I began my fellowship at The University of Tennessee Health Science Center in Memphis in 2008 with the goal of pursuing an academic career. Like many first year fellows, I found myself trying to learn the new language of hematology/oncology while trying to find my academic calling. 

Toward the end of my first year, my program director, Raymond U. Osarogiagbon, MBBS, asked if I would be interested in writing an investigator initiated phase 2 clinical trial for a novel agent to be studied in non–small cell lung cancer. Of course, I jumped at the chance. After many revisions, the trial was ready to submit for approval.  

While writing a trial protocol, one must become an expert in the topic of the trial. Our research ended up not being funded because the drug was found not to be effective in other trials, but this led to my interest in lung cancer and I soon joined Dr. Osarogiagbon, who had since become my mentor, on his thoracic research team.

I’d found my calling—my “orange,” if you will. 

We stayed very busy. We met regularly with formal sessions that went well past dinnertime and held many impromptu gatherings during the day. All that hard work resulted in multiple abstracts and presentations at the American Society of Clinical Oncology Annual Meeting and the World Conference on Lung Cancer (WCLC). We submitted several manuscripts that ended up being published. By my third year, I had a dedicated continuity clinic seeing just patients with lung cancer and we had 11 abstracts presented at the WCLC. I was well on my way to becoming an academic thoracic oncologist.

During this time I met my wife, who was a physician doing her residency in internal medicine. She wanted to pursue a hematology/oncology fellowship and ended up matching at Tulane University in New Orleans, Louisiana. At the time, I was finishing my fellowship and had decided to stay on for a year to continue doing research but started searching for academic positions in New Orleans. My search led me to interview at Louisiana State University (LSU) Health Sciences Center where the program was still rebuilding after Hurricane Katrina but was ripe with opportunity. I did the required presentation for an academic job and discussed all the highlights of the thoracic research team I was leaving and what I could bring to LSU. I told them I was excited to join their team as a thoracic oncologist.

Their response was deflating: “We don’t need a thoracic oncologist. We need a neuroendocrine oncologist.”

I had read about neuroendocrine tumors (NETs) during fellowship but saw those diseases only a few times—usually on the boards and the treatment answer was always “octreotide.” We had a few patients on octreotide (Sandostatin LAR) and it seemed to be enough. How could someone, especially me, dedicate an entire practice to NETs? Could I switch from enjoying oranges and learn to enjoy this lemon?

The LSU group had a well-known NET team in collaboration with its community partner, Ochsner Health, which is known as the New Orleans Louisiana Neuroendocrine Tumor Specialists (NOLANETS). They attracted patients from throughout the United States and internationally. They were also quite productive from a research standpoint and well known among their peers in the handful of NET programs throughout the world.

One of the founding members of the group had left about a year prior and they were looking for a permanent replacement. They offered me the position and I accepted.

It turns out that NETs are not that uncommon. Although they still account for less than 1% of malignancies, the incidence is rising.

 The other factor that interested me was that about 25% of the carcinoid tumors originate in the lung, even though they account for only 2% of lung cancers.

My partners were more interested in gastrointestinal and pancreatic NETs—lung NETs would be my area to own. I learned as much as I could before I started and continued learning from my patients, partners, and peers every day. It was not long before I became immersed in the NET community. I was soon presenting research, publishing, and becoming involved in the North American Neuroendocrine Tumor Society, where I have since served on several committees. I have established research collaborations with many physicians around the country and have developed lifelong friendships with others in this small NET community.

I was with the NOLANETS team for almost 9 years before moving to Vanderbilt University Medical Center in Nashville, Tennessee, in 2021, where I am helping expand an established NET program. I am focusing more on general thoracic oncology but also thoracic NETs and continue to educate and mentor the next generation of NET oncologists. As a bonus, I am again working with Dr Osarogiagbon, who is director of the multidisciplinary thoracic oncology program at Baptist Cancer Center in Memphis and a research professor here at Vanderbilt.

I learned to want oranges during my fellowship. I studied hard and planned to make oranges my career. But life handed me lemons—and, it turns out, lemons are not so bad.

Dasari A, Shen C, Halperin D, et al. Trends in the incidence, prevalence, and survival outcomes in patients with neuroendocrine tumors in the United States. 

