"Hello. Is this Kristen Anderson? This is the breast center calling with the results of your biopsy. I am so sorry to give you this news, but the results indicate that you have a malignant form of breast cancer, and we’re going to need you to come in to talk about a treatment plan. Can you come in today?”

I don’t remember much after this phone call, but I do remember crumbling to the floor in tears. Not the delicate misty tears some people experience at the climactic end of a tragic movie or at those commercials about animals being kept in squalid conditions, but the heaving, unable-to-breathe sobs of someone whose world has just collapsed. Shock, fear, denial, and overwhelming sadness hit me all at once.

I had just turned 28. I had just started my fourth year of graduate school studying immunology. I was so close to finishing my first scientific paper and starting my doctoral thesis. I was in the early stages of a new relationship that had real long-term potential.

I had way too much going on, both personally and professionally, to have cancer.

I fully recognize this will come as no surprise, but that’s not how cancer works. Cancer doesn’t care about hopes, dreams, goals, or commitments. Cancer just is. And although the impact it can have on a patient’s life is completely unpredictable, it’s a pretty safe assumption that the impact is going to be significant.

I consider myself incredibly fortunate. I was assigned a great medical team at the University of Minnesota Masonic Cancer Center, a Comprehensive Cancer Center with an “outstanding” designation from the National Cancer Institute. Even though I had aggressive, triplenegative disease, driven in part by an inherited BRCA1 mutation, drugs had been discovered that showed great efficacy against my type of cancer. My graduate student health insurance covered almost every single bill. And my life was only partially put on hold: I went to chemotherapy appointments on Fridays, slept all weekend (and usually through Monday), then headed into the lab Tuesday through Thursday. Then the cycle would repeat.

My progress in the lab slowed immensely, and I was pretty much always exhausted. But I was able to keep showing up. Every week. For 6 whole months.

I cannot explain the motivation behind pushing myself that hard. Part of me chalks it up to equal parts perseverance and downright stubbornness. In retrospect, it’s more likely that I just needed something, anything, to help me feel as if I still had some control over my life. I think I needed to feel as though I was still making progress, however small, toward my goals. Perhaps this mind-set helped me feel I was going to live, to maintain hope when I was terrified by the possibility of death. Most weeks, I had the energy to do this without any issues. But some weeks I didn’t, and I am incredibly grateful for my caregivers, friends, and colleagues who recognized that some weeks were better than others and supported me through the entire ordeal.

After chemotherapy and surgery, I went back to school full time with a renewed passion to finish my degree. Even after weekly therapy was done, I encountered more setbacks. I tried to match my peers’ ability to work 14-hour days and memorize and regurgitate details from the (sometimes apparently random) primary literature. But my diminished stamina and the fog of chemo brain kept me from full success.

I recognize now that these self-imposed hurdles were ludicrous. Nonetheless, despite stumbling, I managed to publish 2 primary-author articles and graduate in a bit more than 5 years.

Disease free and PhD in hand, I faced another massive challenge: What did I want to study for the rest of my career? What did I want to do with my life? This is a huge decision for everyone, but a few years earlier, I hadn’t been sure I’d get the chance to even have a career to worry about.

I agonized over leaving Minnesota, which I knew was inevitable if I wanted to stay with my partner (which I did). My whole life up to that point was in Minnesota. My entire support network was in Minnesota—my family, my friends, my physicians. What would I do if my cancer came back?

Finally, I had an epiphany: The chemotherapeutic drugs I was given were discovered by investigators. As an investigator, I had an incredible opportunity to pay it forward, and I could not throw that away. Within 5 minutes, my future was decided. I was going to use my immunology training and expertise to study cancer immunotherapy.

Fortunately, I have an incredible network of colleagues who encouraged me to talk to Phil Greenberg, MD, an internationally recognized leader in the field of cancer immunotherapy and T-cell engineering. I’ve now been a postdoctoral research fellow with Dr Greenberg at the Fred Hutchinson Cancer Research Center (Fred Hutch) for about 5 years. Without any exaggeration, I think I have the best job ever. 

