into place, and I started mak-ing my own independent decisions. During this time, I was also chosen to be a chief fellow and thus became involved in organizing many teaching conferences for fellows, residents, and medical students.

Following the completion of my fellowship training, I became specifically interested in following either a clinician-educator track or clinical practice. Although I enjoyed the teaching and interaction with house staff in a university hospital setting, as I began inter-viewing for a position during my third year, I realized that patient care was what I enjoyed the most.

The American Society of Clinical Oncology predicts a shortage of oncologists by the year 2020. No matter what one decides, I think it is an exciting time to be in the field of oncology.

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Right from the beginning, it was important for me to focus on my overall career plan, which included identifying areas of interest in which to pursue further research.

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Childhood and adolescent cancers require special dedication from patients’ cancer care teams, as a diagnosis of cancer in the younger population can be life altering to both the patient and his or her family.1

When providing care to your patients, it is important to be aware that the types of cancers most often diagnosed in pediatric patients are different from those most often diagnosed in adult patients.2 As seen in Figures 1 and 2,2 the American Cancer Society recently reported that the most common types of cancers diagnosed in children (aged 0 to 14 years) were acute lymphocytic leukemia (26%), brain and central nervous system (CNS) tumors (21%), and neuroblastoma (7%); those most commonly diagnosed in adolescent patients (aged 15 to 19 years) were Hodgkin lymphoma (15%), thyroid carcinoma (11%), and brain and CNS tumors (10%).2

Additional cancers often diagnosed in pediatric patients include non-Hodgkin lymphoma, Wilms tumor, acute myeloid leukemia, rhab-domyosarcoma, retinoblastoma, osteosarcoma, and Ewing sarcoma.2

Cancer survival rates vary based on cancer type and patient characteristics; however, the overall outlook on survival in child and adolescent cancer patients contin-ues to improve with the emergence of newer, more effec-tive treatment options. In fact, the 5-year relative survival rate for all childhood cancers (aged 0 to 14 years) combined has improved from 58% of cases diagnosed between 1975 and 1979 to 83% of cases diagnosed be-

tween 2003 and 2009.2

Based on the improvement in survival rates, more children and ado-lescents are emerging as survivors of cancer. It is important that these patients be monitored for long-term and late effects of treatment.2


Trends in Pediatric Cancers

Reference1. Ward E, DeSantis C, Robbins A, Kohler B, Jemal A. Childhood and adolescent cancer statistics, 2014. CA Cancer J Clin. 2014;64(2):83-103.2. Cancer Treatment and Survivorship Facts & Figures 2014-2015. Atlanta, GA: American Cancer Society; 2014.

BY THE NUMBERS

Figure 1. Most Commonly Diagnosed Cancers Among Children, 2014 (aged 0-14 years)2

Figure 2. Most Commonly Diagnosed Cancers Among Adolescents, 2014 (aged 15-19 years)2

Acute Lymphocytic Leukemia

Brain/Central Nervous System Tumors

Neuroblastoma

30%

25%

20%

15%

10%

5%

0%

26%21%

7%

Hodgkin Lymphoma Thyroid Carcinoma Brain/Central Nervous System Tumors

30%

25%

20%

15%

10%

5%

0%

15% 11% 10%

% D

iagn

osed

% D

iagn

osed

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CONFERENCE CENTER


2015 Oncology & Hematology Meetings

March 12-14National Comprehensive Cancer Network (NCCN) 20th Annual Conference: Advancing the Standard of Cancer CareHollywood, FLhttp://bit.ly/1mb9G93

March 148th Annual Interdisciplinary Prostate Cancer Congress®

New York, NYhttp://bit.ly/1uDFFjB

March 28-312015 Society of Gynecologic Oncology (SGO) Annual Meeting on Women’s CancerChicago, ILhttp://bit.ly/1MadmSl

April 10-122015 American Society for Radiation Oncology (ASTRO) State of the Art Radiation Therapy MeetingLas Vegas, NVhttp://bit.ly/1CR9P8G