. 2017;3(10):1335-1342. doi:10.1001/jamaoncol.2017.0589

Ramirez RA, Chauhan A, Gimenez J, Thomas KEH, Kokodis I, Voros BA. Management of pulmonary neuroendocrine tumors. 

. 2017;18(4):433-442. doi:10.1007/s11154-017-9429-9

Articles

Robert Ramirez, DO, FACP, details his path to clinical thoracic oncology after originally planning on entering the academic field early in his career.

Loving Lemons Even When You Wanted Oranges

Immune checkpoint inhibitor (ICI) therapies have ushered in an exciting new phase of clinical research and treatment for malignant pleural mesothelioma (MPM), offering more effective and less toxic treatment options for patients. The research and clinical oncology communities eagerly await the completion of several upcoming trials focused on refining the role of ICIs in the treatment of this rare and deadly disease.

MPM is a rare cancer arising from mesothelial cells that line the pleura.

 In the United States, physicians diagnose approximately 2000 to 3000 new cases per year.

 Most cases have been linked to exposures to mineral fibers, particularly asbestos, and the prognosis is quite poor.

 The median overall survival (OS) is approximately 12 months and varies by histologic subtype. 

The epithelioid histologic subtype accounts for an estimated 60% of all MPM diagnoses and portends a slightly more favorable prognosis, with a median OS of 18 months. Conversely, the nonepithelioid (sarcomatoid, biphasic) histologic subtypes are associated with poorer outcomes, with a median OS of 5 to 10 months.

 Among patients with advanced MPM who are not surgical candidates, oncologists frequently offer palliative systemic therapies.

 Since 2004, the pemetrexed/ platinum doublet chemotherapy regimen has been recommended as first-line therapy, and until recently was the only FDA-approved systemic treatment for MPM.

 There has been considerable clinical equipoise regarding recommended regimens for subsequent lines of therapy.

Investigators have recently turned their attention to the immune system’s involvement in mesothelioma pathogenesis. Mesothelioma cancer cells are theorized to be immunogenic because tumor antigens trigger a T-lymphocyte– mediated immune response. This immune response is regulated at 2 critical checkpoints, CTLA-4 and PD-1. Mesothelioma cancer cells have been shown to express PD-L1, which leads to local tumor immunosuppression, allowing malignant cells to evade the immune system.

Investigators began developing ICIs targeting both CTLA-4 and PD-1 in the early 2010s to block immune system regulation, thereby enhancing the cytotoxic immune response to cancer cells. As a result, we have seen in a paradigm shift in the treatment of several solid malignancies.

Since 2017, National Comprehensive Cancer Network (NCCN) guidelines have recommended the anti–CTLA-4 agent ipilimumab (Yervoy) and the anti-PD-1 agents pembrolizumab (Keytruda) and nivolumab (Opdivo) for subsequent-line use in patients with MPM. This recommendation was based on the promising early results of the KEYNOTE-028 (NCT02054806), INITIATE (NCT03048474), and MAPS2 (NCT02716272) phase 1 and 2 trials.

Notably, although there is overall moderate expression of PD-L1 in MPM tumors, the nonepithelioid histologic subtypes appear to be associated with relatively higher levels of PD-L1 expression compared to the epithelioid subtype. Accordingly, PD-L1 expression has been demonstrated to be associated with worse survival outcomes.

 Moreover, a 2018 observational study by Yannis Metaxas, MD, and colleagues included patients with MPM treated with subsequent-line pembrolizumab and demonstrated similar OS by histologic subtype (median OS, 7.0 [nonepithelioid] vs 6.5 months [epithelioid]), suggesting that ICI may off er increased clinical benefi t to patients with nonepithelioid disease.

The results of the phase 3 CheckMate743 trial (NCT02899299) comparing fi rst-line nivolumab and ipilimumab with pemetrexed plus carboplatin or cisplatin also suggested a larger eff ect size for ICI associated with nonepithelioid MPM (median OS, 18.1 vs 8.8 months; HR, 0.46; 95% CI, 0.31-0.68) compared with epithelioid MPM (median OS, 18.7 vs 16.5 months; HR, 0.86; 95% CI, 0.69- 1.08). On the strength of the encouraging CheckMate743 results, the FDA approved ICI for first-line MPM treatment in October 2020. 