My research involves engineering T cells to recognize and kill cancer. We focus on making effective therapies for tumors that have been notoriously hard to treat, like ovarian and pancreatic cancers. My team identifies obstacles that prevent T cells from effectively killing solid tumors, and then we use preclinical models to evaluate novel ways to effectively overcome those obstacles. Once we’ve found an approach that works in our models, we test it in human cells to see whether our approach can also work in patients. We now have several tactics with translational potential, which is incredibly exciting and fulfilling. 

And research is not the only way I have found to pay it forward. My experience is a classic example of why early detection is critical. To share what I’ve learned with the community, I became an instructor for the Seattle Rivkin Center’s CanCan education program. CanCan provides free workshops on the signs and symptoms of breast and ovarian cancers and encourages community members to be proactive about their healthcare.

I also try every year to participate in at least 1 fund-raising event to support research. I regularly participate in Fred Hutch’s Obliteride, the Rivkin Center’s Summer Run, and the American Association for Cancer Research’s Runners for Research 5K. This summer, I am going to up it a notch. As part of a Climb to Fight Cancer team, I’m headed to Tanzania to climb Mount Kilimanjaro and help raise money to support cancer research at Fred Hutch. Because cancer is really hundreds of different diseases, and, even if successful, my own studies can help only a fraction of patients. By supporting other investigators, I hope to help many more.

Kristin Anderson, PhD, is a postdoctoral research fellow at Fred Hutchinson Cancer Research Center.

Articles

Kristin Anderson, PhD, shares her journey from patient to investigator.

Paying It Forward in Oncology: A Journey From Patient to Investigator

Imagine you are approaching the end of your fellowship training. Soon all the arduous years of study since medical school will be behind you. You may have even secured your dream job by now or be winding down your search. One question: What are you going to do between completing your fellowship and starting your new job? Rather than letting this be an afterthought, give the question more consideration, especially because for many of us, this may be the only opportunity for a long break before retirement.

During my fellowship training in Chicago, Illinois, I frequently took care of patients who did not speak English. With Chicago as diverse as it is, I treated patients who spoke Spanish, Cantonese, Mandarin, and Polish. For translation, we relied on a service we could reach by phone or tablet. The reception was often poor, tablets were limited, and it seemed patients always remembered 1 more very important question moments after we had disconnected the call.

Hematology/oncology, like all medicine, depends on clear communication and a good rapport with patients. So I decided to learn Spanish to overcome the limits of technology. Part of learning a language is also learning the culture, so I tried to immerse myself in that as well.

Given my desire to improve my Spanish, especially if I wanted to remain in Chicago, and my curiosity to experience healthcare firsthand in parts of the world other than the United States and Zimbabwe, where I earned my medical degree, I developed the urge to practice, if only briefly, in another country.

During one of my vacations while in fellowship, I visited Colombia, where everyone speaks Spanish and very few speak English. I met a linguistics professor from London just starting a 1-year sabbatical, most of which she was planning to spend in South America. I told her I wished I had the opportunity to do something similar. “So why not?” she answered. I told her I was in fellowship. And she replied, “What about when you get done with fellowship?”

No prospective employer would likely allow me significant time off prior to my contract for something outside traditional reasons. Later on, when I was on my own, I thought about my excuses. Were they valid? Or was I just afraid of trying something different?

I started online by researching career breaks and sabbaticals. Other professions seemed to accept and encourage the practice, but I didn’t find much information related to physicians, especially in the United States.

As if by fate, I came across a blog (bit.ly/2S0cZSY) by a US-based physician, Jonathan Kirsch, MD, who went to Cali, Colombia, while on a 1-year sabbatical from the University of Minnesota. He outlined his experiences in the country and gave practical advice on topics such as finding a place to live, getting health insurance in a foreign country, and determining how much to save before leaving.

It seemed reasonable, and the worst any prospective employer could say was no. If I was ever going to do this, the transition from fellowship would be my best, if not my only, opportunity, and I didn’t want any regrets.