April 18-22American Association for Cancer Research (AACR) Annual Meeting 2015Philadelphia, PAhttp://bit.ly/1Fv2da3

April 22-232015 American Head & Neck Society (AHNS) Annual MeetingBoston, MAhttp://bit.ly/1CehqsM

May 6-9The American Society of Pediatric Hematology/Oncology’s (ASPHO’s) 28th Annual MeetingPhoenix, AZhttp://bit.ly/17b65Sk

May 19-21XXVIIIth International Symposium on Technological Innovations in Laboratory HematologyChicago, ILhttp://bit.ly/1DfvKVF

May 29-June 22015 American Society of Clinical Oncology (ASCO) Annual MeetingChicago, ILhttp://bit.ly/1lQaPwB

July 16-1814th Annual International Congress on the Future of Breast Cancer®

Huntington Beach, CAhttp://bit.ly/1INarjs

July 30-August 116th Annual International Lung Cancer Congress®

Huntington Beach, CAhttp://bit.ly/1Ahr2WZ

For coverage from the latest oncology/hematology conferences, visit onclive

.com/conference-coverage

For upcoming CME accredited conferences,

visit gotoper.com

ON THE WEB ON THE WEB

We welcome submissions to Oncology Fellows, a publication that speaks directly to the issues that matter most to hematology/oncology fellows at all stages of training. Oncology Fellows aims to provide timely and practical information that is geared toward fellows from a professional and lifestyle standpoint—from opportunities that await them after the conclusion of their fellowship training, to information on what their colleagues and peers are doing and thinking right now.

Oncology Fellows features articles written by practicing physicians, clinical instructors, researchers, and current fellows who share their knowledge, advice, and insights on a range of issues.

We invite current fellows and oncology professionals to submit articles on a variety of topics, including, but not limited to:

• Lifestyle and general interest articles pertaining to fellows at all stages of training.

• A Word From Your Fellows: articles written by current fellows describing their thoughts and opinions on various topics.

• Transitions: articles written by oncology professionals that provide career-related insight and advice to fellows on life post training.

• A Day in the Life: articles describing a typical workday for a fellow or an oncology professional post training.

The list above is not comprehensive, and suggestions for future topics are welcome. Please note that we have the ability to edit and proofread submitted articles, and all manuscripts will be sent to the author for final approval prior to publication.

If you are interested in contributing an article to Oncology Fellows, or would like more information, please e-mail Jeanne Linke at [email protected].

CALL for PAPERS

With CancerCare, the difference comes from: • Professional oncology social workers• Free counseling • Education and practical help• Up-to-date information • CancerCare for Kids®

For needs that go beyond medical care, refer your patients and their loved ones to CancerCare.

CancerCare’s free services help people cope with the emotional and practical concerns arising from a cancer diagnosis and are integral to the standard of care for all cancer patients, as recommended by the Institute of Medicine.

makes all the difference

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1-800-813-HOPE (4673)

www.cancercare.org

Help and Hope

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We would like your feedback on Oncology Fellows. Please complete the survey below and drop this postage-paid card in the mail!

1. Overall, how would you rate the information and resources found in Oncology Fellows? (1 = not useful at all, 5 = very useful)

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2. Which topics would you most like to see addressed in future issues?

❏ Other (please specify) _________________________________________________________________

3. In my opinion, the number 1 topic that oncology fellows need more information on is: ________________

_____________________________________________________________________________________

4. How important do you think it will be to effectively use information technology in your clinical career, if applicable? (1 = not important at all, 5 = very important)

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5. How often do you go online to research clinical information?

❏ Please contact me—I am interested in contributing an article for an upcoming issue.

Signature (REQUIRED): ___________________________________________________________________

Name/Title: ___________________________________________________________________________

Institution: _________________________________________________ Date: ______________________

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❏ Personal finance and money management❏ Subspecialty-specific clinical and research updates

❏ New developments in medical technology❏ Career advice

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work- life...feature and relocate in support of her spouse. and so, count-ing my blessings, i throw...

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