In our manuscript published May 18, 2021, in 

, we sought to evaluate the real-world uptake of off-label second-line ICI among patients with MPM who received traditional first-line chemotherapy and assess the association of MPM histologic subtype on ICI uptake before and after the 2017 NCCN MPM guideline revision.

Our retrospective, multicenter cohort study used deidentified electronic health record data from the Flatiron Health database and included a total of 426 patients with MPM diagnosed between January 2011 and December 2019 who received first-line and second-line systemic therapies recommended by the 2017 NCCN MPM guidelines. In our study cohort, 310 (72.8%) patients had epithelioid and 116 (27.2%) nonepithelioid histologic subtypes (48 sarcomatoid, 68 biphasic). 

Compared with patients enrolled in clinical trials, those included in our real-world cohort were notably older (median age, 73 years) and more diverse (19% were nonwhite) and had poorer performance status (11% ECOG 2-4). During the entire study period, 144 patients (33.8%) received second-line ICI and 282 (66.2%) received second-line traditional chemotherapy. ICI uptake began in 2015 and in each subsequent year, an increasing proportion of patients received ICI (

 < .001). Beginning the first quarter of 2016, we observed rapid and sustained adoption of second-line ICI, largely driven by pembrolizumab uptake. This was despite ICI not being FDA approved at the time. 

After adjusting for patient age, sex, race, ECOG performance status, clinical center volume, and type of insurance, we found that patients with nonepithelioid MPM were more likely to receive second-line ICI after the 2017 NCCN MPM guideline revision (adjusted OR, 3.26; 95% CI, 1.41-7.54). 

While we were unable to ascertain the exact reason for this association given the inherent limitations associated with our observational study design, we hypothesized that treating oncologists may have been informed by contemporaneous preliminary evidence of possible increased ICI effi cacy in nonepithelioid compared with epithelioid MPM. Another possibility was that the inherently worse prognoses associated with nonepithelioid MPM prompted clinicians to lower their thresholds for prescribing novel therapies in hopes of deriving therapeutic benefit. 

Despite this early enthusiasm for second-line ICI we reported in our study, recent phase 3 studies have not clearly demonstrated superior OS outcomes for subsequent-line ICI compared with chemotherapy. While early results from the CONFIRM trial (NCT03063450) demonstrated improved survival with nivolumab compared with placebo (median OS, 9.2 vs 6.6 months; HR, 0.72), the PROMISE-Meso trial (NCT02991482) did not report any significant improvement in OS for pembrolizumab vs chemotherapy (median OS, 10.7 vs 12.4 months; HR, 1.12).

Thus, in our manuscript recently published in 

, our objective was to evaluate the comparative effectiveness of second-line ICI vs chemotherapy on OS outcomes in real-world patients with MPM who received standard first-line chemotherapy.

 We again used the Flatiron Health database to conduct a retrospective cohort study of patients with MPM receiving second-line therapy from 2015 to 2019. This study included 176 patients, 115 (65%) of whom received second-line ICI and 61 (35%) chemotherapy.

Median OS was 8.7 months (95% CI, 7.7-10.9 months) in the ICI group and 5.0 months (95% CI, 4.0-6.4 months) in the chemotherapy group (

 = .001). The 12-month estimated OS probability was 36.7% (95% CI, 27.6%-45.8%) in the ICI group compared with 15.6% (95% CI, 7.7%-26.1%) in the chemotherapy group (

Figure. Overall Survival of Patients With MPM Receiving Second-Line Therapy

After adjusting for patient age, sex, race, histologic subtype, ECOG performance status, first-line therapy, time since start of first-line therapy, year of second-line therapy, and prior surgical resection, second-line ICI was associated with improved OS outcomes compared with chemotherapy (adjusted HR, 0.52; 95% CI, 0.34-0.81). Although we did not observe a significant difference by histologic subtype, our study was not powered to adequately evaluate this interaction. 

These results suggest possible clinical benefit of second-line ICI over chemotherapy among patients with MPM receiving routine care. However, further research is required to elucidate the role of secondline ICI for MPM treatment, especially with the recent emergence of first-line ICI regimens. Several clinical trials are under way to assess the use of ICI with or without chemotherapy, in the adjuvant and neoadjuvant settings, and with antiangiogenesis therapy, among other clinical contexts.