What I found surprising was how others responded to my plan. At my midyear review, my program director wanted to know more about my plan. Even potential employers I met with were open to both the amount of time I wanted to take and my reasons.

Eventually, I went back to Colombia and settled in the second-largest city in the country, Medellin, the City of Eternal Spring. San Vicente Fundación, a teaching hospital associated with the University of Antioquia, caught my interest. I emailed them my request, and they were excited to receive me. As I would later learn, they often host fellows from Europe who go there for up to 6 months at a time. I figured 6 months in the hematology/ oncology department would be just right for me.

I obviously did not know what to expect and went into the whole project with an open mind. I learned more Spanish than I had anticipated, even though I haven’t been able to shake my accent. I had more free time to prepare for boards and to read in general. I traveled throughout the region. I found my other foot in salsa— learning the dance is a prerequisite for living in Colombia. It is amazing what you can do and learn in 6 months.

If you ever have even the slightest inkling to take a career break or a sabbatical after fellowship for nontraditional reasons, please give it a shot. Employers are more accepting than you think, and you may land your dream job not in spite of your sabbatical but because of it.

Ignatius Nyatsanza, MD, is a hematologist/oncologist at Advocate Health Care.

The question of what to do between completing a fellowship and starting a new job is a big one. 

Should You Take a Break After Your Oncology Fellowship?

Research undoubtedly forms the backbone of our medical knowledge. Whether this comprises basic science research, translational research, clinical trials, or outcomes and epidemiological research, every form plays a key role in the pipeline of scientific discovery, which naturally builds on itself.

Research integrity, then, is a crucial responsibility of any scientist. Scientific publishing has enabled the wide dissemination of knowledge gleaned from research. This is critical for communication with other scientific investigators and potential collaborators, physicians who care for patients, and even patients themselves, who may rely on some combination of journal articles and the media to understand their diagnoses and options.

Integrity means objectively presenting results without overselling conclusions and, more important, not falsifying data. Indeed, research relies on the generation of hypotheses, but investigators must recognize that hypotheses are not always correct. We cannot simply make our data fit our hypotheses; rather, we must acknowledge that the deviations in our observations from our expectations carry importance and may even result in serendipitous discoveries.

With discovery come more questions and hence more opportunities for research. Rather than just searching for answers, much research entails asking the right questions, ones that ultimately advance the medical field and lead to new treatment options for patients on a larger scale.

Although the excitement of conducting scientific research lies in the ability to advance knowledge and make new discoveries, the purity of research is too often tainted by political motives. In academia, research successes often correlate with career promotion, increased funding opportunities, and visibility and reputation within the field. These factors impose external pressures on the need to publish, as a scientist’s h-index and quantity of publications form the basis for academic currency. As a result, negative findings are often released quietly or even buried despite their vital importance.

Responsible investigators must be careful not to allow these pressures to affect the integrity of their reporting. Research misconduct carries with it a substantial cost, with potentially dire consequences for society. Beyond affecting the funding and reputation of individual scientists and institutions, misrepresented data and their portrayal by the media may have a broader impact, affecting scientific colleagues or collaborators and the public health at large.

Patients have entrusted physicians and investigators with their lives. We have been granted a unique privilege and opportunity to partake in their care and to use their tissue or information to generate data. In turn, we owe it to them to practice our trade responsibly. This means conforming to the standards of regulatory bodies, protecting privacy, and engaging in a proper discussion of the risks, benefits, and alternatives of participation in a research study while appropriately addressing any questions the patient may have—that is, respecting the “informed” component and voluntary nature of informed consent.

The tenets of the Hippocratic Oath—by which all physicians must abide, the ethical code that forms the moral basis for the privilege of practicing medicine&mdash;are principles we must uphold in research, which is itself a privilege. Traditionally, these include beneficence (supporting the best interests of our subjects and patients), nonmaleficence (doing no harm to subjects and patients, ie, 

), justice, and respect for autonomy (ensuring the capacity of subjects and patients to make an informed, uncoerced decision). Contemporary extensions of the oath include the realms of veracity and confidentiality, which are undoubtedly just as critical in the research setting as they are in clinical practice.

That same integrity must extend to our day-to-day work in the clinic and our interactions with patients. As physicians, we have the privilege and responsibility of managing individual patients. Patient management does not simply mean equating a diagnosis with a treatment. Instead, we are tasked with educating the lay public about the knowledge and limitations in our field to enable our patients to make shared, informed decisions about their care.

We must learn the art of synthesizing data and distill this information to patients in an interpretable fashion. At the same time, we must stay abreast of the latest treatments and technologies while recognizing the potential drawbacks and limitations of emerging developments.

To communicate our findings with utmost precision, we may be enticed to use technical, often subspecialized, jargon. Although this is necessary for publishing in scientific journals and communicating with other experts, it is important to communicate research with the lay public and the media in an accurate yet understandable manner, tailored appropriately to the audience—a skill set analogous to communicating with patients in the clinic. Striking the appropriate balance between accuracy and clarity can indeed be challenging, especially when communicating with a populace who may misunderstand or misconstrue medical information.

Likewise, as the media and other nonscientific sources often serve as the primary information outlet for the public, the onus is on investigators and physicians to ensure that data are not only reported but also translated accurately to these sources.

Not all physicians are investigators, and vice versa; however, a mutual reliance exists. Research forms the foundation of clinical guidelines and evidence-based medicine, and when its integrity is compromised, the quality of patient care may, too, suffer. Thus, those who engage in research activity of any kind must recognize the multidimensional responsibilities they have assumed and appreciate the potential consequences of their work.

Nirmish Singla, MD, is a clinical instructor/fellow in Urologic Oncology at Memorial Sloan Kettering Cancer Center.

Research forms the backbone of medical knowledge, and research integrity is a crucial responsibility of any scientist.

Oncology Fellow Stresses Integrity in the Lab and Clinic

In May, the Pink Luminous Advocacy Project introduced the Breast Awareness app, the first multilingual, unisex breast self-examination application. Although the nonprofit Pink Luminous organization is tasked with supporting breast health in underprivileged communities, CEO Marilyn Dans maintains that the app is meant to encourage self-examinations across the population.

“In all the places we’ve gone and the women we’ve talked to, women feel uncomfortable with breast self-examination, so the app makes it easier,” she said in an interview with 

. “[The app] is trying make self-examination really simple, trying to educate and empower individuals to live an awareness lifestyle, to embrace the awareness lifestyle, to make it part of their routine.”

According to an analysis of the Surveillance, Epidemiology, and End Results database, the incidence of breast cancer with distant involvement at diagnosis increased by 2.07% annually in women aged 25 to 39 years from 1976 to 2009. Over the study period, the increased incidence was particularly acute among black (annual percentage change, 3.50%) and Latinx women (annual percentage change, 2.67%).

Dans said that an increase in diagnoses among younger women, whose mammograms often are not covered by insurance, inspired Pink Luminous to develop an app to assist these women in particular and, more generally, anyone at risk for breast cancer. The idea was to create something to walk these men and women through a self-exam.

The Pink Luminous Advocacy Project supports and promotes breast cancer awareness in places where education and, specifically, medical education are limited. The organization’s ultimate goal is to “save lives at a global scale by offering educational tools focused on increasing breast health awareness.”

The app presents instructions for self-examination, similar to recommendations from the American Cancer Society, in both text and voice-over formats. It is currently available in English and Spanish and will download in the language set on the user’s device. Dans said a forthcoming update will include more languages.

Early detection is key to successful breast cancer treatment, and regular self-examination can help detect the disease early. The Breast Awareness app serves to educate users and help them become more familiar with their bodies. Dans says it gives individuals the tools to perform routine breast health examinations at home while teaching them how to detect possible abnormalities that require immediate action.

The app, available for Apple and Android, could benefit black and Latinx women, who are often diagnosed with advanced disease and are more likely to die from breast cancer compared with white women, and women who face cultural barriers to screening. In a meta-analysis of 39 studies encompassing more than 5.8 million patients, black (OR, 0.81; 95% CI, 0.72-0.91) and Latinx (OR, 0.83; 95% CI, 0.74-0.93) populations had lower odds of undergoing screening mammography compared with the white population.