Kim RY, Sterman DH, Haas AR. Malignant mesothelioma: has anything changed? 

. 2019;40(3):347-360. doi:10.1055/s-0039-1693406 

Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. 

. 2018;68(6):394-424. Published correction appears in CA Cancer J Clin. 2020;70(4):313. 

Carbone M, Kratzke RA, Testa JR. The pathogenesis of mesothelioma. 

. 2002;29(1):2-17. doi:10.1053/sonc.2002.30227 

Verma V, Ahern CA, Berlind CG, et al. Survival by histologic subtype of malignant pleural mesothelioma and the impact of surgical resection on overall survival. 

. 2018;19(6):e901-e912. doi:10.1016/j. cllc.2018.08.007 

Kindler HL, Ismaila N, Armato SG 3rd, et al. Treatment of malignant pleural mesothelioma: American Society of Clinical Oncology clinical practice guideline. 

 2018;36(13):1343-1373. doi:10.1200/ JCO.2017.76.6394 

Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. 

. 2003;21(14):2636- 2644. doi:10.1200/JCO.2003.11.136 

Scherpereel A, Wallyn F, Albelda SM, Munck C. Novel therapies for malignant pleural mesothelioma. 

. 2018;19(3):e161-e172. doi:10.1016/S1470-2045(18)30100-1 

Weber JS, D'Angelo SP, Minor D, et al. Nivolumab versus chemotherapy in patients with advanced melanoma who progressed after anti-CTLA-4 treatment (CheckMate 037): a randomised, controlled, open-label, phase 3 trial. 

. 2015;16(4):375-384. doi:10.1016/S1470- 2045(15)70076-8 

Brahmer J, Reckamp KL, Baas P, et al. Nivolumab versus docetaxel in advanced squamous-cell non-small-cell lung cancer. 

. 2015;373(2):123-135. doi:10.1056/NEJMoa1504627 

Alley EW, Lopez J, Santoro A, et al. Clinical safety and activity of pembrolizumab in patients with malignant pleural mesothelioma (KEYNOTE-028): preliminary results from a non-randomised, open-label, phase 1b trial. 

 2017;18(5):623-630. doi:10.1016/S1470-2045(17)30169-9 

Disselhorst MJ, Quispel-Janssen J, Lalezari F, et al. Ipilimumab and nivolumab in the treatment of recurrent malignant pleural mesothelioma (INITIATE): results of a prospective, single-arm, phase 2 trial. 

. 2019;7(3):260-270. doi:10.1016/S2213-2600(18)30420-X 

Scherpereel A, Mazieres J, Greillier L, et al; French Cooperative Thoracic Intergroup. Nivolumab or nivolumab plus ipilimumab in patients with relapsed malignant pleural mesothelioma (IFCT-1501 MAPS2): a multicentre, open-label, randomised, non-comparative, phase 2 trial. 

. 2019;20(2):239-253. Published correction appears in Lancet Oncol. 2019;20(3):e132 

Mansfield AS, Roden AC, Peikert T, et al. B7-H1 expression in malignant pleural mesothelioma is associated with sarcomatoid histology and poor prognosis. 

. 2014;9(7):1036-1040. doi:10.1097/ JTO.0000000000000177 

Metaxas Y, Rivalland G, Mauti LA, et al. Pembrolizumab as palliative immunotherapy in malignant pleural mesothelioma. 

. 2018;13(11):1784-1791. doi:10.1016/j.jtho.2018.08.007 

Kim RY, Mitra N, Bagley SJ, et al. Immune checkpoint inhibitor uptake in real-world patients with malignant pleural mesothelioma. 

. 2021;2(6):100188. doi:10.1016/j.jtocrr.2021.100188 

Fennell D, Ottensmeier C, Califano R, et al. Nivolumab versus placebo in relapsed malignant mesothelioma: the CONFIRM phase 3 trial. 

. 2021;16(suppl 3):S62. doi:10.1016/j.jtho.2021.01.323 

Popat S, Curioni-Fontecedro A, Dafni U, et al. A multicentre randomised phase III trial comparing pembrolizumab versus single-agent chemotherapy for advanced pre-treated malignant pleural mesothelioma: the European Thoracic Oncology Platform (ETOP 9-15) PROMISE-meso trial. 

. 2020;31(12):1734-1745. doi:10.1016/j.annonc.2020.09.009 

Kim RY, Li Y, Marmarelis ME, Vachani A. Comparative effectiveness of second-line immune checkpoint inhibitor therapy versus chemotherapy for malignant pleural mesothelioma. 

. 2021;159:107-110. doi:10.1016/j.lungcan.2021.06.017

Immune checkpoint inhibitor therapies have ushered in an exciting new phase of clinical research and treatment for malignant pleural mesothelioma. 

Immune Checkpoint Inhibitors Extend Survival for Mesothelioma

One challenging hematologic scenario dreaded by both fellows and faculty involves a rapidly bleeding patient in danger of exsanguination. Conversely, the ability to successfully intervene can be quite rewarding and save lives. What follows are practical points for trainees to approach the initial evaluation for a bleeding-disorder patient.

History is vital to inform differential diagnosis and target lab evaluation. Important aspects include timing and details surrounding the bleeding events, reviewing medications/substance use, and family history.1 Important considerations include:

 Clinically relevant hemorrhage in infancy or childhood is suggestive of an inherited/ congenital bleeding disorder. Hemorrhage in adulthood should prompt an evaluation for an acquired coagulation disorder, a delayed manifestation of a mild congenital bleeding disorder, or a medication effect.

 Is the bleeding spontaneous or only with trauma or invasive procedures? This may indicate severity and provide clues to an underlying diagnosis.

 Primary involvement of mucosal surfaces, epistaxis, gingival bleeding, or spontaneous bruising may indicate a platelet disorder. Hemarthroses, muscle bleeds, or soft tissue hemorrhages suggest a coagulationfactor disorder.

 What procedures were performed and was hemostasis achieved? Was factor prophylaxis used? Be sure to ask about dental work, major surgeries, and the timing of hemorrhage. Noting a need for interventions or blood transfusions also helps gauge severity of bleeding disorders.

 It can be difficult to objectively characterize menstrual cycle severity given its inherently subjective nature and the variable methods of quantifying blood loss. However, menstrual bleeding that interferes with daily activities, cycles lasting longer than 7 days, or the presence of clots larger than 1 cm can be considered clinically significant bleeding. These symptoms could be suggestive of von Willebrand disease (VWD) or another congenital bleeding disorder.

 The bleeding assessment tool, or BAT, helps with consistent reporting of the presence of bleeding and severity. It assists with evaluation for inherited bleeding disorders.

 Severe hemophilia A or B typically has bleeding in infancy, spontaneous hemarthroses, or muscle bleeds. VWD includes mucocutaneous bleeding, heavy menses, or perioperative bleeding. Uremia or liver disease may manifest with ecchymoses, purpura, epistaxis, or bleeding at sites of intravenous access.

 Other relatives with a similar bleeding history, even if there is no formal diagnosis, may suggest inherited bleeding disorder and inheritance patterns.

 Care should be taken to review any over-the-counter medications: Nonsteroidal antiinflammatory medications, turmeric, St. John’s wort, and garlic can worsen bleeding.

 Excessive alcohol use may point to liver disease as a bleeding contributor. Illicit substance use may suggest a need for evaluation for contamination with brodifacoum, a longacting vitamin K antagonist.

assessment of the joints for stigmata of prior or current hemarthroses;

evaluation for bruising or petechiae, as this may be suggestive of thrombocytopenia, a platelet disorder, or VWD;

assessment for telangiectasias, particularly on skin, oral mucosa, or fingertips. This may be suggestive of hereditary hemorrhagic telangiectasia; and

evaluation for hypermobile joints suggestive of Ehlers-Danlos syndrome or a collagen vascular disorder.

Labs are often needed to formalize a diagnosis. Although steps 1 and 2 will inform which tests are needed, the results may confirm the clinician’s opinion.