These disparities appeared in both the 40-to-65 age group and the >65 age group of black women and in the 40-to-65 age group of Latinx women. No difference in mammography utilization was observed between Asians/Pacific Islanders and whites (OR, 1.82; 95% CI, 0.09-38.41).

Lead author Ahmed T. Ahmed, MD, MS, said in an interview with 

 that early detection can reduce the risk for disease-specific death by 20%. He added that factors including socioeconomic status, insurance coverage, location, culture, language barriers, and religion play a role in screening rates.

Muslim women, for example, are not routinely screened and treated for breast cancer because breast exams and mammograms are not widely accepted in that community, Ahmed said.

“The purpose is to be aware of what your normal breasts feel and look like, to detect any changes, and then to bring up those changes with your doctor,” said Giselle B. Ghurani, MD, a gynecologist/oncologist with Mercy Hospital in Miami, Florida, and a member of the Pink Luminous advisory board. “The next step would be to raise concerns with a physician, usually a gynecologist.

“I treat both healthy women and women who are at increased risk for breast and ovarian cancers, as well as women with [gynecologic] cancers. Early detection and disease prevention have always been a big passion of mine because I see how devastating the cancer diagnosis and treatment can be for the patient, the family, and the whole community.”

The app also allows users to create a philanthropic channel and raise money for the Pink Luminous Advocacy Project. Those funds go to supporting the distribution of Pink Luminous Breast devices to women in need, the donation of sonogram machines to breast cancer clinics, and the construction of health facilities in developing countries.

Johnson RH, Chien FL, Bleyer A. Incidence of breast cancer with distant involvement among women in the United States, 1976 to 2009 [erratum in JAMA. 2013;309(12):1229]. 

. 2013;309(8):800-805. doi: 10.1001/jama.2013.776.

Ahmed AT, Welch BT, Brinjikji W, et al. Racial disparities in screening mammography in the United States: a systematic review and meta-analysis. 

. 2017;14(2):157-165.e9. doi: 10.1016/j.jacr.2016.07.034.

Davis K. Mammography disparities found among black, Hispanic women. 

 website. bit.ly/2K4KukU. Published December 16, 2016. Accessed July 30, 2019.

Pink Luminous Advocacy Project's Breast Awareness app is the first multilingual, unisex breast self-examination application.

First Multilingual App for Breast Exam Aims to Improve Early Cancer Detection

I was 13 years old when I decided to become a doctor. At that age, I could not have guessed how challenging that path would be. Seven years of being immersed in textbooks, then 3 years of intensive internship and residency followed by a 3-year fellowship.

Now I am 30 years old and reminiscing about a life built on hard work and sacrifice. A sacrifice of my 20s, sleep, and even health. But apart from being able to prescribe medications, what has changed?

As soon as the title of MD is added to our names, expectations skyrocket, and anything less than perfection turns into a disappointment. We enter a world of tremendous internal and external pressures to flourish, and without knowing it, we join a malicious culture. A culture of toughness and boldness but also a culture where vulnerability is considered a weakness and any feelings of doubt or fear are buried. A culture that fuels our obsession with perfectionism and fosters unrealistic expectations. A culture that inevitably leads to emotional burnout. 

Despite our bravado, our confidence, and our skill, not everyone makes it. I lost a bright, compassionate, and caring colleague during residency. His suicide was a shock to everyone, including his family, because he was a cheerful doctor who had shown no signs of struggle or depression.

Doctors master the art of compartmentalization and disguise. The world sees us as superheroes. We expect to be superheroes. So how can we admit to fear or vulnerability? How can we acknowledge our weaknesses or confess to our exhaustion? How can we set aside our superhero masks without being judged or feeling shame?

The truth is that physicians are more than twice as likely to kill themselves as the rest of the population. Around 400 doctors in the United States commit suicide every year, more than 1 per day, a higher suicide rate than that of any other profession.