 Initial labs include a complete blood count, prothrombin time (PT) evaluating the extrinsic coagulation pathway, and an activated partial thromboplastin time (aPTT) evaluating the intrinsic pathway. A platelet function analyzer (PFA-100) may be helpful in screening for platelet dysfunction or VWD. Additionally, fibrinogen should be drawn to evaluate for disseminated intravascular coagulation or dysfibrinogenemia.

 Based on the initial screening lab test results, further targeted testing may be performed. Prolongation of the PT and/or the aPTT suggests a clotting factor deficiency or the presence of an inhibitor. A solely prolonged PT indicates an extrinsic coagulation pathway abnormality, and a prolonged aPTT alone suggests an intrinsic coagulation pathway defect. Dual prolonged PT and aPTT lab tests suggest a common pathway malfunction (Table 1).

 Remember to repeat a prolonged aPTT from a peripheral lab draw prior to doing additional testing, as it is common for catheterassociated heparin contamination to cause an isolated prolonged aPTT. If it persists, perform a “mixing study” next. An equal amount of patient plasma and normal pooled plasma are mixed at a ratio of 1:1. The test “corrects” when the PT or aPTT normalizes and thus suggests a factor deficiency that improved with the addition of normal plasma. If the patient’s PT or aPTT remains prolonged and does not correct, this indicates the presence of a factor inhibitor. This information can be combined with the prior results to aid in selection of factor activities to measure as clinically directed.

 Thrombin time measures the conversion of fibrinogen to fibrin. This lab may be helpful if there is a suspicion of anticoagulant use (direct thrombin inhibitor) or a fibrinogen disorder (Table 2).

The assessment and evaluation of the history, physical exam, and laboratory testing in a patient with a bleeding disorder are complex and multifaceted. The hematologist plays an essential role in the collection and review of these data. Management of individual conditions is outside the scope of this article; however, once a diagnosis is confirmed, management is much simplified.

Recall that if one does not at least consider the diagnosis, one will certainly fail to recognize it. The correct diagnosis is the foundation on which all management of bleeding disorders hinges. Without this cornerstone, one cannot hope to proceed to effective hemostatic control.

Hunt BJ. Bleeding and coagulopathies in critical care. 

. 2014;370:847-859. doi: 10.1056/NEJMra1208626

Rodeghiero F, Tosetto A, Abshire T, et al; ISTH/SSC joint VWF and Perinatal/Pediatric Hemostasis Subcommittees Working Group. ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders. 

. 2010;8(9):2063-2065. doi:10.1111 /j.1538-7836.2010.03975

Michelle Chi, MD and Jennifer R. Green, MD, share practical points for trainees to approach the initial evaluation for a bleeding-disorder patient.

Assessing Bleeding Disorders: Keys for Hem/Onc Fellows

Like many physicians, Leslie S. Kersun, MD, MSCE, MSEd, has known since childhood that she wanted a career in medicine. She found her calling in pediatric oncology while she was an undergraduate at Dartmouth College in Hanover, New Hampshire, while volunteering with the child life service at a local hospital. The program provides developmental stimulation, support, and advocacy for children’s emotional and psychological needs.

“I met a lot of children with cancer because they were in the hospital the most,” she said. “Then I noticed in medical school that I was really interested in cancer and blood disorders as we were doing those sections. Things kind of all fit together over time. I didn’t have a lot of deciding; each step of the way sort of fell into place.”

She earned her MD at Albany Medical College in New York and was a pediatric resident at Children’s Hospital of Philadelphia (CHOP) in Pennsylvania. She completed her first year of pediatric hematology/oncology fellowship at Children’s Regional Medical Center, now Seattle Children’s Hospital, in Washington and returned to CHOP to finish her training. During her training and early in her faculty appointment, she realized she had a passion for medical education.

“As a fellow, I enjoyed teaching residents and medical students,” she said. “Soon after I finished fellowship, I was given an opportunity to help with the resident rotation on our oncology unit. It was my job to figure out and adjust how the residents were educated when they participated in their oncology rotation.”

Soon after, she became the inpatient medical director in oncology, in addition to becoming more involved with the fellowship program. Later, she was named associate fellowship director and now serves as the program director for one of the largest pediatric hematology/oncology fellowship programs in the country. Except for the year she spent in Seattle, Kersun has been at CHOP since 1996.

She has recently taken on the role of associate designated institutional official and, along with the Graduate Medical Education leadership team, helps to oversee more than 70 training programs at CHOP. Working at CHOP is fantastic, she said. “It’s a great place to work. There’s a lot of expertise and dedication to education there. We have a lovely culture, and there’s always somebody to be able to help you with a patient or a question.”

Kersun sat down with Oncology Fellows to talk about finding the right fellowship program; the challenge of balancing research, patient care, and education as a trainee; and finding one’s focus during fellowship.

You didn't struggle figuring out your career path, but how do you help fellows find their focus when they come into the program?

: One of the most important things to consider as you’re looking at a fellowship program is what kind of mentorship is available to help you develop professionally. You need to think about the program’s clinical mentorship structure because those faculty members will help you learn how to take care of the patients. Two of the 3 years of fellowship training are focused on research. Depending on what type of research you’re interested in—whether strictly laboratory-based, more translational research or clinically oriented research—you need to consider what type of mentors and resources are available. This is critical as you plan for your career and determine who at that institution can help to guide you on your desired path.

Then, of course, there are the life mentors. These may not be one of your assigned mentors for a particular area. They are faculty who have either chosen a similar path, structured their life in a way that resonates with you, or have advice that can help to guide you.

What should residents look for in a fellowship program?

Fellowship is, for most, the last step in their training before transitioning to a faculty position. It’s crucial to have mentors, resources, and a program that can help to support your career interests and a culture that allows you to thrive during training. Those are really important questions to ask as you’re thinking about applying to a program or if you’re interviewing at a program; [it’s important] to [understand whether] that program can support your development and the areas of your career that are most important to you. It’s a little bit different than residency training. The interview process and aspects that are most important for the program may be quite different.

Typically, people who go into fellowship are looking to go into academic medicine, but is there value in fellowship for people who want to be community physicians?

There’s value in whatever you choose to do, so we don’t feel like those physicians who are in an academic center doing research are more valuable than those physicians who choose to have a primarily clinical career. Our fellowship would certainly train you for whatever career path interests you. In pediatric oncology, there are many fewer opportunities in community medicine or private practice—it’s just not how most practices are structured. Children with cancer and blood disorders are most often seen in a hospital setting because you need a blood bank; lab-based diagnostics; multiple specialties such as radiology, pathology, surgical specialties, radiation oncology; and various disciplines to best care for the patients. It’s not that there aren’t available community or private practices; it’s just less common.

A fellow who comes to you midway through their third year and says, “Dr Kersun, I’m not sure how to get a job.” What do you tell them about taking that next step to actually go to work as a physician and researcher?

We talk with them about it from the very beginning. Our division chief gives a lecture about the process of finding a job that is right for each trainee. He reviews how he can assist in reading cover letters and reaching out to potential employers to help our fellows get connected with opportunities that will fulfill their career goals. He also reviews what fellows should be thinking about accomplishing during training and then how to pick a faculty position that will help to continue to foster their career. Our research mentors and clinical mentors are talking with the fellows as they progress in training about what their interests are and what opportunities there might be for them.

Our program also has instructor positions, which serve as a transition period that lasts 1 to 3 years prior to getting a faculty appointment. This type of position is primarily for fellows who have an interest in research. With only 2 years of fellowship dedicated to research, many trainees haven’t had enough research experience to apply for a grant to support their salary right at the end of training. They can use this transition time to develop their projects further and work with their mentors to move toward independence. They can also serve as an attending physician during this time while further developing their research projects. When they’re finished with that period, they’re ready to apply for a job.

Leslie S. Kersun, MD, MSCE, MSEd, discusses finding the right fellowship program; the challenge of balancing research, patient care, and education as a
trainee; and finding one’s focus during fellowship.

Finding Focus in Fellowship

We now find ourselves in a world in which doors are opening once again, allowing slivers of light to reach into our new reality. We blink in the brightness as we take cautious steps toward a new normal, recognizing that it is still an evolving destination. We are confronted with the fact that the COVID-19 pandemic is not over—it may never be “over”—but our spirits must somehow be filled with the richness of living to survive.