 And for every doctor who dies by suicide, thousands more contemplate the act. Good people are dying, friends of mine and friends of yours. It’s time for a change.

Our jobs can often lead to complete physical and mental exhaustion, yet our culture has taught us to suck it up and refuse to seek help. Oncology, in particular, is one of the most stressful medical specialties. It takes a great amount of physical and emotional energy to care for patients with terminal cancer. Watching patients deteriorate and suffer, in addition to repeatedly breaking bad news, can be emotionally draining.

Results of a qualitative study among oncologists showed that exposure to frequent patient death motivated clinicians to improve patient care (66.7%). However, it also led to exhaustion (62.0%), burnout (75.9%), and compartmentalization of feelings at work and home (69.6%).

Furthermore, we are expected to stay ahead of a constantly advancing field and novel treatment strategies, which is a challenge on its own.

So how do we deal with careers that often lead to complete physical and mental fatigue? We often hear the same suggestions: mindfulness classes, meditation, wellness retreats, resiliency training. These are great. However, doctors are resilient by nature. The problem is not our lack of resiliency; it’s numbness to our feelings. We see far too much pain to pretend as though it’s nothing. We need to be able to voice our worries and fears, share our vulnerabilities, connect with our feelings, and find comfort in our peers. It’s time to put an end to a culture that supports bravado and intolerance. Asking for help is 

Emotional resilience fluctuates over time, and recognizing when this resilience is wearing away is important. Acknowledging our feelings is the first step toward a healthier state of well-being. We can start by simply asking ourselves at the end of each day, “What are the 3 most difficult things I had to deal with today?” Once we are comfortable with identifying our own feelings, we then become capable of sharing these feelings with friends and colleagues.

Talking about those stressors is an important step in fighting burnout. A study done at the Mayo Clinic found that giving physicians time to spend with their colleagues in small groups for private discussions provided them with mutual support to deal with challenges, resulting in lower burnout, greater well-being, and improved job satisfaction.

A shout-out to all my friends and colleagues in residency and fellowship who helped me become the resilient physician I am today. It is vital to encourage community at work and cultivate an environment of collegiality and support.

We all go through a similar path of struggles and challenges, so why not share our fears with one another? Pamela Wible, MD, is a family physician in Eugene, Oregon, who has worked to combat physician suicide and burnout since 2005 and encourages healthcare providers to defend and protect one another. As she put it in a 2015 Ted Talk, “If we all shine our lights together, then there is no darkness to fear.”

Being a physician is not just a job, it’s a calling—a calling to be that superhero who saves lives. We have chosen a long and difficult path filled with ongoing daily sacrifices, yet we take pride in the work we do. Nonetheless, it is crucial to recognize that everyone experiences burnout, even superheroes.

There is no higher calling than being able to help people in need and alleviate suffering. However, we can’t give patients care that we have never received. Therefore, let us care for ourselves, and care for one another. Only then we can fulfill our calling and be true superheroes for our patients.

Yara Abdou, MD, is a clinical hematology/oncology fellow at the Roswell Park Comprehensive Cancer Center.

Medscape national physician burnout, depression & suicide report 2019. Medscape website. medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056. Accessed April 4, 2019.

Granek L, Ariad S, Nakash O, et al. Mixed-methods study of the impact of chronic patient death on oncologists’ personal and professional lives. 

. 2017;13(1):e1-e10. doi: 10.1200/JOP.2016.014746.

Wible P. Why doctors kill themselves. TEDMED website. bit.ly/2YsyUEO. Accessed April 26, 2019.

Yara Abdou, MD, sheds light on the challenging path of becoming an oncologist.

September 2019 | Oncology Fellows

Paying It Forward in Oncology: A Journey From Patient to Investigator

Should You Take a Break After Your Oncology Fellowship?

Oncology Fellow Stresses Integrity in the Lab and Clinic

First Multilingual App for Breast Exam Aims to Improve Early Cancer Detection

Even Superheroes Can Burn Out in Oncology