In my case, when the pandemic first hit, the “busyness of just doing” provided a buff er and a distraction for what I would otherwise be feeling. In the middle of a crisis, I find that keeping busy can be protective. I could concentrate on the task in front of me and not on the horrors I was seeing.

I found comfort in a structured medical center response that always told me where to go, what to do, and how to serve. In fact, I quickly found that, to create more structure for myself, I needed to go into the offi ce every day rather than work from home. The structure itself was soothing.

When the first call for volunteers went out, I witnessed providers saying, “Sign me up for everything.” I candidly asked them how they were thinking about this lifechanging event. I was often told, “If I don’t keep moving, I will cry.”

My grieving was relegated to quiet times at home. But if I did not allow myself to grieve, my feelings of anger, sorrow, and fear would then pop out sideways at unexpected times, manifesting as irritability, depression, and a lack of concentration.

Moreover, my usual coping mechanisms—like eating out with a great group of friends and hanging out with my husband, an emergency department doctor—suddenly disappeared.

Like so many others throughout 2020, I learned to create distant social opportunities with friends such as Zoom cocktails, virtual movie nights, and wine parties in the driveway. These events were never as good as they would have been in person, you can’t hug through a computer monitor, but necessity compels.

I also tried to “lean in” to the solitude and find the peace of my own company. I realized that the busyness of my usual life—going out multiple nights per week, traveling for work several times per month, attending large professional meetings held in hotels or convention centers—was something that did not always support a personal sense of peace.

I am an extrovert. I am the extrovert. I am the poster child for extroverts. Throughout my life, I was the social organizer, the life of the party. But I found as the pandemic wore on that I could recharge by being alone and by doing quiet things. This was an important discovery when the world seemed to be on fire from every front. I wondered what would happen to me when the world opened up again? Would I be ready for reentry? What have I learned and what can I do diff erently to maintain serenity in a world that is unpredictable, unforgiving, and frightening?

So here I am, on the precipice of reentry. I suspect this is similar in some ways to what a fellow experiences at graduation upon starting a fi rst job. A fellow is used to working within limits set by Accreditation Council for Graduate Medical Education rules and regulations, but limits such as “caps” or duty hours do not exist in the real world. Moving into a limitless environment can be scary and unsettling. In my case, I had to learn how to incorporate the lessons I learned about myself during this “quiet period” and apply them to my reengagement with life. The forced process of reevaluation and refl ection during these quiet periods has been a gift and I will apply the lessons learned to this new world.

Self-compassion and giving oneself grace are key to weathering critical events. They are underutilized and underrated forms of resilience.

Work travel is exhausting. A great deal of activation energy is required to attend every meeting around the country or world. It is OK to decline some in-person meetings or to attend some events virtually.

It is OK to cautiously enter previously “unsafe zones.” For example, I am now triple vaccinated but live in an area with a relatively low vaccination rate. I began avoiding restaurants, one of my pleasures in life, when the pandemic started. Recently, though, I went to a restaurant with a few friends, and it felt like a slice of heaven, a bit of normalcy. I asked to sit in a less-crowded area of the restaurant and although I did not feel 100% safe, I realized that the risk-benefi t ratio at this point favored the need to feed my soul by embracing these relationships. I recognize that I will always have some fear, but that life must go on and I have the agency to choose how to proceed.

I share some qualities with introverts. I now realize that I do not always “charge” by being with large groups. It is a mix. Sometimes, I charge by reading a great book on my back porch. I will seek balance in how I recharge.

Fear will be with me for the foreseeable future. I accept that fear without shame. I aspire to not let the fear prevent me from living. I also give myself the grace to opt out of activities that seem too risky.

A little self-refl ection and a lot of self-compassion go a long way in a world of immense change.

Jill Gilbert, MD, is a Professor of Medicine and Vice Chair for Professional Development in the Department of Medicine of the Division of Hematology-Oncology at Vanderbilt University School of Medicine in Nashville, TN.

A little self-reflection and a lot of self-compassion go a long way in a world of immense change.

Vol. 13/No. 4 | Oncology Fellows

Loving Lemons Even When You Wanted Oranges

Immune Checkpoint Inhibitors Extend Survival for Mesothelioma

Assessing Bleeding Disorders: Keys for Hem/Onc Fellows

Finding Focus in Fellowship

Cautiously Reentering the World